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Home My WebLink AboutNorwood Hospital 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:. STEWARD NORWOOD HOSPITAL, INC. Whose place of business is: NORWOOD HOSPITAL - 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: MARGARET LUTZ Permit Expires: October 02, 2018 Food Fee: License Number: T-1 WAIVED BOARD OF HEALTH MichaeCMcCCean, Chairman SeP.11. 2018 1:05PM No.0258 P. 2 FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: D--td0L)f) I 2) Establishment Address: p 0 i r 1 q•c i �'"� S l O�]rt/tf VIJ Q 3) Establishment Mailing Address (if different): -' (bp'L 4) Establishment Telephone NO: I IRA 5) Applicant/Owner Name & Title: S' �JAIWQI1 30 A', 6) Appllcant/OwnerAddress:e 7)Applicant/OwnerTelephone No: r t)dCa 8) Applicantlowner Email address: 9) Person Directly Responsible For Onsite Operations: Name &Title: (t'1M—''�11``n(7tT C. T-7 COMMU1 f "o t Address: ,t got? AS/fi�(,P,0¢.SOP•^.trn(ai� il%IA, W Telephone No: (0 D2, Fax: Emergency Telephone No: ` s> ,. �' 59 &,)-pc� 10) Event Attending Date(s): pp 6 (J.x`.. `�. 110 11O Event Name: (Lti J�pw N �,,A Event Location: VI )(��l Nri(� Uvy ��4 ' , Event time: 11) Check one 0 Food Truck 0Caterer ��9 t{uS4i-tl?t1_ __ 1,5-/ Other:h 12) Solid waste disposal plan: ( 4 13) Water Source: V\o 14) Sewage disposal plan: >n. 61 15) Please give a brief description of the food to be served: f C-- �+k- Kip to V�c fr4xAie�e 00�kpo0 t \1MP N5U �, Sep, 11. 2018 1:06PM No. 0258 P. 4 Food Protection Questionnaire for Catered Events Date of Event: 10 , 2 ' 1' Event Time: !;- I evh Location of Event: )(`Fin1I0�GeAItzD� M'4M4()(WP,MA - List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Food Manager Certification Person Trained On Site? El Yes No Allergen Awareness Menu Label Present? ❑ Yes >�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: How will the PHF be kept at or below 41 °F? r l'� How will the PHF be kept at or above l40'F? !C\ Time of PHF? Setup Served _Removed 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. —Sep. 11. 2018— 1 :06P;" No, 0258—P, 16 ) Food will be prepared: 'Pl� Onsite for immediate consumption ❑ Onsite and held at proper hot/ cold holding temperatures 0 Olfsite and held at proper hot/ cold holding temperatures 0 Offsite, cooled and reheated on site ❑ Other JV f„ r S p J 17) If PWF is being served, please list the person who has completed the following trainings and attach appropriate certificates: 0 Food Safely Manager: ❑ Allergen Awareness: I� I 18) For caterers: Cityl7own 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 establishment operation will con by the board of health on how to 19) Signature of Applicant: _ of the information provided in this application and I affirm that the food 105 MR 599,000 and all other applicable law. I have been Instructed bviiof 105 CMR 590.000 and the federal Food Code. Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: _ Sep- 11. 2018 1:07PM No.0258 P. 6 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. � Signature of Individual or Corporate Name By' C rate Officer (Mandatory, if Applicable) 21-- 2j-� -� Wg-� **Social Security No. (Voluntary) or federal Identification Number "This license will not be issued unless this certification clause is signed by the applicant. *'Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A, CAUsm\51ciWr esktop%9cotrs Documents\Food Establishments- Temp\TAx CERTIFICATION FORM.doc SeP.11. 2018 1:07PM - `.......... .......... .Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www,ntass.gov/dia Workers' Cotupensation Insurance Affidavit: General Businesses Business/Organization htk-�) IN91LvU 0 Do Address: �V� W/V KDt3 .�r City/State/Zip: 099��,00, VP Phone #: ��'1 �� `iy o rj No.0258 F. 5 Are you an employer? Check the appropriate box: Business Type (required): 1.9 I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (iticl, real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised 9.. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]" I I NHealth Care 4. ❑ We are a non-profit organization, staffed by volunteers, ❑ with no employees. rNo workers' comp. insurance req.1 12. Other "Any applicant that checks box ul must also fill out the section below Showing their workers' compensation policy infonnatiop. "'If the corporate officers have exempted themselves, but ate corporation has other employees, a workers' compensation policy is required end such an organization should cheek box p I. I ant an employer that is providing workers' Insurance Company Name: Insurer's City/State/Zip: insurance for my employees, .Below is the policy information. 80V 061fltirwS-t- ,99MWOt (1 0`).L)&IL— rajPpWr Self -ins. Lic. 4 108 Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fuze up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby co d r the pains and penalties ofperjary that the information provided/ above is true and correct. q;"Mnra' Date: 411 l Official rise only. Do not write in this area, to be completed by city or town official. City or Town: Perinit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityrrown Clerk 4, Licensing Board 5, Selectmen's Office 6.Other Phone www.mass.govidla SeP, 11. 2018 1 : 0 8 P M No, 0258 P. 8 1 Afz� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOn'YYY) 12l282017 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 pollcypos) must have ADDITIONAL INSURED provisions Or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the polley, certain policies may require on endorsement. A statement on this certificate does not confer rights to the eortlflcate holder in lieu of such endorsement(s). PRODUCER Strategic Risk Solutions (Cayman) Ltd. Caribbean Plaza, end Floor, North Building 878 West Bay Road P.O. Box 1159 Grand Cayman KY-i 102, CAYMAN ISL uCOANTACON PHONE uc Na: p.MNL INSURERIS)AFFORDINGCOVERAGE NAIL% _ INSURER A: Tailored Risk Assurance Co. Ltd. TRACO IN5UREo Steward Norwood Hospital, Inc. 800 Washingpton Street Norwood MA 02062 INSURER B : INSURER C; — - INSURER Dt INSURERE: INSURER F: 39571574 V 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 YHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSfl LYR TYPE CFINSUPANCE A POLICY NUMBER POLICYEFF MMlpp POLICYEXP M pAM1'YY LIMITS A COMMERCIAI-GENERAL LIABILITY . HL3010118 1/112018 1/1/2019 FACHOCCURRENCE $2500000 CLAIMS-MAGE ❑ OCCUR PREMIE crane $ MCC EXP (Any ode enon)$ PERSONAL 6 ADV INJURY T GEN'L AdOREGATE LIMIT APPLIES PER GENERALAGGREGATE $2%000,000 POLICY �LOC PRODUCTS•COMPIOPA00 $ $ OTHER COMBINED INGLELIMIT $ AUTOM091L$LIARILITY(9..cc1d6dfl AWAUTO BODILY INJURY Rer Parton) $ ULED OWNALLALIA BODILY INJURY(Panwiden0 $ AUTO HIREVNED PROPER DAMAGE $ AUTOAUTOSONLY Pera d $ UMBUR EACHOCCURRENCE $ EXCEIM&MACE AOOREGATE $ OEO 1 1 RETENTION$ _ $ WORKER5COMPENSAMON 9TR ER AND EMPLOYERS' LIABILITY YIN $ ANYPROPRIETOR/PARTNEVEXECURVE E L.EACHACCIOENT OFFICE RIMEMSEREXClUOEDi NIA L OE.5EASE•EAEMPLOYEE $ (MandMONI"NN) U OEanngdeecRbCRIPTION g Wldgr OF OPERATIONS bah E.L. DISEASE -POLICY LIMN 3 A Hospital Profegslonal Liabilityw HL3010118 1/112018 111112019 Each Claim $2,500,000 Annual Aggregate Included In GL Agg. DESCRIPTION ar OPERATIONe l LOCATIONS I VEHICLES (ACORO 1d1, Additional RamarKg 9chedulo, may ba aHSchad If mam apace la,aqulradl SHOULD ANY OF THE ABOVE Steward Norwood Hospital, Inc. THE EXPIRATION DATE T 800 Washington Street ACCORDANCE WITH THE Pot Norwood MA 02062 ©19US-2015 AC' ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORO 29a71574 I Oc A Pb I Chrieeine Hprlando 1 12/20/2017 11:15:Aa AR (VET) I Page 1 ee 1 POLICIES BE CANCELLEO BEFORE OTICE WILL OF DELIVERED IN reserved. Sep. 11. 2018 1:07PM No, 0258 P. 7 Form W�9 Request for Taxpayer Give Form to the (Raw AUguat Pots) Identification and Certificatlon requester, Do not Depemaont OFlho T/4asaty .Number Send to the IRS. Inle n I nevanuesanice Nome (as shown at ycur Income mz return) Steward Norwood Hospital, Inc. of Business Wme/dIstagarded entryname, lydlffereht From above m Check appropriate box for lateral tax classification: F-xampflom (sea u.brumloW); m ❑ IhdividdWaole propdolor ❑� CCorporation ❑6Corporation ❑ PSdnemblp ❑Tmegeatete at p 6xemPt peyoa 0004 Of any) o ❑ Um(tod liability company. Enter Ills tax cnasslgosdan 10-C corporation, SS orporadan, P=partmmhg))� Exemption from FATCA reporting %%Ahh coda(I1 any) u ❑ Other (sea lnatmollons)F !& Address (number, coast. and opL or curia no.) Reggselar'a name and address (aptloneq (am, 800 Washington Street rim City, State, and ZIP coda m rn Notwaod, MA 02082 List account number(a) here (optional) T91 aver Identification Number (TIN) rmar your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line I Social cacti ty number Is your the P rt I h rbr mintier( Pag However, fora to event backup withholding. For isre arde enthisity, raBldenr alien, sole proprietor, or disregarded enllty, see the pad I Inshllcgane on page S. For other � y m entities, It Is your employer Identification number (EIN). If you do not have a number, ace How to get a TIN on page 3. Note. If the account Is In more then one name, are the chart on page 4 for guidelines on whose Fin layer fdBntalcetinn number number to enter. F-1 Under penalties of petluty, I certify that: i- The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a number to be Issued to me), and 2. 1 am not subject to backup WRItholding becausa' (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup wlthholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 sin a U.S. citizen or other U.S. person (defined below), and 4. The FATCA codes) entered on this form (If any) Indicating that I am exempt from FATCA reporting in eoymot, Certification melrucildns. You must cross out Item 2 above If you have been notified by the IRS that yo r are currently subject to backup withholding because you have felled to report all Interest and dividends on your tax return. For real estate tranagolionc, Item 2 does not apply. For mortgage Interest paid, adqulattlon or abandonment of secured property, cancellation of deb% cvntYlbuumu to an Individual retfrement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the cadlQeation, but you must provide your correct TIN. See the Immopngha on page 3. cpsit Here I UlSnptereanfhUW R%0—V'—` UNI Data). J/81 L., General Instructions Section references are to the Internal Revenue Coda unless othetwhe noted. Future developments. The IRe has created a page on Mery for Information about Farm W-9, at wws,da.povAYB. Information about any luWre dowlopmanla ejecting roan W-a (Such gwation mooted after we release Iq Will be posted on that paoe. Purpose of Form A person who to required to Ole an information Arum with the IRS must obtain your correct taxpayer Idehilfloelloh number (11N)to repot, for example, Income paid to You, poymante made to you In Settlement of payment card and third party network herharch as, Teal estate dane49110m, mortgage Idtoreetyou paid, eogUlsldOR W abandonment of secured property, eAmollaeon of debt, or contributions you made to an IRA. Use Form W-9 only If you as a U.S. person Qncludlog a resident Stan). to pmvlde your correct TIN to the person requesting It Oho requester) and, when applicable, to; 1. Captfy that the TIN you are giving Is cormot (or you Are Walling for A number tnbelssuad), 2. Caney that you are not subject to backup w44hholding, or 3. Claim exemption from backup wlthholding It you am a U,e, sxampt payee. If applicable, you are also mANyirgInd as a U.S. person, your grumble share of any partnership Income from a U.S. trade or business Is not Subject to the withholding lax an foreign partners' sham of effectively connected Income, and 4. Caddy that FAToacode(s) entered on this form Of any) Indicating that you ere exempt from the PAT CA reporting, Is correct. Note. If you am a U.S. person end a requester gives you a form other than Form W9 r0 request your TIN. you muat ass the requester's farm If It Is Suhiumil ily elmllar to this Form W-9. Aagnition of a U.S. porson. For federal lax purposes, you are considered a U.S. Person ](you are: • As Individual who Is a U.S. cri an or U.S. resident allon, • A partrunablp, corporation, company, or association created or Organized In the untied Slates or under ale laws of the United states, • An estate (other than a foreign estate), of • A domestic trust (ea defined in Ragulallona Bechar, 301.7701-7), Special miss for partnerships. Partnerships [hat conduct a trade or business In and Unliad States ale generally required 10 pay a withholding tax under SWIM 1445 on any foreign partners' share of effectively conneoted taxable Income from Short business. Further, In pertain Woes whine a Form W-9 has not boon recoNad, the rotes under section 1446 require a partnership to presume that a partner Is A foreign person, and pay the section 1446 wlthholding tax. Therefore, If you are a U.S. parson that Is a partner in a pertnarahlp conducting a trade or business In His United Slates, pmvlde Form W-9 to the parr graisp to establish your U.S. Statue and avoid aooicr 1440 withholding on your Share of psrtnarahlp Income, Col. No. 1023lx Fomr Sep. ll. 2018 1:10PM No.0258 P. 12 TOWN OF NORWOOD BOARD OF HEALTH Commonwealth of Massachusetts PERMIT TO OPERATE A FOOD ESTABLISHMENT NUMBER: FEE.: 24032 $250.00 DATE: January 1, 2018, 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: STEWARD HEALTHCARE, LLC DBA: NORWOOD HOSPITAL WHOSE PLACE OF BUSINESS IS: 800 WASHINGTON STREET NORWOOD, MA. 02062 PRIMARY BUSINESS SECONDARY BUSINESS SEATING CAPACITY; - SQUARE FEET FOOD SERVICE MILK, SALAD BAR 200 3897 SQ FT TO OPERATE A FOOD ESTABLISHMENT IN NORWOOD PERMIT EXPIRES:,DECEMBER 31, 2018. NORWOOD BOARD OF HEALTH. SIGALLE REISS Follow us on Twitter ®NorwoodHD h[tp:healthmomoodma:gov 566WASHINGTONSTREET—P.O.BOX 40--NOAWOOD,NA 02062 TEL. N0. (781) 762.1240 —FAX NO. (781) 278,3000 Sep. 11. 2018 1:08PM No.0258 P. 9 Sep, ll, 2018 1:09PM No.0258 P. 11 Mansfield Board of Health Request for Fee Waiver for Food Permit Date 1/'/ /b We, CP'r'— _ (restaurant/ 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, n ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. " Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. 9 Other: The Taste of the Tri-Town Thank you, 4� Si ture Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: