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HomeMy WebLinkAboutAlden Park 10/31/2018Commonwealth 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 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:. WALTER WUNDER, OWNER Whose place of business is: PARK RESTAURANT MANAGEMENT GROUP, LLC DBA ALDEN PARK @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: WALTER WUNDER, OWNER Permit Expires: October31, 2018 Food Fee: $125.00 License Number: XFS-23 BOARD OF HEALTH wlichaet .McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued J FOOD ESTABLISHMENT PERMIT APPLICATION cation mu�-uum—iffe—daiTas t 3 ays e ore the planned opening a e 1) Establishment Name C� 'Aq L. 2) Establishment Address 0A -�Y�6 r 3) Establishment Mailing Address (if different) 4 Establishment Telephone No _` 5) Applicant Name &Title: r ,)jCA [/� V�_ 4 , a� 6) Applicant Address 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title 9) Owner Address (If different from applicant) -- ' Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers W1 An Association or partner. IN A Corporation Name Title Address A An Individual ® A Partnership J `'Other legal Entity G� 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (vv -- Address: Telephone No:_0(%._p // 31 b S 24 Hour Emergency No: FAX: %7� �a_�rr!! ji l v E-mail: (N(tv\GtLY a1 /r�GLY'C 2Sd Cop4,_ Alt E-Mail: 13) District Or Regional Supervisor (If applicable) Name & Title: L Address: Telephone No: 24 Hour Emergency No FAX: E-mail: - Food Establishment Information 14) WATER SOURCE: � Y 15) SEWAGE DISPOSAL: Y , � , W 3C� � w rti r a t�2 Uri DEP Public Water Supply No: (If applicable)�I 16 No. of Food Employees: j 17 AD YS/HOURS: IJ�Iv a V1Cp4_� V 0.SJ 0 v, S � ✓v( ik C P/lrvi-'(E 18) Name of Person In Charge Certified in Food Protection Management: n , Y�M� If more than 3 individuals are certified, complete list is on file. QY Required as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: ® Permanent Location 22) Establishment Type loblie Mobile Start Date: VK J Z l® � Retail ( Sq. Ft) Moblie End Date: O C� Food Service up to 100 or Mobile Comments: 21) Length of Permit: (M Annual Seasonal Dates: VVly FRITemporary - Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: up to 10' PHF display $125.00 ® Food Service up to 101 -200 or up to 25' PHF display $150.00 ® Food Service up to 201 + ,3' or 25'+ PHF display $275.00 O Food Service - Institution ( Meals/Day) ® Caterer $25.00 Milk & Cream $10.00 Food & Consession $75.00 ® Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: [J Residential Kitchen $100.00 U Retail Food $100.00 ® Retail Snack Food $25.00 ® Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (lime/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature contacts required) (Check all that apply): RTE-ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ® Sale of Commercially Pre -Packaged Non-PHFs (Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs ra Reheating of Commercially Processed Foods for Service Within 4 Hours ® Customer Self -Service of Non PHF and Non - Perishable Foods Only ® Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the accu y of the establishment operation will comply it1 10 CP board of health on how to obtain pie of 5 ( 24) Signature of Applicant: _PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ol Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [e PHF and RTE Foods Prepared For Highly Susceptible Population Facility ® Vacuum Packaging / Cook Chill A Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ® Juice Manufactured and Packaged for ® Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ® Offers RTE PHF in - Bulk Quantities [) Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food I I To be completed by the Total Permit Fee: Payment is due with application n waived ovided in th/dpplication and affirm that the food id all othe ypplicable law. I have been instructed by the and the eral Food Code. 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. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: (Y,(� 4_ _ 09 �f T'NY 1 H I�/i/I/XQQ�/�lF/tI� / ( )✓(iL2 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. eS Ol° �/du Signature of Individual or Corporal Name By: Corporate Officer (Mandatory, if Applicable) ,,�?7 zne�ersl "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 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. Q\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassachasetta Department of £ttdtrstrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www maasgovfdla Wnrkexs' Com(Seusation Insurance Affidavit: General Businesses BusinessWOrganization Venue: ra _ r�9�zl l v( Yr l Gnnr p t a � n Address: ( p uitylState/Zip: PI�����1{ti�}_����hotte#: SaF-.P3�^/777 Are You an employer? Check the appropriate box: I am a employer with kLt _ employees (full ands or parbtime).' 2.0 lam a sots proprietor or partnership and have no employees Working for me in ally capacity. (NO workers' comp. irswonee required) 3. ❑ We are a corporation and its officers have exeroised their right of exomprioa per C. I52, §1(4.), and We have no employees, (No workom' comp, insurance requiredj' 4.0 We are a non-profit organization, staffed by volunteers, with no employees. No Workarg` comp. insurance rea.1 ! am an employer drat iv insurer's Addr city/state/Zip: Business Type (required): S. 0 Retail . 4MRestaurant/BarBating Establishment 9. ❑ Office and/or Soles (roo), real estate, auto, cte) S. 0 Non-profit 4 © Entertainment 10,11 Manulhota ing I t.0 Mealth Care 12.(] Other to fiilout @escetion htlow ahoWina rMvxmRas' tampcnsadon policy intarmatron. thetntelvet, but to oorpomtfon hot other employers, a we tM, ce, ea.arlon policY is raauired and a xh to Is the Expiration Date: i ( l Attach a copy of the workers' compensation policy declaration page (showing the pofiey number and expiration date), Failure to secure coverage as required under section 25A of M.GL c, 152 can lead to the imposition of crltninol penalties of a fine up to $Ir500.00 alwor otteryear imprisonment, as well as civil ponalfies in the form of. a STOP WORK ORDER and a Sno of up to $250.00 a day against the violator. Be advised that acopy of this statement maybe forwarded to the Office of that the Official ttse only. Do not write in this area, to be completed by d{y or totva oKetai City or Town: PermittLicensea Issuing Authority (cireia one); 1. Board of Health 2. Bniiding Department 3. City/'Town Clerk 4, Liaensing Board S. Selactmen's office 6.Other .- _ ....... r INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent$ 812 MA Retail Merchants WC Group Inc. Renaissance Alliance Insurance Ser PO Box 859222-9222 981 Worcester St Braintree, MA 02185 Wellesley, MA 02482 (Carrier Code: 34355) Carrier Policy #: 014005032595118 Carrier Prior Policy #: 014005032595117 1. The Insured: Park Restaurant Management Group, LLC Alden Park Mailing Address: 160 Colony Place Plymouth, MA 02360 Fein: 272086831 i Other workplaces not shown above: Type of Business: Corporation NO OTHER WORKPLACES FOR THIS POLICY Risk ID: 2. The policy period is from 12:01 a.m. on 1/01/2018 to 12:01 a.m. on 1 Ol<2019 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA 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 $ 1,000,000 each accident Bodily Injury by Disease $ 1 000 000 policy limit Bodily Injury by Disease $_ 1,000,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000308(04/84) WC000414(07/90) WC000422B(Ol/15) WC200102(01/14) WC200301(04/84) WC200302A(09/08) WC200303➢(08/10) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 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 No. Total Estimated Annual Remuneration SEE SCHEDULE OF OPERATIONS Total Estimated Annual. Premium $ 5,627.00 Minimum Premium $ 292.00 Expense Constant $ Rate Per Estimated $100 of Annual Remuneration Premium 00 Deposit Premium $ .00 gWIS 0 ®®.TIFICATION WALTERE WUNDER for sumeesfully mmplefing the standards set forth for the SewSafe® Food Prolection Manager Cerfifimlion Examination, which is accmdited by the American National Standards Institute (ANSIKonference%r Food Protection (CFP). MBER EXA E OF E a.«7,�.5,� DATE OF EXPIRA .s apply. Ch Ienq for mcerlifimfion requirements. In t..uoe.,. girtalo 175Wb =9 . % I S ,, ak, ,L 6NOA! Sw5✓, ,ee n.ag CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: WALTMNDER Certificate Number: 3012933 Date of Completion: 7125/2017 Date of Expiration: 7/25/2022 7be above -named person is hereby issued this reiti neate for eonepleting an allergen awareness training program recognized by the Massachusetts Department ofPublie Health in accordance with 105 CMR 590.009(G)(3)(a). Ibis artiJirate will be validforfi've (5) yearsfrom date ofcompletion. Issued By: NATIONAL' RESTAURANT ' ASSOCIATION, Masmchusctts Restaurant Association 800.765.2122 333 Tusnp!L Road, Suite 102 w '.taumntorg Southbomugh,MA 01772 508-303-9905 x muesmue ntossocorg