HomeMy WebLinkAboutPepsi Beverage Co. 10/2/2018Commonwealth 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: TEMPORARY 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:.
,/:10I014do1*IIN14WA
Whose place of business is:
PEPSI BEVERAGE COMPANY - 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING
@ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
ABBY HOOVER - USM
Permit Expires: October 02, 2018
Food Fee:
License Number: T-23
WAIVER
BOARD OF HEALTH
MichaeCMCCCean, Chairman
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
ii- Establishment —Name:—,
hment Addrass;
3) Establishment Mailing Address (H differeng.1
4) Establishment Telephone No:
_5j*_Xp_pFIcant/Own9r —Nams & Title.
-if 4P_IIcsnVOwnar Address:
7) ApplicantfOwner Telephone No:
8) ApplicentfOwner Email address!
0) Person Directly Responsible For Onatte Operations:
Name & Title:
Addrese:
Telephone No: Fax:
Emergency Telephone No:
10) Event Attending
Data(s):
Event Name:
Event Location: I
Event time:
!eO
12) Solid waste disposal plan:
11) Check one
Food Truck
caterer
Other;
13) Water Source:
14) Sewage disposal plan:
of the food to be served:
t Kjo A
Si
----- ---- ---------- -
Food Protection Questionnaire for Catered Events
fr 9
Date of Event t o fir, Event Time: '
Location of Event: ),OA oH-- , C-Rx'A«a-
List all foods that you will be chilling, holding, cooldng, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
__�tJ,_1- ram_—_ 1•.�.4�� T�
Food Manager Certification Person Trained On Site? Ax I'M C No
0 Yes
Allergen Awareness Menu Label Present? � 11.� ❑ Yes ❑ 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:
t�' del
How will the PHF be kept at or below /, , ( $)
41'F? --.. --
Removed - - _--
How will the PHF be kept at or above t -
140'F?
Time of PHF? Setup Served
�—
List all equipment that will be supplied for an event, including but not limited to food thermometers,
cleaning wipes, utensils, non latex gloves, heating utensils, ice etc.
10) Food will be prepared:
Onslte for Immediate consumption
Onshe and held at proper hot/ cold holding
temperatures Offsite and held at proper hollcold
holding temperatures Offshe, cooled and reheated
on site Other 1
17) if PHF le being eerved, please Ilot the person who has completed the following training$ and attach
certificates:
Food Safety Manager:_,,,,_
Allergen Awareness �`..
18) For caterers: CIty/Town where food establishment permit Is hold. 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:
nl�f
1, the undersigned, attest to the accuracy of the
establishment operation will comply with 106 C
the board of health on how to obtain coplo"li'
19) Signature of
provided In this application and I affirm that the food
rnd all other applicable law. I have been instructed by
.000 and the federal Food Code.
Pursuant to MOIL Ch. 62C, sac. 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 10 i " , rt
21) Signature of Individual or Corporate Narne �r
Please include copies of
ServeSafe ie ', to Allergen
training certificates
TAX CERTIFICATION FORM
I certify under the penalties of perjury that L to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
'f
Signature of I dividu�al ,or Corporate Name 83Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
*TWo license will not be issued urdess this certification clau8e 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:1Ueembte1e0ok1oplEcof0s 13mmontlWood Establishments-Temp1TAX CERTIFICATION FORM.doc
Department of IndustridAccidenis
Ohice of Investigations 600 Washington
Street Boston, MA 02111 www.nrass.gov/dia
Workers' Compensation insurance Affidavit; General Businesses
Applicant Tnfprmatinn please
Print Legibly
Business/Or anizadonName.._.�t-t
ti
Address;______
(1/State/7i_t .Phone
Pho
)nCev#:
': t,t• � :: i Y-.}.—, i,t J
Are you an employer? Check the appropriate boxt
1. I am a employer with �t ei t) 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, § I (4), and we have
no employees. [No workers' comp. Insurance requited]** 4.
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. Insurance req.)
Business Type (required);
5[ Retail r
6. Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl, real estate, auto, etc.)
8. Non-profit
9. Entertainment
10. Manufacturing
11. Health Care
12. Other
*If the em"to officers have" mpted themselves, but the corporation has otheremployera, a workers' compcosatton policy is required and such an
rtgenimtion should check box el.
' am as employer that Is provtd/ng workers' compensation Insurance for my employees Below 6 the polhey Wormadon
nsusance Company Name: f_ t tI .Eu,�- t' nK )7r, t v'_ - /?&- �%o t <.
nsurer's Address:_ L 1V L 9 1 ��12 V
7 ,$ 10
1 :ity/State/Zip:.. 1.Ie--11c-_1,_ j'6`r',d.,}
'olicy # or Self -ins, Lie. #_ _ Srq f--; _2 oq "p :�3 Expiration Date:
%ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
?allure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
Inc 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
)f up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
nvestigadons of the DIA for insurance coverage verification.
'do hereby ceH&, anr(r:rgie pains rind penuldes of perj'ury that the ift/brnladon provided above is true geld correct
,hone M 4
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[0-07clal use ouly. Do not
or Town:
s area, to be completed by city or torus
Permit/Llcense #
suing Authority (circle one):
Board of Health 2. Building Department 3, City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Other
Phone P
www.moes.gov/dis
MEMORANDUM OF INSURANCE o1 oaizol6
THIS MEMORANDUM OF INSURANCE IS FOR AUTHORIZED VIEWERS ONLY. USE, DUPLICATION OR ALTERATION OF THIS
DOCUMENT, WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE INSURED, 18 EXPRESSLY PROHIBITED, THIS MEMORANDUM IS
FOR INFORMATIONAL PURPOSES ONLY AND DOES NOT EXTEND, ALTER OR AMEND THE COVERAGE NOTED OR CONFER RIGHTS
UPON ANY VIEWER OR OTHER PARTY. COVERAGE DESCRIBED BELOW IS AS OF THE ABOVE DATE.
PRODUCER
LOCKTON COMPANIES
2100 ROSS AVENUE, SUITE 1400 DALLAS TX 75201
214-969.6700
INSURED
roaea/a
PEPSICO, INC; FRITOLIY NORTH AMERICA, INC; QUAKER
OATS CO; PEPSFCOLA METROPOLITAN SOTTLINGCO,INC, TROPICANA PRODUCTS, INC.;
NEW SERN TRANSPORT CORP, BOTTLING GROUP, LLC; IZZE SEVERAOE COMPANY; THE
GATORAOE 00, NAKED JUICE 00. OF OLENDORA, INC. 700 ANDERSON HILL RD.
PURCHASE NY 1057
COMPANIES AFFORDING COVERAGE
COMPANY A: ACE Amedcan Insurance Company
COMPANY B: Indemnity Insurance Cc of North America
COMPANY c: ACE Fire Underwrtters Insurance Company
COMPANY D: Agri General Insurance Company
COMPANY E:
! COVERAGES 'PEPSI01 _
_._.--.__._...__..... ...- ----------------
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
.TERM EXCLUSIONS AND CO_NDDIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS., _
OD — I POLICYEPFECTA'E POLICY EXPIRATION
LTR TYPE OF INSURANCE,. POLICYNUMBER DATE DATE UMITB
A owwALUAanv HDOG27872336 1/1/2018 1/1/2019 EADHocaRRwce 6000,000
COMMERCIAL GENERAL L y•meo _rme i12000,000
a
LIABILITYOCURRENCE DAMAGE
, 1000
GEN'L AGG LIMIT pauoNua rvouyP 6,000 000
.APPLIES PER: POLICY 1 6,000,000 j
4NYAT0MPLITY See Attached '1/1/2018 11/1/2019 COI®BEDRNBLeLIMIT 1 See Below
BODILY DIJURY __
. eDDarwwNr
f I PROPFAIY DAIMON
EXCESS UABBITY NOT APPLICABLE! ,toi urry9E_ 1
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ADDITIONAL INFORMATION
ADDITIONAL NAMED INSURED: FRITO-LAY, INC., ROLLING FRITO-LAY SALES, LP; FL TRANSPORATION, INC.; 17ZE
BEVERAGE COMPANY; QUAKER OATS MANUFACTURING; SVC MANUFACTURING INC.; STACY'$ PITA CHIP CO.; PEPSI-
COLA SALES AND DISTRIBUTION, INC.; PEPSI-COLA TECHNICAL OPERATIONS, INC; P-AMERICAS, I.I.C.
PEPSICO SALES, INC; PEPSI-COLA ADVERSTISING AND MARKETING, INC.
SEE ATTACHED FOR ADDITIONAL INFORMATION.
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EaiSaR D•W oyu
ADDITIONAL INSURED IS ANY PERSON OR ORGANIZATION FOR WHOM THE
NAMED INSURED HAS SPECIFICALLY AGREED BY WRITTEN CONTRACT TO
PROVIDE ADDITIONAL INSURED STATUS, SUBJECT TO POLICY TERMS,
CONDITIONS AND EXCLUSIONS, PROVIDED THAT:
A) THIS INSURANCE APPLIES ONLY TO EACH COVERAGE WHICH THE NAMED
INSURED HAS AGREED TO PROVIDE BY WRITTEN CONTRACT, BUT IN NO EVENT
SHALL THE COVERAGE EXCEED THE COVERAGE OTHERWISE AFFORDED BY THE
POLICY.
B) THE AMOUNT OF INSURANCE IS LIMITED TO THAT REQUIRED BY SUCH
WRITTEN CONTRACT, BUT IN NO EVENT SHALL THE LIMITS OF LIABILITY
EXCEED THE IMITS OF LIABILITY PROVIDED BY THE POLICY.
C) THE INSURANCE APPLIES ONLY WITH RESPECT TO LIABILITY ARISING OUT OF
THE OPERATIONS, ACTIVITIES OR BUSINESS CONDUCTED BY OR ON BEHALF OF
THE NAMED INSURED.
Mansfield Board of Health Request for
Fee Waiver for Food Permit
Date
We, _(restaurant/ organization )
request a waiver of the Food Service Permit Fee for the following reason:
This is a request from a town department.
Please list the department:
We are are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. .
We are donating ALL proceeds earned directly to a 501(c)(3) organization. "
Please list the organization: //}}
%"m' 0('K, 44 'e?4oy't We are not charging a fee
for food/drink being served.
We are a religious organization.
Other: The Taste of the Tri•Town
Thank you,
Signature
Title
"Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Signature: Date: