Loading...
HomeMy WebLinkAboutTrolley Dogs 4/22/2018Commonwealth 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 - NEFFA 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:. JOYCE DENTE Whose place of business is: DENTE ENTERPRISES, LLC DBA TROLLEY DOGS/BOSTON ITALIAN ICE - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: JOYCE DENTE Permit Expires: April 22, 2018 Food Fee: $75.00 License Number: NEFFA-5 BOARD OF HEALTH MichaeCMcCCean, Chairman u %k' FOR BOARD OF HEALTH USE ONLY � Date Received Permit Fee Approved By Permit # Issued 102 Temporary Food Establishment Permit Application 1) Establishment Name: C/%7,.� 2) Establishment Address: 3) Establishment Mailing Address (If different): 4) Establishment Telephone No: 177 6) Applicant/Owner Name & Title: 6) Applicant/OwnerAddress: a 7) Applicant/Owner Telephone No: 6 / 7 8) Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: F Telephone No: (Q) 7— 1 f12 _ Fax: Emergency Telephone No: CD/ 12 10) Event Attending Date(s): Event Name: Event Location: Event time: 1S':Oo , .O; cc _ 7 "O O — 9 ; 00 S'; O o 11) Check one 15 Food Truck Caterer ❑ Other: 121 Solid waste disposal plan: r/2u7Y� t �'✓1 13) Water Source: 14) Sewage disposal plan: 16) Please give aeebrief description of the food to be served: n 0/ /e(SfX,(/�f 18 ) Food will be prepared; m*�Onsite for immediate consumption *r 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 lrainings and attach appropriate certificates: Food Safety Manager V Xi Allergen Awareness: V 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: �iSTOK� 1, 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 copies of 105 CMR 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 tax returns and paid state taxes required under law. (7 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: QO-M Food Protection Questionnaire for Catered Events Date of Event: QL-ka 2/ 22. -/23 Event Time: s�°0 'B,00 4�pp ' 8%00 -9106 Location of Event: Mai. . s4 fU i�Sc A MA List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated 1-.1- Cooking Reheating A4.41 rig Food Manager Certification Person Trained On Site? IV Yes C7 No Al lergen Awareness Menu Label Present? f-Yes ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: �4ye-1 tCt.t Dn�,. � �a • A+t St° - 375• My* — LIM List the required temperature for each food as it leaves your preparation site: A ems IS3 ,v,ti R -4n.to 9%.s yes • How will the PHF be kept at or below 41 °F? 4- c �_ How will the PHF be kept at or above 140°F? r j ((J� Time of PHF? Setup 7; p0 -7; 70 Served 9.'00 ^ 4: as 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 s 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. J!J C'_ Sinaature of Individual or Corporate Name By: Cor rate fficer (Mandatonj, if Applicable) i "Social Security No. (IVol uttanj) 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. C:\Users\sleite\Desklop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth bf Massachusetts Department of IndustrialAccidents a Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibl Business/Organization Name: (/� �D -TA Address: o? �yw d ppt6t_.. C Lf C199 City/State/Zip:, 1��� r7�2Q+c Phone #: /1 / 7 -- 4//9 —4G r / Are you an employer? Check the appropriate box: ,.Von am a employer with 'P-. employees (full and/ or part-time).* 2. ❑ 1 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 real 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 10.0 Manufacturing 11.0 Health Care 12.0 Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy mfomation. **If the corporate officers have exempted themselves, but the corporabon has other employees, a workers' organization should check box #1. compensation policy is required and such an I am an employer that is providing workers' compensation insurance for my employees. Below is thepollcy laforntatton. Insurance Company Name: in /le- ,( At�t A,. 4 Insurer's City/Stge/Zip: 01 / O / Policy # or Self -ins. L` is #- - 'V 9 V)F r T & (. P I Ex tp piration Date:_ '�4/-/ 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 a 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 DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury tit at the information provided above is true and correct. /7- Y12 --%G �/ Official use only. Do not write in this area, to be completed by city a town official. City or Town: PermitfLicense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitY/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www.mass.gov/dia t3DBTON iMBpIC fief L S�Rt"GE8 p PAIKIN T HpaNh Qiviafpn 1a"tU NRac{aK:!tU:el°f flYMVJ $aA.'4'+1. 3.1/. D2.18 T"Phap* t4 f'•�B:a;;.b .°b Koot RM osro...41*0t,4.V W'it o£RALD VANTln 26 CI.k,OFTTF 4:9Ct r �RAWSOH-W, MA 0':;+1 > ?QSTQNTRol4r(1GN b ' :t7t IJI9E $T F QSY.bJ 6t+t. U@'?8 HEALTH PERMIT 220181 PIMMIT NIJ4 911 PFRWT TYFF 13$2e2 ,aF;nr a ro* F ocd �n�s, 0,, THIS PERMIT EXPIRE& 12/31/2i118 This Permit Must Be Posted in a Conspicuous Public Place Complaints regarding the sanitary condition of this establishment may be referred to the Health Division at: (617) 635-5326 5 6 9LIN01_ n cav/isdlh� ea_, tth 0 Z' z -- LIA w aj <OT co �z IMj -%,t A, m T 1-315 flj U DENTENT-01 TGEORGACOPOULOS A� CERTIFICATE OF LIABILITY INSURANCE D041021201YY) 04102/2078 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER hROJACT Sclarratta & Doucette House The Corcoran & Havlin Insurance Group 287 Linden Street Wellesley, MA 02482 PHONE FAX aop€$S• _-_._ _____ INSURER(SI AFFORDING COVERAGE _ NAICW INSURER A: HertfordAccident &IITdemnity_ _ 22357 INSURED INSURER e : INSURER C.: Dente Enterprises, LLC DBA Trolley Dogs & Boston Italian Ice INSURER D : 26 Claudette Circle Framingham, MA 01701 INSURER E -- INSURER F t COVERAGES CERTIFICATE NUMBER' REVISION Nl1MRFR- 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP MMIDDIYYYO LIMITS COMMERCIAL GENERrAL L1IABILITY AIMS -MADE OCCUR CI -AIMS -MADE a EACH OCCURRENCE S DAMAGE 51 RENTED _ $ .___ MED EXP (Any one arson It GE_N'L PERSONAL&ADV INJURY S AGGREGATE LIMIT APPLIES PERK, POLICY�JEL'T ILOC OTHER GENERAL AGGREGATE--___ $ S _PRODUCTS-COMPADPAGG $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AU�gqT��O��S ONLY AUUoTTNOpSSyyyyNNEUp FUTOe ONLY gUTO50NfLV `BINED LIMIT $ BODILY INJURY Per arson S BODILY INJUppRY Peraccidord IPe0acci4entlAMAGE $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAI MADE EACH OCCURRENCE___ AGGREGATE S DED RETENTION$ _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIE70ftIEXCLUDRIEXECUTIVE YIN OPFICE�IMJ g�q EXCLUDED? E 1 andac NH) Dyaa, dIP Nurwer DESCRIPTION OFOPERATIONS below NIA OBWECCT8621 08/04/2017 08104/2018' X PER OTH E. L. EACH ACCIDENT S 600,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.t. DISEASE -POLICY IMIT 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD