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HomeMy WebLinkAboutPlainridge Park Casino 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:. EDWARD CLOONAN III, EXECUTIVE CHEF Whose place of business is: PLAINRIDGE PARK CASINO - 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: EDWARD CLOONAN III, EXECUTIVE CHEF Permit Expires: October 02, 2018 Food Fee: License Number: T-13 WAIVED :1011-A0 RX91 a:I *109:' michaet-McChean, Chairman Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the plan jt,00 qp?M,7q afe) 1) Establishment Name: 1 ?VA Ptrtiviri 2) Establishment Address: 1 n 3) Establishment Mailing Address (if different): 4) Establishment Telephone No; Z wo 6) Applicant/Owner Name & Title:/ � OLP wW'J )rcu -(vC 6) Applicant/Owner Address: G (Ju cu 4t I M 7) Applicant/Owner Telephone No: a 8) Applicant/Owner Email address: C 8) Person Directly Responsible For Onsite Operations: Name & Title: 2 r Address: ( U Owc' vL movt Telephone No; i-d - �qe-- 1503 -VMmv0'X,Mk Fax: Emergency Telephone No:t�— ^�%� :a"¢,Fe% 10) Event Attending Dale(s): ja r o Event Name:�osle n U rW Event Location: Jo✓ cVVt Event time: 5 bG M •- �--'p 11) Chock one 12) Solid waste disposal plan: Food Truck Caterer Other: ���. I (,JG.iGLi S1Wi'i 13) Water Source: 14) Sewage disposal plan: n 15 )Please give a (brrie descripti n of the food to be sery d^�,` r . ,, 'J ( Frt.31, �1111c �P� "YSR�'s irl�(.,m GAt tecktwIs(Wat;..) I1't+l��✓1iM 2'ir% Food Protection Questionnaire for Catered Events Date of Event: l t �Envent Time: Location of Event: 0 1) d J t' tAAVh 1 AA( i l, List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice efrigerated \ t�s��rS ll�uw }�G3J Cooking Reheating Food Manager Certification Person Trained On Site? Cif Yes ❑ No Allergen Awareness Menu Label Present? F Yes n No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: 0 S1•tri yo" LP NbAsQ List the required temperature for each food as it leaves your preparation site: 0 e0 M("AsAMghl 1WOw How will the PHF be kept at or below 04 (J ev,,^ } 41OF? How'will the PHF be kept at or above 140°F? 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. &W 1 a T4to 110 i�,ho'• l� (Jvel v 1 16) Food will be prepared: nsite for immediate consumption to and held at proper hull cold holding hu w temperatures s a e a proper hot/ cold holding temperatures OHsite, cooled and reheated on site Other: 17) If PHF is tieing served, please list the person who has completed the following tralnings and attach appropriate certificates: Food Safely Manager: (- WLJJ (60,IUA r Allergen Awareness: �s/(w.7W ) uUp n� 18) For caterers: City/Town 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 accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 106 CMR 690.O0O and all other applicable law. I have been Instructed by the board of health on how to obtain cqpfeo,ef 10.5 9MR)690,000 and the federal Food Code. 19) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state is rBturas an old state t as required under law. 20) Social Security Number or Federal ID; � i 21) Signature of Individual or Corporate Name: can fie Please include copies Serveb"*. ., and Allergen trainingcertificates 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; Corporate Officer (Mandatory, if Applicable) *"Social Security No. (Voluntary) or Federal IdenWcation 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. C:\UserslsleiteWesktop\Scotl's Documents\I'ood Establishmonts- TempWAX CERTIFICATION FORM.doe Department of Inhistrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wivw.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization { Addreaa- ` 00 i� /Ate you an employer? Cheek the appropriate box: I am a employer with employees (full and/ �� orpart-time).* 2. I 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.] must Phone #: / '- kgt/ - `3a` Business Type (required): 5. Retail 6. Rostarvant/Bar/Eating Establishment 7. Office and/or Sales (inci, real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing It. Health Care bat the corporation has other employees, a workers' compensation policy is required and such an arltati employer flint is provitling workers' coatpensation itistirence for »ry employees. Beiow is the policy lrrforitmtioa, nsurance Company Name: ttMU J%A t� t, nsurer'sAddress: 17� l� & lett A :ity/State/Zip: 60c, 'olicy g or Expiration Date: lttach a copy of the workers' compensation policy declaration page (shoving the policy number and expiration date). ?allure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ire 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 if 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, tle hereby cerilfy, tender the pabis mrdpenaldes ofperjory that the brforamtlon provided above Is true and correct. linnature: Dite• hone'N: Do not write in this area, to be conildeted by elty or town Town: Permit/License going Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Other Phone irvtv.mnss,gov/dia ACC )RIJ CERTIFICATE OF LIABILITY INSURANCE D09/27/2018DmYY) 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(ies) 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 endomement(s). PRODUCER Marsh USA Inc. 1717 Arch Street CONTACT NAME: PHONE FAX AI.N^1L. Philadelphia, PA 19103-2797 Alin: PHILADELPHIA.CERTS@MARSHAOM/212-948 0360 FAX EMAIL AooRESS: INSURERSAFFORDINGCOVERAGE -- NAIC# e1SURERA: Zurich American Insurance Company 16535 CN102736633-PENN GAW-18-18 INSURED Plalondge Park Casino INSURER B: American ZUfICh Insurance Company 40142 301 Washington Sl INSURER C: INSURER O: Plainville, MA 02762 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: CLE-006329302-01 REVISION NUMBER: 1 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. INSR LTR TYpE OF INSURANCE AOa aD w.k POLICY NUMBER POLICY EFF MMIDOII'YYY POLICYEXP MMIDDIYYVY - LIMITS A X "--' COMMERCIAL GENERAL LIABILITY l-�-� CLAIMS -MADE OCCUR GLO115539700 10/01/2018 0410112020 EACH OCCURRENCE $ 1,0W000 DAMAGETO RENTED PREMISES Eaoccunence ------ $ 1,000,ODD X GEN'L X MED EXP(Any one person) $ $500,000 SIR PERSONAL BADV INJURY $ 1,000,000 _ AGGREGATE LIMIT APPLIES PER: RO- POLICY ❑ PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000.000 _ $ A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLYNAUTOS X HIRED NON -OWNED AUTOS ONLYAUTOS ONLY BAP115539900 1010112018 04/010020 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY(Peraccldmd) $ PROPERTY DAMAGE Permcident $ UMBRELLA LIAB EXCESS LIAB OCCUR CIAIMS-MADE EACH OCCURRENCE _$ AGGREGATE $ _ DED RETENTION$ $ B A WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY Y IN ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, desctlba under DESCRIPTION OF OPERATIONS below NIA WC115539800(AUS) EWS1155400-00 (OH XS WC Policy) 'XS WC SIR: $500,OW 1010112018 010112019 10101I2019, X PERTUTE ETH- STA ER __ E.L. EACH ACCIDENT $ 1,000,000 EL DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe allached if more space is required) Re, The Taste of Tn-Town on October 2, 2018. CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Health Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Mansard Mukherjee ._Jvto, o��}d....tc.a.ina-e-c. @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD .,rvSafe ITIFICATION EDWARD CLOONAN III for wccossfelly compleling the standards set forth for the SeNSafe® Food Protection Manager Galificalion Examination, which is accredited by the American National Standards Institute (ANS)-Conference for Fcod Ndedion ICFP). 10440 R EXAM FORM NUMBER 8/2/2020 DATE OF E DATE OF EXPIRATION local la«s apply. th eacy for recMils.fl. requirements. 4.-. 9u.-,.IIS Wk nW. N.IM, Gk: , 160604 aSvba(ReewvmNae CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: EOwAR0ct0ONANIII Certificate Number: 2667210 Date of Completion: 11e17n6:6 Date of Expiration: I M712021 Die above-aiunedperson is hereby irsaed this rerti rcnte, far rompleeing an allergen awareness training program recognized by the Massaehruens Depamnent of PablscHealih in acrordnaro with 105 CMR 590.009(C)(3)(a). Ibis centRate will be valid fbr five (5) years fron7 date ofcompletion. ❑ ❑ M Mood By: mea) C NATIONAL L\e [ RESTAURANT ASSOCIATION® Mavaehusetta Rostan Att AsseAation 800.765.2122 333 Turnpike Road, Suite 102 Suuth6osough, MA 01772 sysyse.rcstaurantcug 508-303-9905 wuae..tNumnnssoamg Mansfield Board of Health Request for Fee Waiver for Food Permit Date / ►►M- 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 are not charging a fee for food/drink being served. We are a religious organization. Other: The Taste of the Tri-Town Thank you, Signature n C�XZ cc#'tt l V Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: Jane Doucette From: Cloonan, Edward <Edward.Cloonan@pngaming.com> Sent: Thursday, September 20, 2018 4:33 PM To: Jane Doucette Subject: Taste of Tri Town Attachments: Taste of Tri Town.pdf Hello Jane, Attached is the taste of tri town packet for a permit to attend the event. Let me know if there is anything else you may need. Thank you very much and have a great day. Chef Ed Edward Cloonan III Executive Chef 301 Washington Street Plainville, Massachusetts 02762 Office: 508-576-4441 Cell: 508-298-5053 Edward.Cloonan@pn_gqmigg.com Ty PLAINRIDGE PARK CASINO 1 Jane Doucette From: Cloonan, Edward <Edward.Cloonan@pngaming.com> Sent: Thursday, September 27, 2018 12:37 PM To: Jane Doucette Subject: FW: Certificate of Insurance Below is the Federal EIN number. Let me know if you need anything else. Thanks Edward Cloonan III Executive Chef 301 Washington Street Plainville, Massachusetts 02762 Office:508-576-4441 Cell: 508-298-5053 Edward.CloonanC@DnRaming.com i 111w P, PLAINRIDGE PARK CASINO From: Silva, Amy Sent: Thursday, September 27, 2018 12:36 PM To: Cloonan, Edward <Edward.Cloonan(c@pngaming.com> Subject: Re: Certificate of Insurance Federal E1N 37-1714120 Sent from my iPhone On Sep 27, 2018, at 12:29 PM, Cloonan, Edward <Edward.Cloonan@pngaming.com> wrote: Edward Cloonan III Executive Chef 301 Washington Street Plainville, Massachusetts 02762 Office: 508-576-4441 Cell: 508-298-5053 Edward.Cloonan(@oneamina.com <image001.png><image002.png><image003.png><image004.png> <image005.png> 1 From: Jane Doucette <Jdoucette@mansfieldma.com> Sent: Thursday, September 27, 2018 12:17 PM To: Cloonan, Edward <Edward.Cloonan@pngaming.com> Subject: RE: Certificate of Insurance Do you have a Federal Identification number? -----Original Message ----- From: Cloonan, Edward[mailto:Edward.Cloonan@pngaming.comj Sent: Thursday, September 27, 2018 12:07 PM To: Jane Doucette Subject: FW: Certificate of Insurance Hello, Attached is the updated Certificate of insurance for Plainridge Park Casino. Sorry for the delay, we just received from corporate offices. Thanks, Chef Ed Edward Cloonan III Executive Chef 301 Washington Street Plainville, Massachusetts 02762 Office: 508-576-4441 Cell: 508-298-5053 Edward.Cloonan@pngaming.com -----Original Message ----- From: Silva, Amy Sent: Thursday, September 27, 2018 10:04 AM To: Cloonan, Edward <Edward.Cloonan@pngaming.com> Subject: Certificate of Insurance The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. 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