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Home My WebLink AboutHealthcare Service Group 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 SERVICE 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:. JENNIFER GALLAGHER Whose place of business is: HEALTHCARE SERVICE GROUP - 11TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER PERSON(S) IN CHARGE: JENNIFER GALLAGHER, FOOD SERVICE DIRECT. Permit Expires: October 02, 2018 Food Fee: License Number: T-10 WAIVED I: PL' 1 N oxel0: 1 O9 y 1:1 -%lichae(McC(ean, Chairman Will We Prepareu: Onsite for immediate consumption Onsite and held at I cold din temperatures site and held at proper hoU cold i holding temperatures Offsite, coole an reheated on site Other: ,7)) If QHF is being served, please list the person who has completed the following trainings and attach appropriate Ci ificales: ) Food Safety Manager: Allergen Awareness: 18) For caterers: Citylrown 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: - .. tific:al 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 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain,capies of 105 CMR 590.Og0 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 tax returns and paid state taxes required under law. 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: include* Please copies • ServeSafe and Allergen training certificates } n i 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) � 7-s3 y5-6&=:� ""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. CA(J t vRcVksktop\Scan's DocumentstFood Establishments-TcmptTAX CERTIFICATION FORM.doc Name Tire Connmmmvealth of Massachusetts Department of IndrtstrialAccidents I Congress Street, Strite 100 Boston, MA 02114-2017 rvtvtv.mass.govAlia nrorkersCompensation Insurance Affidavit: Builders/Cont[-actors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. City/State/Zip: 6&7 p ! A OR -Pone #: 9��0 C Cs L -I a /) i Are you an employer? Check the appropriate box: Type of project (required): r employer with employees (full mrd/or pnrl-lime).* 7. ❑ New construction ❑ 1 oat a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. ]No workers' comp. insurance required.] 3.❑ I nm o homeowner doing all work myself. [No workers' comp. insurance required,] t 9. ❑ Demolition 4.❑ i ran o homeowner and will be hiring contractors to conduct all work on my properly. twill 10 ❑ Building addition ensure that all contractors either have workers' compensation insurance or are sole 11.[:] Electrical repair's or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5.❑ I nm a general contractor and I have hired the sub -contractors listed on the attached sheet. (3.�Roof reP air's TTtese sub-conhnclocs have employees and have workers' comp, insurance.[ 6.❑ We are a corporation and its officers have exercised their right ofexentplion per MGL C. 14. ❑ Other 152, §i(4), and we have no employees,[No workers' cmnp. insurance required.] "Any applicant that checks box NI must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 2Cpmractors that check this box must attached an additional sheel showing the name of the sub -contractors and state whether or not those entities have P I employees, If the sub-contraclors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation ims trance for fay employees. Below is the policy and job site information. Insurance Company Name: The Insurance Company of the State of Pennsylvania Policy # or Self -ins. Lie. #: WC 066-83-0224 Expiration Date: 01/01/2017 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine 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,ngainst the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Jr find Official use i s i. Do not write in this area, to be completed by cio, or tmvn afl7cial. City or Town: Permit/License Is true and correct. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other Phone IE m .P 3 N 0 1 W 5 °n i R 9 U L 00 m q O N N � O v o 0.� , �z � U l � � �° soot o� O •3 h W ti cC CL N ti Q 4a v� 0 O� W a � H (:D Z H H E Mansfield Board of Health Request for Fee Waiver for Food Permit Ict,:ate �`� i We, rant/ 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. IluOther: The Taste of the Tri -Town Thank you, -v ,(Aja Si tare Title *Please provide proof of valid 501(c)(3) status $fDH Use Only Approved Denied Reason: Signature: Date: 11 th Annual Tri -Town ,'Chamber "Food Tasting "Congratulations, because of your past support and with the help of our partners, we have been able to donate $52,682 to the food pantries of- Foxborough, Mansfield and Norton" es, Sign Us Up! ■0 TrImTown i ne I ri-Town Chamber Food Tasting Event Date: Tuesday, October 2, 2018 Time: 5:00pm — 7:00pm Location: the Vinity Center 885 South Main St., Mansfield Note: There is no fee for a Restaurant to Participate. The Chamber Supplies; 8'Banquet Table, Table Cloth, Table Top Restaurant Sign and will hand out Larjze Plates, Napkins & Utensils.for Attendees at the door IMPORTANT NOTES If you are located outside of Mansfield you must obtain a food permit (the fee has been waived, but you still need the permit) see 2nd attachment. PROP NE: If You will be using Propane you will need a permit in advance from Mansfield Fire Department 508-33 UNO 2 - Do You Need Electric? YES lei / qd / UL4 j,4 V �/rar Au U b , Ivre)7Ai» , 14,4 0 --,a207-- ld,5 / Mit--,1WIrL, 0 IUl)woh,>S tr-.C,6m - Would you like to contribute to the Raffle Table?� YES qr NO Please list Description .j Please Respond to the Chamber to Reserve Your Space - Thank You p: 508-339-5655 f: 508-339-8333 e: office@tri-townchamber.org Tri -Town C�Qfnf?il'h 9 �&ninPhGE xnvw.tri-towuchambcr.org Foxborough• nlausfield.Nortou r Silver Sponsor: Silver Sponsor: Friend of: ��t,ANSF/pyo Fen_ Town of Mansfield, Massachusetts 'Fq�TABA0�41p�'l` Six Park Row, Mansfield, MA ozo+s Oty �N August 7, 2018 Taste of the Tri -Town Participants: Massachusetts state law requires food establishments obtain a permit from the local board of health. A food establishment is defined as: "... an operation that stores, prepares, packages, serves, vends or otherwise provides food for human consumption. A food establishment includes an operation that is conducted in a ...temporary or permanent facility or location; where consumption is on or off the premises; regardless of whether there is a charge for the food." (Food means a raw, cooked, or processed edible substance, ice, beverage used in whole or in part for human consumption.] If you do not already hold a food establishment permit in the Town of Mansfield, you will need to complete ALL of the following documents: 1. Temporary Food Establishment Permit Application (include copies of Serve Safe and Allergen Training Certificates) 2. The Tax Certification Form 3. The Worker's Compensation Insurance Affidavit: General Business is required. (Read the third paragraph on the "Information and Instructions" sheet.) It must be filled out by the organization that is actually vending the product. 4. Fee waiver form Any filing for that does not meet these requirements will be returned and no permit will be issued. Amy Donovan -Palmer Health Agent FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued A� V0 CERTIFICATE OF LIABILITY INSURANCE TEMMDM DAl/z/201 YY) 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 pollcy(les) must he 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 endorsement a . PRODUCER CONT C Dan 9antoleri A E: SCBM, LP PHONE (610)6687100 FAX (610)667-2200 a ,L__ 300 Conshohocken State Rd 'MAIL clsantOleri0acbm.com ADDRESS: Shite 405 INSURERLS)_AFFORDINGCOVERAGE NAIC0 INSURER A:National Union Sire 19445 West Conshohocken PA 19428 INSURED INSURER B:New HaM shire ins, 23841 INSURER C; Healthcare Services Group, Inc. INSURER D: 3220 Tillman Drive INSURER E: Suite 300 INSURER F: Bensalem PA 19020 COVERAGES CERTIFICATE NUMBER:18 M (STANDARD AOS) REVISION NUMBER: 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. ILSR TYPE OF INSURANCE I D1 VIVO R POLICY NUMBER PODDNW MWODPOLICEXP LIMITS A X COMMERCIALOENERAL LIABILITY � CLAIMS -MADE l n l OCCUR $500,000 OL 4611473 1/1/2018 1/1/2019 EACH OCCURRENCE E 1,000,000 GETO Er ED 10,000 REMISES f coma a oe $ _ME_DEXP(Any one arson) $ 100,000 PERSONAL S ADV INJURY $ 500,000 _m, GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY jPOT LOC __. OTHE: GENERAL AGGREGATE $ 10,000,000 PRODUCTS COMP/OP AGO S 1,500,000 —_S_ —_ A AUTOMOBILE X X LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS NON OTOS WNED HIREDAUTOS X AUTOS M.7093429 1/1/2018 1/1/2019 01) $ 1,000,000 Eae ED E an BODILY INJURY (Per person) $ BODILY INJURY (Per eocldent) $ PROPERTY DAMAGE Pereceldenl $ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMSMADE EACH OCCURRENCE b AGGREGATE b DED I I RETENTIO S H WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR,PARTNER/EXECUTIVE- OFFICERIMEMBER EXCLUDED? a (Mandatory In NH) If yVes describe under DESCRIPTION OF OPERATIONS below NIA I WC 014122418 1/1/2018 1/1/2019 PER X STAT E —FUER _ E.L. EACH ACCIDENT E _. 1,,000, 000 E. L. DISEASE - EA EMPLOYE $ 1,000,000 - "---'-' EL DISEASE -POLICY LIMIT E 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remark.Schedule, may be attached if more apace Is required) Not Applicable CERTIFICATE HOLDER CANCELLATION NORT041 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WINGATE RESIDENCES AT NORTON ACCORDANCE WITH THE POLICY PROVISIONS. 190 Mansfield Ave Norton, MA 02766-1349 AUTHORIZED REPRESENTATIVE J Shefsky, CPCU, ARM/ ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) 'v-�� Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: iMz11h 2) Establishment Address 3) Establishment Mailing Addre (if different): rl' /qt&ojJ Law u 4) Establishment Telephone No: 6) Appli,c,ant/Owner Name & Title e G ' e ood 6) Applicant/OwnerAddress: � ld� 7) Applicant/Owner Telephone No: 1 , T W 8)Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: 0 7 G/i /V Telephone No: Tele R / / �J� � �fC/ � / � G�d_� Fax: O (G� EmeNgncy Telephone No: 61 7 i /75! - 9�%6 ^' 10) Event Attending Date(s): Event Name: Event Location: li Ui^ Event time: ` 11pCheck one 12) Solid waste disposal plan: Food Truck Caterer Other: 13) Water Source: 14) Sewage disposal plan: a 15) Please ive a brief description of the food to be served: Food Protection Questionnaire for Catered Events Date of Event: /0 2 Location of Event: List all foods that you will be �O^en�ice/Refrigerated ��l�ecl /qql•�`t-i7i"Y��oG Event Time: `420 �ca1�2 holding, cooking, and/or re heating at the event location: Cooking Reheating Food Manager Certification Person Trained On Site? R/YeS ❑ No Allergen Awareness Menu Label Present? li(Yes ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: A cid Ow Likt the required temperature for each food as it leaves your preparation site: qk , How will the PHF be kept at or below nr (� 41°F? How will the PHF be kept at or above —' . Removed 140°F? i Trine of PHF? Setup 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. 4GAG/-C'� V S0 /c!e 1 r��C' Cev1