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HomeMy WebLinkAboutM. Fanelli's Traveling 10/1/2018Commonwealth 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 - ELKS CARNIVAL 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:. MARK FANELLI, OWNER Whose place of business is: MARK FANELLI'S TRAVELING AMUSEMENTS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE JOSEPH FANELLI, MANAGER Permit Expires: October01, 2018 Food Fee: $125.00 License Number: XFS-21 BOARD OF HEALTH 34ichaet McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit# Issued Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: Ao,�(;� IGVet;n /��w✓ nk`� 2) Establishment Address: I'z ,5 f,� 1 (c, K A`1 L ✓tJ, 6'34 (0 ( 3) Establishment Mailing Address (If different): Po IJ J 4) Establishment Telephone No: 2qA — `vt UO 5) Applicant/Owner Name & Title: \U52Q� PPIP k�' — /t9,,ny�r6- 6) Applicant/OwnerAddress: l(vL Q Gt2 �( P �d i�U�tt2 AA( 04L�4X 7) Applicant/OwnerTelephone No: Uu2j_ Z(-L$ _ 8) Applicant/Owner Email address: i 9) Person Directly Responsible For Onsite Operations: Name &Title: o)dk P�r`,(At Address: 4,(,- 14 it, ct ���✓l(J �Gl'�- .N i\ 6 ���1 �S Telephone No: j _ 'Z,qcL ,- (o'L(Q 3 Fax: Emergency Telephone No: 10) Event Attending fit' Event Name: 11�� C L kx J Event Location: Event time: �,- 10 Pw, d Z —I u P°'^ , -Z 11) Check one ❑ Food Truck ❑ Caterer X Other:"\ e 12) Solid waste disposal plan: l 13) Water Source: C,` ,4 t v r 14) Sewage disposal plan: (�66�, 11)4i�-s 62 S:1e 15 ) Please give a brief description of the food to be served: 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: 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: 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 acc racy of he information provided In this application and I affirm that the food establishment operation will comp) with 1 5 CMR 590.000 n a ther applicable law. I have been instructed by the board of health on how to or ain c ies of 105 Ci�90.0 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. �p�1 �i3�ty 20) social Security Number or Federal ID: _ �______�________________________________ i 21) Signature of Individual or Corporate Name: _---------- ________________ _____________ 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. of Individual 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 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\sleate\DesdopNSootts Do mtAFood Establishments-Tarp\TAX CERTIFICATION FORM.doc It Commonwealth 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 PERMIT - ELKS CARNIVAL 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:. MARK FANELLI, OWNER Whose place of business is: MARK FANELLI 'S TRAVELING AMUSEMENTS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOSEPH FANELLI, MANAGER Permit Expires: October 01, 2018 Food Fee: $125.00 License Number: XFS-22 BOARD OF HEALTH Mlchae(MCC(ean, Chairman J FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit# Issued , €= 5 - .- , Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: (locv,,A 4a f-x o`er V) 2) Establishment Address: G' 7 fA+ ((`'r 1 03Q6( 3) Establishment Mailing Address (if different): PO 66-j-, �(�ct t"n,�� L411 p3(/(9( 4) Establishment Telephone No: 1pn i't, `tfzU% 5) Applicant/Owner Name & Title: �ci7l',Y� �uro� i t A4 e� e- 6) Applicant/OwnerAddress: 7) Applicant(Owner Telephone NO: iLe-7(o 8) Applicant/Owner Email address: )O�Qet, 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: Telephone No: Fax: Emergency Telephone No: 10) Event Attending Date(s): Uik _ �w� ( i Event Name: �� �(u � w� rl tv",1 Event Location:ni ' nC Event time: l (Z C') 11) Check one ❑ Food Truck ❑ Caterer )Mp b(2 CN Other: 12) Solid waste disposal plan: c� no 13) Water Source: C1VA 'oe- d e'r 14) Sewage disposal plan: Conti ez,,V oe) on 5i l � 15) Please give a brief description of the food to be served: 46t561 Ott-) glt� c��s 16 ) Food will be prepared: YJ Onsite for immediate consumption ❑ Onsite and held at proper hot/ cold holding temperatures G 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 trainings and attach appropriate certificates: 1,., + ❑ Food Safety Manager: �t J���y 7 . ❑ Allergen Awareness: z 'L 1 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: of ALA , L G vi_i0�i4/1-r f�(Gr fi _ j3� 50 5 - c �,' S I, the undersigned, attest to the accur cy of einformation rove in this application and I affirm that the food establishment operation will comply ith 10 CMR 590.00 and all of r applicable law. I have been instructed by the board of health on how to obt in cq es of 105 C R 590.000 d the federal Food Code. 19) Signature of Applicant:-_ __�________________________________________________ Pursuantto 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: (> =Llt C� �r --------------------------- /j�, �;=/kvG� 21) Signature of Individual or Corporate Name: !- � _--___ (-_ _ G �e �` 4---------- 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. 1 Individual or Corporate Name G i✓a. - 6 4(4 5 "Social Security No. (Voluntary) or Federal Ideat�Fication Nunnber By: Corporate Officer (Mandatory, ifApplicable) *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:\Usas\sleite\Desktop\Smtts Doammts\Food Estabiidt ts- Tarp\TAX CERTIFICATION FORIA.doc IT Commonwealth 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 - ELKS CARNIVAL 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:. MARK FANELLI., OWNER Whose place of business is: MARK FANELLI'S TRAVELING AMUSEMENTS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOSPEH FANELLI, MANAGER Permit Expires: October 01, 2018 Food Fee: $125.00 License Number: XFS-20 BOARD OF HEALTH NichaeCNcCCean, Chairman v4co-X 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: ���� t-°°Al"C'.) T(-"e,601-) l�rwheAtovl � 2) Establishment Address: (Z-5 4,1- (h- 3) Establishment Mailing Address (if different): b �( 4) Establishment Telephone No: S 1 ,67 octet - `icwc) II% 5) ApplicanUOwner Name & Title: j/Pll- VI-Vo(L i 6) Applicant/Owner Address: (�`� v��•r t- h�,�. �yr"��'LVl`�h k') botC� 7) Applicant/Owner Telephone No: 663 ",V'G 8) Applicant/Owner Email address:����'Sfi!>��l 9) Person Directly Responsible For Onsite Operations: Name & Title: "c' y1ke- Address: Telephone No: Fax: Emergency Telephone No: 10) Event Attending Event Name: �( aL,' �,�iLrioUa 1 Event Location: Event time: l z -1 o e,* l 11) Check one ❑ Food Truck ❑ Caterer M„y1t L. Other: P "' 12) Solid waste disposal plan: I 13) Water Source: ' � j 1 14) Sewage disposal plan: , ' rk f'�� 1 15) Please give a brief description of the food to be served: tick �c;�s VC�,54t 60- V-cCe) 16,) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hol/ 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 trainings and attach appropriate certificates: ^� ❑ Food Safety Manager: ��L�� / ❑ Allergen Awareness: t/'" ` ��✓Q'�� �b����' 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: A" M-, l -U�rr���M�/ NV o4 MW - �- 4-. -------------------------------------------------- I, the undersigned, attest to the ac uracy f the informatio rovi a in this application and I affirm that the food establishment operation will com y with 105 CMR 590. 0 and all oth r applicable law. I have been instructed by the board of health on how to taiqVloples of 105 R 590.000, a 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 returnsandpaid state taxes required under law. 20) Social Security Number or Federal ID: 6� _S `1� C,15' ------------------------------------- 21) Signature of Individual or Corporate Name: A4_ V(- Jr k (u°�, cct x I Vt- " rwL,�WWvtS --------------------------------- fc-ot,' C A- FCC-5 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. Pnatuief Individual or Corporate Name 0- 01 Litt-5 C,5 **Social Security No. (VoLtntary) or Federal Identification Nwnber 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. CAUsas\sleiWADe ktop\Scotfs Doamm%\Faod Establistmmts-Tenp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Stt•ee:4 Suite 100 Boston, AM 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERIVIYHTMGAUTHORITY. Applicant Information {�Q T Please Prin Business/OrganizaticiaNa(me:( `qv✓� ` �'S t `/�� Address: J 1 7 (i� r i��; U 1�, Zvi 0 City/State/ZiA: 41 Are ou an employer? Check t e appropriate box: Business Type (required): I. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. Restaurant/Bar/EatingEstablishment 2:Cj I am a sole proprietor or partnership and have no q• Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity, [No workers' comp. insurance requu'ed] 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 wehave 10,UManufacturing no employees. [No workers' comp, insurance required]* l l.❑ Health Care 4. ❑ We are a non-profit organization, staffed by voluntee s, with no employees. [No workers' comp. insurance req.] 12.[] Other kAny applicant that checks box I must also fill out the section below showing their workers' compensation policy information. C°If the corporate of6ccrs have excmpled tbemselves, but the corporation has other employees, a workers' compensation policy is required and such as organization should check box'#]. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon. Insurance Company Insurer's Address: City/State/Zip: Policy # or Seif-ins. Lic. # Expiration Data: 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 $1,50Q.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.OQ a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations crthe DrI)k for insurance coverage ver.ifjcatien, Ida the pains and 2 the information providgd above is true and correct. Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License 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 w .mns.gov/dia Pbon l ® a`airo CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDD/YYYYI 0212312018 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 Allied Specialty Insurance, Inc. 10451 Gulf Blvd CONTACT NAME: PRCGNE FAX o Exl : (AIC, Not: EMAIL -- ADDRESS: Treasure Island, FL 33706-4814 INSURERS AFFORDING COVERAGE NAICH INSURERA: T.H.E. Insurance Company 12866 _ INSURED MarkFanelli's Traveling Amusement Park INSURER B: P O: Box 249 INSURER C: INSURER D: Rindge, NH 03461 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 LTR TYPE OF INSURANCE Ann $ SUER POLICY NUMBER POLICYEFF MMIDD/YY1'Y POLICY EXP MMUDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR EACH OCCURRENCE $ DAMAGE T PREMISES JE. occurrence $ GEN'L _ MED EXP (Any one person) $ PERSONAL&AOV INJURY $ AGGREGATE LIMIT APPLIES PER: POLICY[ jECT LOC OTHER: GENERALAGGREGATE $ PRODUCTS-COMP/OP AGG $ $ AUTOMOBILELIABLITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY _ AUTOS ONLY J 1 COMBINentL_ LELIMIT Ea accident $ BODILY INJURY (Per parson) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE _Pm accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACHOCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE ❑NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below WCP0004451-015 04/16/2018 04/16/201g /� PER EORH E.L. EACH ACCIDENT $ 1,000,000 E. L. DISEASE - EA EMPLOYEE $ 1,000,000 E. L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Coverage is afforded in the State(s) of: MA, NH & RI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ,s /REPRRE,SSE/'NTA/TI/V,EJ//j ©1988.2015,ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD f•. V I� -4 w O Q r w u �.0z a z a b U U cN " w� QCd B zoo � o ¢�Q N o¢_ v g zoo -cC y G O h-i R N men sc,���a E� M0 � " M z 0 � y 42 N N N \ QQ a 2 A W 0 � z � z \5 ■t I - t \ ® R § � C 0 .. / m / I k CD B k ( E 0 w 2 z c a)