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Home My WebLink AboutOlson Restaurant Group 9/15/2018Commonwealth 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:. OLSON RESTAURANT GROUP FOXBORO Whose place of business is: OLSON RESTAURANT GROUP FOXBORO - MANSFIELD BOOSTERS FUNDRAISER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOHN JULIO Permit Expires: September 15, 2018 Food Fee: $25.00 License Number: T-MOBILE-2 BOARD OF HEALTH -%4ichaeCMcCt6an, 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: D�SO✓� 2) Establishment Address: lJ-G7 )�w {,r-z a'/" Q(4-4 thou-d �rtr- G•a.p ,y 3) Establishment Mailing Address (if different): �14 ,y �.++� S.Y 30, l- 76 3 / J, S '-t 4) Establishment Telephone No: ..�f_j .-j'�-7 1 5) ApplicanVOwner Name & Title: 50C- (} (S O,, 6) ApplicantfOwner Address: y Leb6.n d� `l0 iK wt — 34- S 0, 1-c- '7 , J /• 7) ApplicanVOwner Telephone No: .7 �( �� Z `j 1- 7 r / 8) ApplicantlOwner Email address: UC C r Coil 9) Person Directly Responsible For Onsite Operations: Name & Title: 0 h % +t Address. G 174C-t S'r Tc -'-' tc �• .uc- p d 7 tiG Telephone No: &- .5.5 9-- 6 7 9 6 Fax: Emergency Telephone No: eft '3 _ '3-6 s• 7 10) Event Attending Date(s): Event Name: Event Location: t Event time: 11) Check one VFood Truck Caterer Other: 12) Solid waste disposal plan: i0, y 7C,sc <i O'F- 't- 3-6 Z f nl c.-r=t •- .fhJ ro ern rL 13) Water Source: /n� I ,)'6. j Pc%rz 0'r iJ( -e, Co yY era 14) Sewage disposal plan: SGNwG ems' a_i30 ✓e-. 15) Please give a brief descdption of the food to be served: f�dEd Geld 5JbS d S dwac�•J. �c.n e Sa fcr hoT r- i - `/ Food Protection Questionnaire for Catered Events Date of Event: he's" / V Event Time: ,b 4" — Location of Event: H n' hl 6. 4�r '11'S F+ C4 1! List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating ��..)+ Nye<„fr' $.J -k, C, 4, ]�bl r Food Manager Certification Person Trained On Site? 1,' es . 1 No Allergen Awareness Menu Label Present? i.e'S'es No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: Sbcwc.d Slcat+- "I z YC t-tz ilt-Iz N1 v�' CL�sc- List the required temperature for each food as it leaves your preparation site: a, r// AW How will the PHF be kept ator below4l°F? &rf,-4cr A,J c)n, tf o, }ry ,/ How will the PHF be kept at or above 140°F? a (t t+,,,,. s Time ofPHF? Setup 4/'.30 Served s_s�.-,, Removed g't36 +�w�c•�•j List all equipment that will be supplied for an event, including but not limited to food thermometers, clean)/n//g,/wipes, utensils, non latex gloves, heating utensils, ice etc. j'l;1,1 --------------- �j oY.lJ 16 ) Food will be prepared: K Onsile for immediate consumption eC Onsite and held at proper hot/ cold holding temperatures oL. OHsite and held at proper hot/ cold holding temperatures Offsite, cooled and reheated on site Other: /4-11 ofz-r„3 rrc or_4_(z-p1er d'dz 17) If PHF is being served, please list the person who has completed the following trahungs and attach appropriate certificates: ✓ Food Safety Manager: J (TAn � U 1, 0 ✓ Allergen Awareness: J 011 w 3 U i r d 18) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit: 4-6 )--A c r J For food tracks, please list additional communities where a food permit is held and attach copies of the permits: prG 5 4U t7 I, the undersigned, attest to the accuracy of the information provided in this application and I affirm thatthe 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 cyy94pies of 105 CMR 590.000 and the federal Food Code. 19) Signature of Applicant: , ��cc...o<�' : f Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, 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: "/0-LO'3-/53 t/ 21) Signature of Individual or Corporate Name: 0 ✓1 L �'�'- 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. Signature of Individual or Corporate Name By: orporate fflcer (rMandatorq, IfApplicsble) y6 -lo36ts3y "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 lUsersklci(clUcskmpScoa3 De,..t ls,F.M Ewblifiments- Temp1TAX CERTIFICATION FORM doc The Commonwealth of Massachusetts T _ Department q% 'In duslrialAcc'idenIs F r I Congress Street, Suite 100 }' Boston, MA 02114-21117 www.muss.gov/din Workers' Compensation Insurance Affidavit: General Businesses, 'I'0 BE FILED WITI THIs PL12,,vIl y rING AI'THORI'rl'. P Business/Organization Nalne: i ' n � ✓ '`� a=�'` -� Address V.J) ! -- r. Phone City/State/Zln: o Lu e I I _ti� Are you in employer? Check the appropriate box: I .t[ I am a employer with. employees (full and/ or part-time).* 1 ❑ I 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, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] F iness Type (required): ❑ Retail � estaurant/Bar/Eating Establishment ❑ Office and/or Sales 011cl, real estate, auto, etc.) ❑ Noil prof t Entertainment MR Manufacturing 1 I.❑ Iiealth Care 12.0 Other.---___---_ •Any applicant that checks box It l mull also till out the seen,),, below showing then workerscompensmion policy mlonmaion. r'll'the corporate officers have exempted themselves. hat the enrporaion has other e nplowes, a workers' annpemm�un policy is aquned and such an Organization should check box N I I am an employer that is providing workers' compensation insur•anc•e jor nrr employees. Below i.s the policy infortation. Insurance Company Name:-'C ' _T Insurer's Address: } t, _�� •'i'_:��- _r =l '/l r'` — " City/State/Zip: cs'L- , Z/--- - j Policy 8 or Self -ins. Lic, 9 J .�' i -=(!(n f Expiration Date: f I j ?r! . Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required wider 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 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. 1 do herehv certifj,, under the dins and penalties of perjury that the information provider/ above is true and correct. t Sienature:�r rt'} � Date: Cf^ f FEOfficialuseonly. Do not write in this area, to be completed bycity or town of Rein(. wn: Permit/License #hority (circle one): Health 2. Building Department 3. Cityrrown Clerk 4. Licensing Board 5. Selectmen's Office rson:--___ _ Phone k; wwwcmass. gor,uw WYYYY A`4ORbr CERTIFICATE OF LIABILITYINSURANCE DATE(xx/zo/o17MMID2017I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CO FERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND R ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONI RACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy()es) triust be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsemen . A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). Eastern InSUrSJCe Group LLC 233 West Central St ( rxoxE »� (800) 572-4538 1 in,A ,,,.781-586-8244 Natick mA 01760 INSURERA adia Insurance CoMpany 31325 INSURED INSURER 0:TeChnOlOoV Insurance Co Olson Restaurant Group Foxboro, LLC INSURERC: 840 Main Street INSURER D: Suite 203 INSURERE: Millis NA 02054 INSURER F: ewrec PCCTIOPATC 1JI nACCO Ii-iR TA Ahilil- RFVimnNN11MRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS 3UrD 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. ILTR TYPE OF INSURANCE A UBR PODCY NUMBER PO MW ICY EFF 0 POLICY MWDDPEXPYYYY UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A CLAIMS -MADE ®OCCUR p E - emmerce $ 300,000 MEDEXP(Anyonepelson) $ 10,000 ADV5261986 11/ 1/2011 11/21/2018 PERSONAL &AOV INJURY $ 21000,000 GENL AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $ 4,000,000 PRODUCTS - COMPIOP AGG S 4,000,000 R POLICY 0 PHIECT � LOG Employee Benefits $ 2,000,000 OTHER: AUTOMOBILE LIABILITY M NED I L L Ee as iL $ BODILY INJURY (Pot person) _ $ ANY AUTO BODILY INJURY (Pat student) 5 ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Pent eracdd - $ S R UMSRELLAUAB X OCCUR EACH OCCURRENCE $ S,000,000 AGGREGATE E 5 000 000 A EXCESS UAS CLAIMS -MADE DED R ENTI0N$ $ CUAS281981 11/ 1/2011 11/21/2018 B WORKERS COMPENSATION AND EMPLOYERS' UASILITY ANY PROPRIEfORIPART MEXECUTNE YIN OFFICE(Mandatory In H)E%CLUDED7 ❑Y OFFICE NEM NH) NIA MC3667357 11/ 9/201711/19/2018''E.L.DISEASE-EAEMPLOYE R STAT E OERH E.L. EACH ACCIDENT $ 500,000 $ 500 000 E. L. DISEASE -POLICY UNIT E 500,000 IDESC( yes, d90'uRI[PTIONN OFrAef DPERATIONS belwt DESCRIPTIONOFOPERATIONS/LOCATIONS/WHICLES(ACORD tat, AOdIUOn4l Remarks schedule, may be al Acheal "mom apace is required) Deli Restaurant TOWN OF FOXBOROUGH 40 SOUTH STREET FOXBORO, t4A 02035 SHOULd ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOR ANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE 1D CORPORATION. All rights reserve ACORD 26 (2014101) The ACORD dame and logo are registe d marks of ACORD INS026 n0/4nn COMMONWEALTH OF MASSACHUSETTS NUMBER Town of Foxboro BHP-2018-0411 Board of Health FEE $50,00 Capriotti's DATE ISSUED NAME January 0 1, 2018 267 Patriot Place Foxboro, MA 02035 IS HEREBY GRANTED A FOOD ESTABLISHMENT (1-100 SEATS) PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2018 unless sooner suspended or revoked. — Board of Health Health Director COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-201 B-0411 Town of Foxboro Board of Health FEE $50.00 Capriotti's DATE ISSUED NAME January 01,2018 267 Patriot Place Foxboro, MA 02035 ..... ..... . ADDRESS IS HEREBY GRANTED A FOOD ESTABLISHMENT (1-100 SEATS) PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2018 unless sooner suspended or revoked. Board of `• �� Health Health Director COMMONWEALTH OF MASSACHUSETTS NUMBER Town of Foxboro BHP-2018-0412 Board of Health FEE Capriotti's $100.00 DATE ISSUED NAME January 01, 2018 267 Patriot Place Foxboro, MA 02035 IS HEREBY GRANTED A CATERING PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2018 unless sooner suspended or revoked. Board of Health Health Director COMMONWEALTH OF MASSACHUSETTS NUMBER Town of Foxboro BHP-2018-0412 Board of Health FEE $100.00 Ca riotti'S DATE ISSUED NAME January 01, 2018 267 Patriot Place Foxboro, MA 02035 IS HEREBY GRANTED A CATERING PERMrr This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2018 unless sooner suspended or revoked. Board of Health Health Director COMMONWEALTH OF MASSACHUSETTS Town of Foxboro Board of Health Capriotti's NAME 267 Patriot Place Foxboro, MA 02035 NUMBER BHP-2018-0469 FEE $100.00 DATE ISSUED January 01, 2018 IS HEREBY GRANTED A MOBILE FOOD SERVICE, CANTEEN TRUCK PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2018 unless sooner suspended or revoked. Board of NOTES: TRUCK / � Health NOTES: TRUCK Health Director COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2018-0469 Town of Foxboro Board of Health FEE $100.00 CaDriotti'S DATE ISSUED NAME January 0 1, 2018 267 Patriot Place Foxboro, MA 02035 ADDRESS IS HEREBY GRANTED A MOBILE FOOD SERVICE, CANTEEN TRUCK PERMIT This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires December 31, 2018 unless sooner suspended or revoked. Health Director Board of Health MRQsTQN INSPECTION cooytrCc nGPARTMENT ' Health Division 1010 Massachusetts Avenue Boston, MA 02118 Telephone: (617) 635-5326 Martin J. Walsh Mayor EstabllshmentIVBA Owner CAPRIOTTI'S CAPRIOTTI'S SEAN OLSON, PRES. 1 CITYWIDE ST 840 MAIN STREET STE. 203 BOSTON MA,02128 MILLIS, MA 02054 HEALTH PERMIT 2018 PERMIT NUMBER PERMIT TYPE PERMIT DESCRIPTION 143687 MFW Mobile Food Walk On Comments: Plate #R87.852 THIS PERMIT EXPIRES: 12/31/2018 This Permit Must Be Posted in a Conspicuous Public Place Complaints regarding the sanitary condition of this establishment may be referred to the Health Division at: (617) 635-5326 www.cityofboston.aov/isd/health a) 6 g wj MOO w CD w U w w U v J w z w P4 z w 1/C�I71� w 0 'vl �•y � �y N 4 , y.� �O w wa � �tla v Z v 7 12 � lei ch o