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Home My WebLink AboutIHeart Radio 8/2/2018Commonwealth 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 RETAIL SNACK FOOD 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:. BIO NUTRITIONAL RESEARCH GROUP Whose place of business is: (HEART RADIO @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: OLGA BRICENO, DIVISIONAL MARKETING MAN. Permit Expires: August 02, 2018 Food Fee: $25.00 License Number: XT-5 BOARD OF HEALTH Michae(MCC(ean, Chairman FOR BOARD OF HEALTH USE ONLY Date 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) Establishment Name: 'tl-vc(+Odk--F Xfinity center 2) Establishment Address: 885 S Main St, Mansfield, MA 02048 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant/Owner Name & Title: Power Crunch 6) Applicant/Owner Address: 6 mor an suite 100 Irvine CA 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address: obriceno@powercrunch.com 9) Person Directly Responsible For Onsite Operations: Olga Briceno Name & Title: Olga Briceno Divisional Marketing Manager Address: 6 mor an suite 100 Irvine, CA Telephone No: 4076683788 Fax: Emergency Telephone No: 10) Event Attending Summer Jam Date(s): 8/2 Event Name: summer Jam Event Location: Xfinity center Event time: 11) Check one 12) Solid waste disposal plan: Food Truck Caterer X Other: N/A 13) Water Source: 14) Sewage disposal plan: N/A N/A 15 ) Please give a brief description of the food to be served: .32oz prepackaged wrapped sampler 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 X Other: No cooking involved. Only prepackaged power crunch bars samples 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: 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: N/A For food trucks, please list additional communities where a food permit is held and attach copies of the permits: n/A 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 copies of 105 CMppR��590.000 and the federal Food Code. 19) Signature of Applicant: Dufw �e 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: Food Protection Questionnaire for Catered Events Date of Event: Location of Event: Event Time: 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? I I Yes I I No Allergen Awareness Menu Label Present? I I Yes I I No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: 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. �j� You-Evi-�.cvlw� �cse�� Signature of Individual or Corporate Name 33- 671 � 088 "*Social Security No. (Voluntary) or Federal Idenlifioilion Nnmhcr t, hA1\0 Ill't44L I3y: Corporate Officer (MnrtdaHny, 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 filhlg 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`\UseWslcue\Desklop\Sttfli's Dotumellt Pkf I I slubhshnums- IcmpAl AX CERTIFICATION FORM.doe The Connnonurealth of Massachusetts Department of Industrial Accidents Of offit vestigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit; General Businesses Applicant Information � �7 P Please Print Leeibiv Business/OrganizationNan7e:�� A-11p,6 h' _ ItiP�P � I�YZ� t�J Address:i_ 'Mc)y�, Mtn --1k [ oo City/State/Zip: Phone t{:�c Are you an employer? Check the appropriate box: Business Type (required): I .® I am a employer with $SO _ employees (full and/ 5. ® Retail or part-time).* 6. ❑ Restaurant/BarlEating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (me], real estate, auto, etc.) employees working for me in any capacity. & ❑ Non-profit [No workers' comp. insurance required] 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 I.❑ Health Care 4. ❑ We are a unteers non-profit organization. staffed by vol, with no employees. [No workers' comp. insurance req, I 12,0 Other 'Any applicant that checks box 91 must also Iill out the section below showing their m rkers' compensation policy information. •'ll'the corporate ol7iears have exempted themselves, but the corporation has other car ployces, a workers' compensation policy is required and such an orgnnieAron should check box N 1. l ant an employer that is providing workers' compensation insurance for my employees. Below if the policy information. Insurance Company Insurer's Address: ] S .S (._ kU k4 eL 9� YY -_.__—-----____- City/State/Zip: ---Io ___�_-y-- —k4C,11G01 Policy N or Self -ins. Lie, ti _ --1 ( Z L-A 9� (�a- Expiration Date: pl t� L7 Attach a copy of the workers' compensation policy declaration page (shoving 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 clay 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. l do hereby�c'e'r'li�ftt under the pains analpenallles ojperjary that the information provided above is true an correct ( SienatureT 1 �Q�f (P� t� Date %, 3 1 ] c`5 G Official use oulp, Do not write ht this area, to be completed by chy or town cjftcial. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfl'own Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact caw. Hass govtd'e Phone BIO-RES-01 DKELL G ACofzo` CERTIFICATE OF LIABILITY INSURANCE DATE 06/28/2018 ) `-� os/za/zo1 a 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 PRODUCER INSURED Services, Inc. Bio-Nutritional Research Group and Metaphysique, Inc 6 Morgan, Suite 100 Irvine, CA 92618 263-8850 INSURER A: Federal Insurance. Company ,._ [20281 INSURER B ; INSURER C INSURER D : INSURER E : COVERAGES CFRTIFICATF NIIMRFR- RFVISIC)N NIIMRFR- 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 'ADS LSUBRL. POLICY EFF' POLICYEXP LTR rypE OF INSURANCE POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY 1 CI X OCCUR 36028302 11010112017 10/01/2018 EACH OCCURRENCE I$ DAMAGETORENTED 1,000,000 1,000,000 -AIMS -MADE j X X PREMISES HE. ocwRence) , $ MED EXP (Any one person) 10,000 PERSONALB_ADV INJURY I$_ 1,000,000 G LIMIIT AP PLIES PER GENERAL AGGREGATE L5 2,000,000 NPOLICYEGATE PRO- JECT LOC PRODUCTS-COMP/OP AGG $. Excluded OTHER: A AUTOMOBILE LIABILITY! COMBINED SINGLE LIMIT i 1,000,000 X ANY AUTO X 173586089 10101/2017 !, 1010112018 BODILY INJURY (Per person).$_. OWNED (SCHEDULED AUTOS ONLY I AUTOS li BODILY INJURY (Per acGdenl) $ X AUTOS ONLY X NOoNAVVyyNNED AUTOSONLY li r40PER,atrMAGE $ (Pere cutlenL) A X UMBRELLA HAD X OCCUR ''. EACH OCCURRENCE I is 9,000,000 EXCESS LIAR CLAIMS MADE: 79895307 I10/01/2018. 10/01 /2017 AGGREGATE j$ 9,000,000 _ BED ! RETENTION8 A i WORKERS COMPENSATION AND EMPLOYERT LIABILITY YIN 71749862 1 X PER I .STATUTE. ORH 10/01/2Q17' 10/01/20181,, 1,000,000 ANY PROWPRIETORgIPARTNER/EXECUTIVE X EL EACH ACCIDENT $ FILE MEMBE EXCLUDED? Y ?M t H N/A'' 1 E.L.DISEASE-. EA EMPLOYEE$ 1'000000 If yea,tle'0000 under DESCRIP�ON OF OPERATIONS below 1 E L DISEASE - POLICY LIMIT $ 1,000,000 I I i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Summer Jam Live Nation Worldwide, Inc. and it's respective parents, members, partners, affiliates, divisions and subsidiaries, and their respective officers, directors, shareholders, employees, agents and representatives are Additional Insured with Primary & Non -Contributory Wording & Waiver of Subrogation when agreed by Written Contract with the insured per endorsement on the GL policy Live Nation Wide, Inc. 9348 Civic Center Drive Beverly Hills, CA 90210 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) 91988.2015 ACORD CORPORATION. All rights reserved. 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