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HomeMy WebLinkAboutBar Louie Foxboro 10/02//2018tic 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:. BL RESTAURANT OPERATIONS, LLC Whose place of business is: BAR LOUIE FOXBORO - 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: WILLIAM COCHRAN Permit Expires: October 02, 2018 Food Fee: License Number: T-9 WAIVED BOARD OF HEALTH Nichaet-.9 cCtean, Chairman Temporary Food Establishment Permit Application ,. (Application must be submitted at least 7 business days before the planned opening date) f- 1) Establishment Name D(�c' LbU't: 2) Establishment Address: 2,Y2 PAi'v-in�' I�4Lz 1-Oiz�orG 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: Jr-©-V j,' > I ( `IS 5) ApplicantlOwner Name & Title; . 6) Applicant/QwnerAddress: hd (19 7)7) Applicant/Owner Telephone No: DO 8) ApplicantlOwner Email address: �rp , �YY� 0. / (QLFdk�tirdQ�'2,� N 9) Person Directly Responsible For Onsite Operations: Name & Title: kNh � VI 0 Address: i..,._7 (1 tJ7 Y ' " o y. ("? W lJ J Telephone No: (1 (� n I)) (� !� Fax: Emergency Telephone No: ' J)'I --LIl�-1Y—U""I�q�. 10) Event Attending Date(s): Event Name: — Event Location: V ej C' ' 1 � _ Event time:--- 11) Check one 12) Solid waste disposal Tr Cattereruck �p/lan:Food C, It 1 } Other. 13) Water Source: 14) Sewage disposal plan; C 1Vt 15 ) Please give a brief description of the food to be served: 0 Food Protection Questionnaire for Catered Events Date of Event: 6-t Z 2 01 Event Time: LocationofEvent: Kf" +C"h" List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: III -On ice/Refrigerated Reheating Food Manager Certification Person Trained On Site? U4es ❑ No Allergen Awareness Menu Label Present? W es ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: Gh<ac� M- J, 4,�I ke.IJ a ILIO (i' °/© pa�uw Goole List the required temperature for each food as it leaves your preparation site: cl�,.�k r 1615, + ow will the PHF be kept at or below /4+ 0=- V", ; u (4 t)O� &A 1 s fa C r1OF? �Hof"11 otx-" d (U Removedow will the PHF be kept at or above 40°F? ime of PHF? Setup -4-As rk 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. ale tU,� Si Ula I I I �v�y or, ci�'vS ��gN,,., .Sadw✓-»n5 �661&J 16 ) Food will be prepared: 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: ����y1f Allergen Awareness: 18) For caterers: CitylTown 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 105 CMR 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 690.000 and thQ federal Food Code. 19) Signature of Applicant: Pursuant to MOIL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all statq tax returns -and pai'ate taxes required under law. 20) Social Security Number or Federal ID: 11�� 21) Signature of Individual or Corporate Name; m. " ����'�� /✓�+" ox", l Please copies of ServeSafe d Allergen trainingV TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. If\ 3,or Lor�.'z Signatureofl'ci[i 'vrc zLorCorporate Name *"Social Security No. (Vol indary) or Federal (dent yication Number By: Corporate Officer (Mandatory, if Applicable) *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. CaUscrsulehcADasktap4Sirou's PacnmcwsVFood flslablishmmtls• TmnpATAX C17RI WtCATION RORM.doo Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 tvtviv.ntttss govIefla Workers' Compensation insurance Affidavit: General Businesses Applicant Information Please Business/Organization Name: Dv�c Address: 2-31P,6 � n e F p k,' �rc you an employer? Check the appropriate box: V i. I am a employer with employees (full and/ or part-time).* 2. f 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, § l (4), and the 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 Business Type (required): 5. Retail 6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing 11. Health Care 12. Other Any applicant that checks box 41 must also fill out the suction below showing thefnvorkrors' uompensation policy inlbrmalwar *If the corporate officers have escalated ntemselves, but the corporation has other employces, a workers' compensation policy is required and such an rtganizatien should check box N1. ant all employer that is providing workers' compensation insarancefor nit, employees. Below Is the policy Information. nsurance Company Name: usurer's ity/State/Zip: )olicy # or Self -ins. Lie. 9 Expiration Date: attach it copy of the workers' compensation policy declaration page (showing the policy munber and expiration (late). -allure to secure coverage as required under Section 25A of MOL e. 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 a STOP WORK ORDER and a tine )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 ovestigations of the D1A for insurance coverage verification. ' do hereby eerlifj; trader ate pains and penalties of petjgty that the Iafornnallon provided above is Into and correct. ,rvnature Date: Official use only. Do not write la this area, to be completed by city or town offlelal City m• Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6.Other Contact Person: Phone #: www.n)ass.gar/dtx NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above -mentioned chapter by insuring with: 100 0001403 STARR INDEMNITY & LIABILITY CO NAME OF INSURANCE COMPANY 399 PARK AVENUE NEW YORK, NEW YORK 10022 ADDRESS OF INSURANCE COMPANY 05/30/2018 to Lockton Co LLC Miramar FL 33027 F.FFF.CTiVF DATFS 3601 SW 160TH AVE STE 200 954-883-2000 NAME OF INSURANCE. AGENT ADDRESS _ PHONE # SL RESTAURANT OPERATIONS, LLC 121 BROOKLINE AVE BOSTON MA 02218 EMPLOYER --'—' ADllRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (iF ANY) DATE MEDICAL TREATMEN The above named insurer is required in cases of personal injuries arising out of and in the course of employment to famish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act, A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own he insurer, i f thhe eatre treatment onable Is necessaryst ofthe services nd reasonably rovided by the treat ing works elated injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the TO BE POSTED BY EMPLOYER w � o U °s w O w V z *00 �4 H W z w z w r`�TJI, w �z O U Q' M J O �U � ory woO q O � p � M � 0 � O � tl d b w Mansfield Board of Health Request for Fee Waiver for Food Permit CDatee, 1�Q l ` (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 for food/drink being served. We are a religious organization. Other: The Taste of the Tri-Town Thank you, (�—Signatu—re Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: