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HomeMy WebLinkAboutMoe's Southwest Grill 10/02/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: TEMPORARY FOOD PERMIT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:, JERRY BLAU, DIRECTOR OF OPERATIONS Whose place of business is: MOES SOUTHWEST GRILL -11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: CLARISSA SAMUELS Permit Expires: October 02, 2018 Food Fee: License Number: T-22 WAIVED BOARD OF HEALTH 34ichaeCMcC(ean, Chairman Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Es - en Name: -Fh / 2) Establi hment Address, 4 0d O,� i lJNr 3) Establialiment Malting Address (if different): a) Establishment Telephone No: 5) ApplicanUOwnor Name & Title: 6) ApplicanVO I—n rAddress: Q 1�40�� f 7) ApplicanUOwne Telephone No: 8) Applicant/Owner Email address: , Ort+1 9) Person Directly Responsible For Onsite Operations: Name 8 Title: ez liaaak Address: yAg%Lc,46ZQ G J 3 0 Telephone No: dd fp� cil Fax: Emergency Telephone No: D 10)Event Attending Date(s): Event Name: Event Location: �,c e Event time: 11) Check one 12) Solid waste disposal plan: Food Truck Caterer (. Other: ?d�t�/CM/F5B24Je. 13) Water Source; 14) Sawaga disposal plan: 0 N 15 ) Please give brief description of the food to be served: eaj6t4 rc 4 's- Food Protection Questionnaire for Catered Events Date of Event: !o 02 L06 Event Time: t5'~7 PM Location of Event: _/ /? 1 WAN c 4-: List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/R(tef igerated / s�fljCl.- Cooking Reheating Food Manager Certification Person Trained On Site? t es El No Allergen Awareness Menu Label Present? es ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: Ilow will the PHF be kept at or below -rr rya j 06t&)A.) 41°F? ^� Removed How will the PHF be kept at or above 1409F? P M Time of PHF? Setup � ?a Served , _ / List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. I oxe)s �rcrl �Ns ) ;j "d soo - 16) Food will be prepared: Onsite for immediate consumption Onsite and hRId at proper hot/ cold holding ✓. lemperatures Off �Site and held at proper hot/ cold holding temperetures✓ Offshe, cooled and reheated / on site Other: !A t r "A // Z'Ce t-4oc.rj Ai GYf d /&nn Fold G e le-4 17) If PHF is being served, please list the person who has completed the following tminings and attach appropriate certificates: Food Safety Manager: difs Allergen Awareness: 18) For caterers: CityfTown where food establishment permit is held. Please attach a copy of the caterer's permit For food trucks, please list additional communities where a food permit is held and attach copies of the permits: I, the undersigned, attest to the a uracy of the establishment operation will tom ly with 105 C the board of health on how to obihin copies o 19) Signature of Applicant: lw I rprovided in this application and I affirm that the food and all other applicable law. I have been instructed by I.000 and the federal Food Code. Pursuant to MGL Ch. 62C,#c. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, ha filed all state tax returns and paids�q to taxes required under law. 20) 7 Social Security Number or Federal 10: /Q � q 3 A(.-e 21) Signature of Individual or Corporate Name: Please include copies of ServeSafe and Allergen training certificates Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 rvwramas's.gov/dia Workers' Compensation Insuranee Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name Address: Are you an employer? Check the appropriate box: I. 1 am a employer with '_ employees (full and/ or part-time).* 2. 1 am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. insurance required) 3. We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]** 4. We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.) Phone #: l 1 Business Type (required): 5. Retail 6.� i Restaurant/Bar/Fating Establishment 7 Office and/or Sales (me]. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing 11. Health Care Any applicant that checks box # 1 must also rill out the section below showing their workers' compensation policy information. 'If the corporate officers have exempted themselves, but Iho corporation has other employees, a workers' compensation policy is required and such an aganization should check box It), ' mn on crq;loyer ilrril is provldhig workers' contpensatiott insurance for my enrployeea, Below Is the policy Information. nsurance Company Name: -C. f- ..r usurer's Address 'Ity/State/Zip: �L�� ..��� 1 L�.Ot <J'%ft 'olicy N or Self -ins. Lie, # _ _ N ( ,� 1 a Expiration Date: ( � lttach a copy of fire workers' compensation policy declaration page (showing the policy number and expiration date). ,allure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a ine up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine >f up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. rlo lrerenP cer!lfy, under Idle pains and penalties of perjury that the Information provided above is rare and correct. ,r mmaro: mate: C� >1t hone H: LI. Ll` \.' C)l ( fD Offlelal use only. Do not write In this area, to be completed by city or lawn offlclal. City or Town: Permit/License N Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone a: www.mass.gov/dia ACORO® CERTIFICATE OF LIABILITY INSURANCE lk . 9/1/2019 DATE IMMIOD VY YI 9/25/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER Lockton Companies Three City Place Drive, Suite 900 St, Louis MO 63141-7081 (314) 432-0500 NAMRCT PHONE r 0 1aC No: .MAIL ADDRESS: INSUREfl S AFFORDING COVERAGE NAIC e INSURER A: Liberty Insurance Corporation 42404 INSURED Raptor Payroll Services Inc. 1451765 4 Foxborough Blvd INSURER a : Liberty Mutual Fire Insurance Company 23035 INSURER C:L Insurance Cooration 33600 INSURER o: National Surety Corporation 21881 Unit 410 Foxborough MA 02035 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 15628311 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�TR TYPE OF INSURANCE ADS SUBR POLICY NUMBER POLICY Err MMIDDM'YY LIMITS q tXMMERCIAL GENERAL LIABILITY CIAIMS-MADE 1XI OCCUR N N 7'D7--L91-469442.036 9/I/2016 9/I/2019 EACH OCCURRENCE 3 1,000,000 OAMAGEB aRENTED a ce S 1,000,000 GENT MED E%P (Any one eeraon) PERSONAL B ADV INJURY $ 10,000 S 1000000 AGGREGATE LIMIT APPLIES PER: POLICY PROJECT X LOC OTHER: GENERAL AGGREGATE 3 2,000,000 PRODUCTS -COMPIOPAGO 3 2 OOO OOO $ B AUTOMOBILE X LIABILITY ANY AUTO OWNED $CH AUTOS ONLY ACTOSUtEO HIRED I I NON -OWNED AUTOS ONLY AUTOS ONLY N N AS2$91-469442-028 9/1/2018 9/112019 COMBINED SINGLE LI IT Ee eWdenl $ 1000 000 BODILY INJURY (Pe, person) $ XX)(XX (X BODILY INJURY(P., accident) $ XXXXXXX PROPERTYDAMAGE Pe ami oil $XXXXXXX $XX)XXXX D X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS MADE N N SSE00049073976 9/i/2018 9/1/2019 EACH OCCURRENCE $ I000Q000 AGGREGATE $ 10,000,000 DEO L1 RETENTION$ $ XXXXXXX C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICERIMEMBE0. E%CLUDANY wD9 ECUTIVEFN (Mandatory in NH) IIue DCRrdIPTION OF OPERATIONS below N/A N WCS-Z91-469442-018 9/i/2018 9/1/2019 PER OTH- X. ST9TUTE___. ER__.....__. E.L.EACH ACCIDENT $ 1000000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES tACORD U1, Addillonal Romarhs SchadulP, may be altachod If morospaoo Is mquirma CERTIFICATE HOLDER CANCELLATION 15628311 FOR INFORMATIONAL PURPOSES ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTAT ©1988.2MnCORD CORPORATISN. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 14� tf Sent from my Whone Jerry Blau 401.529.5820 Mansfield Board of Health Request for Fee Waiver for Food Permit MIA organization ) request a waiver of the Food Service Permit Fee for the following reason: This is a request from a town department. Please list the department: We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * We are donating ALL proceeds earned directly to a 501(c)(3) organization. Please list the organization: We re not charging a fee for food/drink being served. We are a religious organization. Other: The Taste of the Tr Thank you, Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: