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HomeMy WebLinkAboutHIlls Home Market 10/02/2018I Commonwealth 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:. SUZANNE WASSERMAN Whose place of business is: HILLS HOME MARKET - 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JEFF HOLMES Permit Expires: October 02, 2018 Food Fee: License Number: T-2 WAIVED BOARD OF HEALTH Michae(McCCean, Chairman Temporary Food Establishment Permit Appic,Uo'iIl 20i8 (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: 2) EstablishmentAddress: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: y _ - 0 / 5) Applicant/Owner Name & Title: -yl- zc�/ U Z n rr t✓ S 5 �? PY�'� '? � .S.S / ✓ � . 6) Applicant/Owner Address: 1.3 1'lNd c%' 7) Applicant/Owner Telephone No: u �] 8) Applicant/Owner Email address:Be G � j 6./ ) U rn 2 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: 3 ©%% Telephone No: q _ Fax: 2 _ A� /G� Emergency Telephone No: ''7 e 10) Event Attending Date(s):�� J Event Name: O � I rJ ZC/ ✓7 Event Location: Ce YI 1� Event time: 11) Check one 12) Solid wasted disposal plan: Food Truck Caterer J/ Other: 13) Water Source: II j� `�r� 14) Sewage disposal plan: `/ /t II 15) Please give a brief description of the food to be served: Cj I ,l k q ry\ p -j I( Q rn '5f k-, q '�5 FA Food Protection Questionnaire for Catered Events Date of Event: // ��? Location of Event: I List all foods that you will be chilling, On ice/Refrigerated Event Time: 4 & cooking, and/or re heating at the event location: Cooking Reheating y�r��oin5 (�vl<5�r"tp�e5 Food Manager Certification Person Trained On Site? "❑ No Allergen Awareness Menu Label Present? t ---�es ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: 0S dl -t" :51egX List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41°F? How will the PHF be kept at or above 140°F? Time of PHF? Setup Served wJ<i�f iuZC'_i1 / /y t=e�C✓(Ei ZC�IrC �' 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. ��U✓%�� 4 � J) c� v. + 1 'Z L' ` �l15il5 --- --- 16) Food will be prepared: — - - - A- Onsite for immediate consumption Onsite and held at proper hot/ cold holding temperatures Offsite and held at proper hot/ cold holding temperatures Offsite, cooled and reheated on site Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager: `-,\ e Allergen Awareness: _ P I'm C' - 5 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: 1, the undersigned, attest to the accuracy of the information pro ided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and II other applicable law. I have been instructed by the board of health on how to obta" "es of 105 CMR 590.00 and the federal Food Code. 19) Signature of Applic nt: 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 tax returns and paid state taxes required under law. 20) Social Security Number or Federal ID: j�d -- 21) Signature of Individual or Corporate Na e: Pleaseicopies of ServeSafe • Allergen training certificates 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. Signatu e of Individual or Corporate Name "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, irApplicable) *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 U1SerSWeneADesktopASc0trs DoeumenlsTood Establishments-TempCRAX CERTIFICATION FORNI.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 CongressShwe4 Suite100 a a Boston, MA 02114-2017 www,mass.gov/dia Workers' Compensation Insurance Affidavit General Businesses. TO BE RILED WITH THE PERaAITITA'G AUTHORITY. B ❑s in es s/Organizalion Are you an employer? Check the appropriate box: I� I am a employer with y_r� employees (full and/ or part-dme). ° 3: ❑ 1 am a sole pmprietor crpartners lip and have no employees workingfor me in any capacity, [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption per n, 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. INo workers' comp, insurance req.] Phone#: y % q - 56 / — / 21e a Business Type (required): 5. El Retail 6. ❑Restaurant/Bar(Sating Establishment 7, ❑ Office and/or Sales (ind. real estate, auto, etc.) 6. ❑ Non-profit 9. ❑ Entertainment I O. ❑ Manufacturing 1 1,E] Health Care 12.91 Other +Any applicant that checks box #1 most also fill out the smtion blow showing their workers' compensation policy information, ^+Iftbe coepomle ofbous Gave cxcmplJWemsdVcs,b�t lbe mryontiou has otheremployers,awohecs'eoospcusation polieyureq�ired cod meh a¢ mganlzatiou should ohcc4. box #I. f am an employer that is prorlding workers' compensation insurance for my employees. Below is the policy informaYiOA. tnsanmce Company N'amc:._ insurer's Address: City/statdZip: Policy # or Self -ins, Lic. #- Expiration Dare: Attseb a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), Failure to scewe covcmge as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fino up to $1,500.00 and/or oD -year imprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against' a violator. Be advised that a copy of Ems statement maybe forwarded to the Office of investigations of �h'e DIA for in uranec coverage verification. f do hereby cc rxi ', finder !%a Qins and p` alW s of per%a rho. t �infornrarion provided abope a tr and correct Si+ -nature• �f,\/ .....e" �� CAl _mate: / J ,j Phone#• ! �� - �V C1 l o—ffl / rise only. Do not write In this area to be completed by city or town official City or Town: Permit'License Issuing Au(harity (circle one): I. Board of Health 2. Building Department 3, City/Town Clark 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone HOMEFOO.01 ,__-,m_CA(Mq(-A A C ORC] CATE :N uaomvn CERTIFICATE OF LIABILITY INSURANCE 03/21/2018 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 BYTHEPOLICIES 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 She 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 an this cortificate does not "center nyhls to the Certificate holder in feu of such endorsr menit(Sl PRODUCER karknr Caitlin O'Brien ;The Corcoran &Havlin Insurance Group 781 235-3100 250 eax iAC 1•o Ea(.1 )._ 287 WellesLindeley, Street ¢NA a CObrienr@iahinsurance.com ` Wellesley, MA 02482 dSGN€-S ..... - - I Ik9 r !'<'., ArfpNG,eHi GOVERAGF _ RA!i_ a IN.SUUE9 H.F.S. of Amercia, Inc. don Hills Home Market 412 River Road Hudson, MA 01749 .-rv-gl vkf" A Amgncan Fire -and Casualty Company, _ _.24066 INs4aARq t7hlo.CasualtyInsurance.Company ,24074 oiSLREA WeDc0 Insurances Company ,,. 25011 :NvvgeNa _ tNauRFR F kSURER' COVERAGES DERTIFIC ATE, NUMBER: -...— _. _. REVISION NUMBER______. CS xT Tt<t. I IL F „ 1 C,, .•1 10$'JraA' .,l ST<'l Bl TON- -I dE BF FN t'...,idO ir. !TNSUVI- 1 NAVED ABOVE FOR THE'-EXICY e'EROC'• Al -:'.0 :.'M Op AIa J;'W'RP! r JR 01HEFi �fOCU M t>NI K'i H RESPECT TO WH I CH I INS (,YH il4 41F it .LH' QF tn' P Ark Tru 3IItiRNC-AFC 1'�-0 6v 1214Oc1;ICy DESORI4� HEREIN IS;iJOJECT IOA'L THE'=U2M$. 6x .w'CH IS AivI ,J�.1.1h i(,F ,..mow ptil _V '`,, oHOLNH MAY)AJE Ei& N xkH11C 1,0-+v PA CLAIM5 .\� .,,, AO9 wus o v«� x vexn-( -.-. -In _,.._LJY np RANCF »O'CY NI/M9ER L!M+TS __ ... 0.�_— '. D •rfTt_.5t.2lV.i .LCL:.._ ,..-_.... ...__,.,. _ A X COMMERC A urN00AL OA8I 0rY b '.c �X SKA58067591 0611412018 0611412019 `��� ; ' c _�.j.. 500,0001, 5.000, 1,000,600 R. . .., ., _l.,L fi... •,A L zaoD.o6o x 2.000 eon' SAA58067591 t , DTI X ,1 L000,Doo. OV1412018OWIVI'2019 ,.DCNJ!tvi av;aorr ny."3 a: f B X ' X000+ UMgHE�LA UAa ExcessuA9 ::. .,a. US058067591 06/14/2019 OW14/2019 A T" 2.000000 I I X aF k ok. 10,000 C w(YAa%ENScoMACNSA oN I X 1 4 {• )a hNG eMY j ENS IAaI T WWG0050459 :. 06114/2018:06/1412019 .. _ SKOOG U'in Airllil it li .r1Ei `4 (.VEKRFNI «. ll_.P *CIA INa fa ory a+7lH) __� r,l St i�G �. F � r . ti _ {_ CA F`rW_D''_fyF1.i '_ 566.6661 It 11, l ,xorv,y —__ 5b0.0001 n 1 r•a.?� 1vk � :.i.'-'.,.i ., _-____.. _"__-__ _.._ _._.__._ _-.. �._ 71vFa ^ ' t 1. �_,#. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Addlttonai Remarks Schedule, may He auched It more space Is mgwied) MEAT, FISH, POULTRY l SEAFOOD STORES OERTIFICATF FIOLOER CA•NCELlAT10N_..-____.. 1 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE ACORD 25 2016103 0 1988 2015 ACORO CORPORATION. All rights reserved. The ACORO name and logo are registered marks of ACORD Hudson Board of Health 78 Main Street Hudson, NIA 01749 Phone: (9'78) 562-2020 Fax: (978) 562-8508 Retail Food Establishment (5k-10k) Permit Fee: $100.00 Permit Number: 71-2018 PERMIT TO OPERATE A RETAIL FOOD ESTABLISHMENT 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: HFS of America Inc, 413 River Road Establishment Type: Retail Food Establishment (5k-1Qk) Number of Seats: 0 Certified Food Protection Manager(s) Name Certification Expiration Jeff Holmes Restrictions: Issuing Date: December 04, 2017 Expiration Date: December 31, 2018 Town of Hudson Board of Health NON -TRANSFERABLE =x; uj cc 9 L 'L + • e r lz _ L y/ 1' 1-4 - d t _ 1 s E f Mansfield Board of Health Request for C7 Fee Waiver for Food Permit Date 6/ �/% 8 We, f�� �� rat-, . /'0v / (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. * We are donating ALL proceeds earned directly to a 501(c)(3) organization. Please list the organization: We are not charging a fee food/drink We are a religious organization. Other: The Taste of the Tri-Town Thank you, Signature Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: