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Home My WebLink AboutFriskie Fries 5/17/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. RANDY DANTUONO Whose place of business is: FRISKIE FRIES - DISTRICT ART SHOW MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: PABLO GONSALVES Permit Expires: May 17, 2018 Food Fee: $25.00 License Number: T-11 BOARD OF HEALTH Michae[McCtean, 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: :�/�l /Af 2) Establishment Address: 7�/ e �5y/G' L�x�..iz1� �J �^ ,_ W 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant/Owner Name &Title: - �.rsi�/'— 6) Applicant/OwnerAddress: a --. / SJ t�'. /`!!!� e 7) Applicant(Owner Telephone No: G✓ 8) Person Directly Responsible For Onsite Operations: Name & Title: 0 ,{,/,5 / ues Address: Telephone No: EJ Fax: Emergency Telephone No: 9) Event Attending Date(s): Event Name: ✓✓✓"' "��___ Event Location: �� Event time: 10) Check � one s� L4,- ood Truck ❑ Caterer ❑ Other: 11) Solid waste disposal plan: 12) Water Source: 13) Sewage disposal plan: 14 ) Please give a brief description of the food to be served: 15 ) Food will be prepared: ❑ Onsite for immediate consumption Lr 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: 16) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: �! [3--Pood Safety Manager: e,/f' /J 1 ❑�AllergenAwareness: � /.�'� ��✓�GI✓�Z� 17) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit: For foo trucks, plea a list additional communities where a food permit is held and attach copies of the permits: I, the undersigned, attest to the accuracy of the information provid d'in this app' ation and I affirm that the food establishment operation will comply with 105 CMR 690.000 and • 1 other aol!qdble law. I have been instructed by the board of health on how to ob ain p' s of 105 CMR 590 00 and a deral Food Code. 18) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the pena ' s of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. % 19) Social Security Number or Federal ID: 7g Sc'� � 52 20) Signature of Individual or Corporate Name: Food Protection Questionnaire for Catered Events Date of Event: Location of Event: ,/ it Time: 5 List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: Cooking Reheating Food Manager Certification Person Trained On Site? ❑ Yes ❑ No Allergen Awareness Menu Label Present? ❑ Yes ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List theyequiretemperature for each food as it leaves your preparation site: 4L,rE 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. (/ �'sf /S 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 **Social Security No. (Voluntanj) 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\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization N Address: �7 J / G ` City/State/Zip: 5 Pho�' ne #: i`Cyf ` Are you an employer? Check the appropriate box: Business Type (required): 1. FrI am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ 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 I0. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I LEI Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I am an employer that is providing_ workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: -60;C) Policy # or Self -ins. Lic. # t20005 bee P'� % Expiration 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 $1,500.00 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 d that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance c rage rification. I do hereby certify, under the pains dial peira�es ofperjury that the information provided above is true and correct. l phnna#• 17V/'-/>/ 1/%/15f< 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 Phone #: www.mass.gov/dia 1 Beacon Mutual Insurance Co. Account Holder: Address: Policy Information Page Friskie Fries, LLC 751 Hartford Avenue Johnston, RI 02919-5424 Date: December 19, 2017 Policy Number: 0000080257 Agent Name: Slaleline Insurance & Financial Services Inc Agent Address: 520 North Broadway East Providence, RI 02914-2132 Phone: (401)438-8345 Agent Number: 01285 NCCI Carrier Code: 30325 Named Insured: Friskie Fries, LLC Dec Type: Amended Group Affiliation: Endorsement Reason Endorsed to Audit Figures Transaction Date: 12/19/2017 Policy Number Endorsement Effective Date Endorsement Expiration Date Account Number 0000080257 1 12 07 2017 1 12 07 2018 1 20508826 2 Policy Period 3 A. Workers' Compensation Insurance: Part one applies to the Workers' Compensation law of Rhode Island. B. Employers' Liability Insurance: Part two applies to work in Rhode Island. The limits of our liability are: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY IN CRY BY DISEASE $500,000 POLICY LIMIT BODILY IN URY BY DISEASE $500,000 EACH EMPLOYEE C. Endorsements & Schedules: Endorsement Endorsement Endorsement I Endorsement BE 00 00_01 - WC and BE_00_00_OIA - BE 00 00 06 - Officers and BE 00 00 30 - Pay as You Employers Liability Policy Cancellation Endorsement Other Exclusion Go Terms and Conditions Endorsement This is not an Invoice Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com Underwriting: 401.825.2667 1 Toll Free: 1,888,886.4450 BE_00_OD_14_V9 Page 1 of 3 a ''Beacon Mutual Insurance Co. Date: December 19, 2017 Policy Name: Friskie Fries, LLC Policy Number: 0000080257 4 Classifications & Rates: The premium for this policy will be determined by our manual of rules, classifications, rates and rating plans. All information required below is subject to verification and change by audit and premium surcharge as allowed by law. There might be additional codes associated with this policy than those listed here. An Extension of Information Page (BE_00_00_14B), might be included if there are additional codes. Premium I Class Description Class Type Estimated Rate Estimated Period Payroll Premium 12/07/17 9083 Restaurant: fast food Standard $162,007 1.77 $2,868 12/07/18 1 Premium Detail: Manual Premium $2,868.00 Waiver of Subrogation Charge $.00 Employers' Liability Increased Limits: .008 effective 12/07/17 to 12/07/18 $23.00 EL Increased Limits Balance to Minimum Premium $52.00 Manual Premium Sub -Total $2,943.00 Experience Modification: 1.00 effective 12/07/17 to 12/07/18 $.00 Modified Premium Sub -Total $2,943.00 Adjustments to Manual Premium - Scheduled Credit/Debit of.00% $.00 - Loss Free Credit of 0% $.00 - Miscellaneous Credit of 0% $.00 - Balance to Minimum Premium $.00 Standard Premium Sub -Total $2,943.00 Adjustments to Standard Premium - Premium Discount $.00 - Expense Constant $215.00 - Miscellaneous Premium Adjustment $.00 - TRIEA/TRIPRA: 1% of payroll effective 12/07/17 to 12/07/18 $19.00 - DTEC/Catastrophe (other than certified acts of terrorism) 1% of payroll effective 12/07/17 to 12/07/18 $19.00 -Audit Noncompliance Charge .00 Estimated Annual Premium $3,196.00 Additional Premium $1,675.00 This is not an Invoice Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutuatcom Undemriling: 401.825.2667 1 Toll Free: 1.888.886.4450 BE_00_00_14_V9 Page 2 of 3 4`Beacon Mutual Insurance Co. Date: December 19, 2017 Policy Name: Friskie Fries, LLC Policy Number: 0000080257 Other locations, endorsements, insureds, and/or classifications, if any, are shown on extension pages of this Information Page. Changes to a Pay As You Go policy will adjust the net rate and future payments. You will not be invoiced separately. This is not an Invoice Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com Underwriting: 401.825.2667 1 Toll Free: 1,888.886,4450 BE_00 00 14 V9 Page 3 of 3 >_Beacon ' - 7 Mutual Insurance Co. Date: December 19, 2017 Workers' Compensation and Employee's Liability Policy Policy Number: 0000080257 Transaction Date: 12/19/2017 Insured: Friskie Fries, LLC Policy Period: 12/07/2017-12/07/2018 Account Number: 20508826 Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconnutual,com Underwriting: 401.826.2667 1 Toll Free: 1.888.886.4450 BE_00_00_14A_V3 °.Seacon Date: December 19, 2017 Mutual Insurance Co. Workers' Compensation and Employee's Liability Policy Policy Number: 0000080257 Transaction Date: 12/19/2017 Insured: Priskie Fries, LLC Policy Period: 12/07/2017-12/07/2018 Account Number: 20508826 Extension of Policy Information Page Risk Locations Risk Location Name Risk Location Address Priskie Fries, LLC 751 Hartford Avenue, Johnston, RI T29062928 Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com Underwriting: 401.825.2667 1 Toll Free: 1,888,886.4450 BE_00_00_14D_V3 _ 4&acon ,a_.":Mutual Insurance Co. Workers' Compensation and Employee's Liability Policy Date: December 19, 2017 Policy 0000080257 Transaction 12/19/2017 Number: Date: Policyholder: Friskie Fries, LLC Policy Period: 12/07/2017-12/07/2018 Account 20508826 Number: Extension of Policy Information Page Officers, Members, and Managers Name Title Status Participation Period Wright, Thomas President Excluded 12/07/2017- 12 07 2018 Dantuono, Randy Vice President Excluded 12/07/2017- 12 07 2018 IIf any officers listed above should be excluded, please file a DWC11 form with the Rhode Island I Department of Labor and Training. Forms can be found on the DLT.RI.gov/WC website. Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beacomnutual.com Underwriting: 401.825,2667 1 Toll Free: 1,888,886.4450 BE_00 00_14F_V1 C O 8 o " WE V .0 `t o d o v o W o• i" M Z _O X W C M W Q E N v O N � w 0) r N Q o CO p .o W pr w a`s M MaIM>IASMN1XVWZIPHP9MnAlelo9oMoo/p/alll/woo'al6006 anpPp:sdllq edrzno DWI uoBjew;o a)eDynjap MZ/Ll/9 5/17/2018 Retail Sales P.ermit.jpeg https:/Idrive.google.com/file/d/OBwg8OtaiyuW5M2FvSl 9PRG1 obFU/view 1 /1 5/17/2018 IMG_33.92.JPC https://drive.google.com/file/d/lj5vgnl-g5iORjg3DpglgUhF-Kh-K1 EWz/view 1 /1 MeinMA95MgIPONxdO1SMnRleaOg6M9O/p/ali;/woo'016006'anup//:sdllq 6adf•asueoilzlgpoop3njl MZ/Lt/5