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HomeMy WebLinkAboutValicenti Pasta Farm 8/25/2018Commonwealth 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: RETAIL FOOD - FARMERS MARKET 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:. DAVID VALICENTI Whose place of business is: VALICENTI PASTA FARM - FARMERS MARKET 888 SOUTH MAIN STREET PERSON(S) IN CHARGE: DAVID VALICENTI Permit Expires: August 25, 2018 Food Fee: $10.00 License Number: RFM-22 BOARD OF HEALTH Michaet'McCCean, Chairman rCFM ` CR -'I— FOR BOARD OF HEALTH USE ONLY Rate 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) EstablishmentName: `1 TA` 1T CI1•t..lyn =A�(Y�-Cv�+ 2) Establishment Address: ` IvtulVilt l�i�iU' It5 1 (V�-� 3) Establishment Mailing Address (if different): ` Q QOx " % U C N 3 K 4) Establishment Telephone No: V t•�lj �. �62� 5) Applicantlowner Name & Title: 4V\\L\ Ll-C(NT( N N I" 6) Applicant/OwnerAddress: 1) M, 7). Applicant/owner Telephone No: S 15tv\� 8) Applicantlowner Email address: 9) Person Directly Responsible For Onsite Operations: D(I,\i LlC vT' \i�IS\ 1L�U!\i�� Name & Title: Address: Telephone No: Fax: Emergency Telephone No: 10)Event Attending Date(s):,iw 6.17"t/' j Event Name: Event Location: Event time: �'AM, -- VrA 11) Check one ❑ Food Truck ❑ Caterer � Other: T(V nf.Eq �p0 7AIL 12) Solid waste disposal plan: �n 13) Water Source: 14) Sewage dispo al plan: 15 ) Please give a brief description of the food to be seeded: �(� S�nngi lNG II�P �ilcrktCY �Ai �, Pns,l} SnNcE FRo2�u �AUIoLI t�fb VtAv%'k-To , EAT CdDD �_ ��G6�hfEo ctz�511 Phsrq 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:. �1hQhg9 A(e' ?nflCnCr� 6FF-Sf(E IN lICEOEo {=Dh INMxcD rhLlLrfY (a? RUA 44r: ONLY, 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Lk Food Safety Manager: * Allergen Awareness: _ 18) For caterers: City/Town where food establishment permit Is held. Please attach a copy of the caterer's permit: For food trucks, Tlease list additone! commtmities where a food permit is held and attach copies of the permits: I, the undersigned, attest to the accuracy of th information provided in this application and I affirm that the food establishment operation will comovt 1R 590.000 and all other applicable law. I have been instructed by the board of health on how to tain o i 105 CMR 590.000 and the federal Food Code. 19) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that], 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: ��� 1ZM �� 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 Indio ual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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 nurnber 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:\usm\sleite\Dcsktop\Scotts Doeumetils\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf wiummass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name' Vltl 1� lrfTT1\� Lii 1'T(�ItY �'tiwt�l Address: 1� h�ol�u MEnlr SQ�I��Ey�� U gok 213 L4DLLt5 all 030K`I City/State/Zip: Are,{�on an employer? Check the appropriate box: 1. yJ I am a employer with �_ employees (full and/ or part-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.] Phone #: Cog , '2� 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.t,�rI{ Other r4&M Any applicant that checks box $1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 91. I otn lot employer that is provhlitig workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: I' 1 I IN -1 V ry t f q r� y r 7 1 Expiration Date: Policy # or Self -ins. Lic. # i /-17 /�"7� � � P 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 MGL c. 152 can lead to the imposition of criminal penalties of 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 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 DI for insurance coverage verification. I do hereb i tt pains and penalties ofperjuty that the information provided above is true and correct. y .,_Ie SO(4N� 1�0(°O _y "Cn?,. 45q, _Z(7.1 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6.Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone DATE (MWDDNYYY) ACOORV ® CERTIFICATE OF LIABILITY INSURANCE 1 06/28/2018 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 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 cmd+ rs ment(s). PRODUCER NAME: PHONE (603)673-1201 0No: (603)673A825 HPM Insurance pka The Holt Agency AIC N Ext: E-MAIL 101 Foreman Road, Suite 1 ADUREss: ^. Amherst NH 03031 INSURER A: Hca°1F INSURED INSURER B VALICENTI FARM, LLC INSURER c: PO BOX 273 INSURER D: 11 MONUMENT SQUARE INsuRER E: HOLLIS NH 03049 -INSURER F: _ _. .. r�.,,c,nel ,.II IMQGQ• COVERAGES CERTIFICATE NUMBEK:"-------- TO THE INSURED NAPAED ABOW FOR THE POCCY PERICD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED CONTRA CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND MP POLICY FF POLIC E%P LIMmS JAIJUL NSR TyPE OF INSURANCE INSD Wen POLICYNUMBER MMIDD MIMIC LTR 1,000,000 3 COMMERCIAL GENERALLIABILITY OCCURRENCE L'Ti'RErJT^C"—'" $ 300,000 CLAIMS -MADE © OCCUR PREEACH e,xunance MED E%P (AnY ona person) MED E ES (AE.ny g 5,000 CPA5325776-10 01/05/2018 01/05/2019 PERSONALS ADV INJURY S 1,000,000 A 2,000,000 GENERALAGGREGATE $ GEN'LAGGREGATE LIMITAPPLIES PER: $ 21000,000 ❑ PRO- ❑ PRODUCTS-COMPIOPAGG POLICY JECT LOC CECER S 100,000 OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY Ea ..Mart BODILY INJURY (Per parson) S ANVAUTO BODILY INJURY (Per acddentl S OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE $ HIRED NON -OWNED PeracGdent AUTOSONLV AUTOS ONLY g EACH OCCURRENCE S UMBRELLA LIAB OCCUR AGGREGATE EXCESS LIAR CLAIMS -MADE S $ DED RETENTION 3 v /� PER ER WORKERS COMPENSATION 'It;' EL EACHACCIDENT g 1,000,000 AND EMPLOYERS• LIABILITY YIN ANY PROPRIETOWPARTNEWEXECUTIVE WCA5325777-10 0110512018- 01/0512019- 1,000,000 A` OFFICERIMEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYEE S EL.DISEASE-POLICY LIMIT 1,000,000 3 (Mandatory In NH) If yes, desmbe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddNlonal Remarks Schedule, may be hashed a more space le reauir-d) OPERATIONS. Manufacture and Sales of Pasta, Pasta Sauces, and Related Goods CERTIFICATE HOLDER - ---- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MMAS Art Center 377 North Main Street AUTHORIZED REPRESENTATIVE Mansfield MA 02048eaa�.�id'.ei-t/a7++ ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD N S m�51 S m � CL 'O = .ic "0 m Ap , :, � z G :0 0 i i00 OOy r byF » pp A0, m 09 "Z _- . ►�Z ABCom Z c d .. - gg 6 Q M _ c Mwi A r 0 / > ( 9(\\ f9% ~/§# .ƒ � �2 a � � � G.2