Loading...
HomeMy WebLinkAboutIHeart Media 6/17/2018Commonwealth 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: XFINITY SNACK 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:. IHEART MEDIA & ENTERTAINMENT, INC. Whose place of business is: (HEART MEDIA - KISS 108'S KISS CONCERT@ XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: KATE BYRNE, PROJECT MANAGER Permit Expires: June 17, 2018 Food Fee: $25.00 License Number: XT-1 -107e1 V IV] 0 : I : F901:I -%lichaeCwicCCean, Chairman FOR BOARD OF HEALTH USE ONLY [D:819Received 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) Establishment Name: 2) Establishment Address:- 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant/Owner Name & Title: Nk r��, 8) Applicant/Owner Address: Iry .. V I tt.t� �cJ vV 7) AppllcanVOwner Telephone No: S..) 0 0 _r Yl , C I 8) Applicant/Owner Email address: y (,\ AC yke, 9) Person Directly Responsible For Onsite Operations: Name & Ti0e:�- Address: l Telephone No: \\ Fax: Emergency Telephone No: 10) Event Attending Date(s): Event Name: Event Location: Y;.y-{.. Event time: 11) Check one ❑ Food Truck ❑ CatererAW r,,�Other: 12) Solid waste disposal plan: 13) Water Source: /U N"C.. 14) Sewage disposal plan: lh 12� 15 ) Please give a brief description of the food to be served: ,-0 16) Food will be prepared: ❑ Onsite for immediate consumption n Onsite and held at proper hot/ cold holding temperatures ❑ Offsite and held at proper hot/ cold holding temperatures ❑ Offsitc, 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 Safely Manager: ❑ Allergen Awareness: 19) For caterers: CltyfTown 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 1 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 ob) in copies of, 1.0, 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 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: r L ZZ IN 21) Signature of Individual or Corporate Name: F. Food Protection Questionnaire for Catered Events Date of Event: _ j -71 1Z Event Time: Location of Event: VVI(1I-SGrf.t( 1114✓=1 List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Food Manager Certification Person Trained On Site? ❑ Yes I<No Allergen Awareness Menu Label Present? Cl Yes 06io List all Potentially Hazardous Food (PHF) and the individual intended temperature required: >tti� 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 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, 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. iHeartMedia+ Entertainment, Inc. / cott Bick, SVP Signature of Individual or Corporate Name 74-2722883 "Social Security No. (Voluntary) or Federal Identification 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. C:\Usurs\sleitc\Dmktop\Scutrs Doc=mtsWood Eaablishmanls- Temp\TAX CERTIFICATION rORM.doo The Commonwealth of Massachusetts i Department of Industrial Accidents ll:' Office of Investigations a 600 Washington Street .. Boston, MA 0211.1 wwwanass.gov/dia Workers' Compensation Insurance Afr►davit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: iHeartMedia+Entertainment, Inc. Address: 20880 Stone Oak City/State/Zip: San Antonio, TX 78258 Phone#: 210-253-5126 Are you an employer? Check the appropriate box: Business Type (required): 1. E3 I am a employer with . 10 + employees (full and/ S. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2, ❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]*' I l Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees, [No workers' comp. insurance req.] 12.[30ther Broadcast and Media *Any applicant that checks box #I must also fill out the section below conversation noliev inforrnvtirn -•u Inc corporate otncers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: XL Catlin insurer's Address: 1 World Financial Center City/State/Zip:,_New York, NY 10281 Policy # or Self -ins. Lic. # RWD3 00052903 200 Liberty St., 22nd F1 Expiration Date: 11 1 19 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 tip 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 p lTatties of perjury that the information provided above is true and correct Signature: _V __ �%V Date: (n Il r- 1201 4l Phone #_d-ty t Z _ '{ 2, 7 Ojpcial use only. Do not write in this area, to be completed by eery or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. i.icensing Board 5, Selectmen's Office 6.Other Contact Phone www.�,�a a.gunria WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insurer: POLICY N O. RWD3000529-03 XL Insurance America, Inc. 505 Eagleview Boulevard, Suite 100 Exton, PA 19341 A Stock Insurance Company 1. Name and Address of Insured: iHeartMedia, Inc. 20880 Stone Oak Parkway San Antonio, TX 78258 NCCI Risk ID#: 910011634 Renewal of: RWD3000529-02 NCCI Carrier Code: 10480 Legal Entity: Corporation Otherworkplaces not shown above: See SCHEDULE OF NAMED INSUREDS AND LOCATIONS 2. The policy period is from 11-01-2017 to 11-01-2018 12:01 A.M. Standard Time at the Insured's mailing address. WC 00 00 01 A Edition 1108 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $5,000,000 each accident Bodily Injury by Disease $5,000,000 policy limit Bodily Injury by Disease $5,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT: Ohio, North Dakota, Puerto Rico, Washington & Wyoming AND ALL STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE D. This policy includes these endorsements and schedules: See SCHEDULE OF ENDORSEMENTS 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium See EXTENSION OF INFORMATION PAGE W II VJUI\ANCE WC 00 00 01 A m 1987 National Council on Compensation Insurance. Page 1 Edition 1/08 © 2007 XL America, Inc.