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HomeMy WebLinkAboutCreedon & Co. Youth Soccer 10/7/2018Commonwealth 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:. CREEDON AND CO., INC. Whose place of business is: CREEDON AND CO., INC. - MANSFIELD YOUTH SOCCER TOURNAMENT 50 PLYMOUTH ROAD PERSON(S) IN CHARGE: JOHN CREEDON/JULIE CREEDON Permit Expires: October 07, 2018 Food Fee: License Number: T-16 WAIVED BOARD OF HEALTH Michae(-%1cCCean, Chairman FOR B USE ONLY Date Received Permit Fee Approved By Temporary Food Establishment Permit (Application must be submitted at least 7 business days before i Permit # plication 1) Establishment Name: C r-e.ta on C-t 1 d 0 Q (- 1 j `C ' 2) Establishment Address: 3 q -JQ I m o. R o (,Ld L1 Q rc e'(sitrr M rV 0 1 0 0 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: j,�-v 7q U - ' j J Applicant Owner Name & Title: n rn o ch n e - rY) arKf 1i n M, �II^ 6) Applicant/Owner Address: I -0 (m 6c � U" W o rc e ftr 6 I L0 J I r l� 7) ApplicantlOwner Telephone No: ITU- l qa - 3 ( 00 8) Applicant/Owner Email address: om @ c)-'tEd o r) Q K d cc). Ct o m -I , 1 ' /� .p 9) Person Directly Responsible For Onsite Operations: 'Vo h n Crc-C `t-(��PR `�,f'1�1�'{ e l--r e l.-d Name & Title: J o h n c 1° ed Q I l P r'.e S 16 l� f. -I- Address: 39 701m6-_I366-� 1UdrCe5-t,a) mP- 01L00y Telephone No: �-5 `- I l a- 3 I O 0 Fax: Emergency Telephone No: MO- .- �i t f I- (3 3 10) Event Attending m "6 h if l d you* �S o suer 10 0 t r o l t. t o t- Date(s): ' Q to 1 0r' Event Name: �j%, Cr/� p- M {-y� r 1 t (,t,' o FI r l d y (i f t �/�occ f -To 1A-+ n a-r' 1`-" r Event Location: }0 J V � 1 t l t o uth O (L d Event time: rn - m 11) Check one Food Truck XCaterer Other: 12) Solid waste disposal plan: /� B ro tn..vt h+ back IT C ,, "� e d U n hh'' 13) Water Source: N/A 14) Sewage disposal plan: 13r0L,(-gh+ hc-Ck to Cre�cif�n btUYl 15 ) Please give a brief description of the food to be served: MENU A-r AC H C-f) )q )n A 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hotl cold holding temperatures X 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 r-� Food Safety Manager: uw-A,l/ Cry e ��d o' Iy� i Allergen Awareness: — dul - c � 1.1 r L, r 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: 1, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the 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 copies of 105 CMR 590.000 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 "L=1 s and paid state taxes required under law. 20) Social Security Number or Federal ID: l/ 1— a cgs-v' 3 21) Signature of Individual or Corporate Name: / Food Protection Questionnaire for Catered Events Date of Event: 0 CD` ) g Event Time: AL M__ Location of Event: I f� m fh R ©(t- c' List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating -tamarNa - c c o kle-d t ix Food Manager Certification Person Trained On Site? Allergen Awareness Menu Label Present? XYes XYes I I No Potentially Hazardous Food (PHF) and the individual intended temperature required: rlt L-L s (00 6 --- t (AC -I _ List the required temperature for each food as it leaves your preparation site: 7 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 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. DOGS 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. �WA,'t_ b,1 S gnature of Individual or Corporate Name by: Corporate Officer (Mandatory, if Applicable) ey-Q97as W 3 "Social Security No. (Volhmtory) 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:AUseis\sleileADesldopAScotl's DoatmentsTood Esttblishmenti- Temp\TAX CF,RTIFICATION FORNI.doc The Commonwealth of'Massachusetts Departnrdnt ofhadustrial Accidents Office of 'Investigations 600 Washington Street If Boston, MA 02111 www. m ass.goV1dla Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C re.)e d oYl Address: 3 q Jo � m c- Road d #: M_ qqa - ,3100 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no T ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity, [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]*' 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care /� with no employees. [No workers' comp. insurance req.] 12. Other Safi f, r *Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy intruncation. **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 #I. f ant an employer that is providing workers' compensation ins^in-ynt iiee for my employees. Belmp is the oltcy htfm•arattioil. Insurance Company Name: z e fn � GcS yer I n t5 tLr" c e Ua -e_net4 Insurer's Address: City/State/Zip: 0 S h r- A V Policy # or Self -ins. Lic. # 15 :�_i—Qt— Expiration Date: 3 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 advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do horohv rPvt;Ao ender the nains and nenafties ofneriury that the information provided above is true aad correct. www.mass.gov/dra Mansfield Board of Health Request for Fee Waiver for Food Permit Date 9 m � _ We c re e hrf 0.n d C O , , Inc (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: xThis is a request from a town department. 1 Please list the department: M an SDI � ICI yO Utth L 0CC e K �h ❑ We 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: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, Signature — OF�ce and MQ..rkelih� Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: g Creedon and C.o..I t'.atnno�. R�rtn G fivvLLs Client/Organization Event Date Mansfield Soccer Tournament 10/6/2018 (Sat) Packing List Saturday, October 06, 2018 #E04887 IN PLACE 6:00 am Booking Contact Site Contact Sales Rep John Creedon John Creedon Amy Penney Event Description Booking Tel Site Cell Guests Concessions (508)792-31000 (508) 792-3100 3000(Pln) - Delivery Location Site Name Site Address Site Telephone Mansfield Youth Soccer Fields 50 Plymouth Road, Mansfield, MA (508) 422-6034 Delivery Date and Time Date Delivery Start End PartyTrack Order# 10/6/2018-Sat 6:00 am 7:00 am 5:00 pin 34697 Food & Beverage Food/Service Items Qty "Concession Stand" Coffee -Large Cup with Lid-3 thermos 3 Hot Chocolate (2 Thermoses) 2 25 Cases Assorted Soda & 30 Cases Bottle Water per I Day 5 Cases Very Fine Juices & 4 Cases Welch Juice I Breakfast Pastries-75 Large Muffins/24 Bagels I Egg, Bacon, Cheese Sandwiches-60 per Day 60 Yogurt with Fruit and Granola-50 per Day 50 Assorted Sandwich Wraps 50 per Day 50 **Chicken Caesar** Hamburger and Cheeseburgers- 10 Cases per Day 400 Jumbo Hot Dogs-5 Cases per Day 200 6 Cases French Fries -per Day 6 Powerbars/Protein-4 Cases Total 100 Sausage, Peppers/Onion Grinders-75 per Day 75 Case Chips 2 Large Fruit Cups-50 per Day 50 Chicken Caesar Salads-25 per Day 25 2 Cases Bananas Total I 10 Cases Chicken Fingers with French Fries I Chicken fingers only Notes Concessions for Soccer Tournament 9/14/2018 - 10:36:07 AM Page 1 of 2 Last Revised: 8/2/2018 (3:02 pm) El NwNt Packing List Sunday, October 07, 2018 Cre--don end Co." #E04888 IN PLACE Cninrin„ lows , rvm(" 6.00 am Client/Organization Event Date Booking Contact Site Contact Sales Rep Mansfield Soccer Tournament 10/7/2018 (Sun) John Creedon John Creedon Amy Penney Event Description Booking Tel Site Cell Guests Concessions (508) 792-31000 (508) 792-3100 3000 (Pln) Delivery Location Site Name Site Address Site Telephone Mansfield Youth Soccer Fields 50 Plymouth Road, Mansfield, MA (508) 422-6034 Delivery Date and Time Date Delivery Start End PartyTrack Order# 10/7/2018-Sun 6:00 am 7:00 am 5:00 put 34697 Food & Beverage Food/Service Items Qty "Concession Stand" Coffee -Large Cup with Lid-3 thermos 3 Hot Chocolate (2 Thermoses) 2 25 Cases Assorted Soda & 30 Cases Bottle Water per I Day 5 Cases Very Fine Juices & 4 Cases Welch Juice I Breakfast Pastries-75 Large Muffins/24 Bagels 1 Egg, Bacon, Cheese Sandwiches-60 per Day 60 Yogurt with Fruit and Granola-50 per Day 50 Assorted Sandwich Wraps 50 per Day 50 **Chicken Caesar** Hamburger and Cheeseburgers- 10 Cases per Day 400 Jumbo Hot Dogs-5 Cases per Day 200 6 Cases French Fries -per Day 6 Powerbars/Protein-4 Cases Total 100 Sausage, Peppers/Onion Grinders-75 per Day 75 Case Chips 2 Large Fruit Cups-50 per Day 50 Chicken Caesar Salads-25 per Day 25 2 Cases Bananas Total I 10 Cases Chicken Fingers with French Fries I Chicken fingers only Notes Concessions for Soccer Tournament 9/14/2018 - 10:36:08 AM Page 1 of 2 Last Revised: 8/2/2018 (3:01 pm) El -4� E® CERTIFICATE OF LIABILITY INSURANCE DD DATE,M,I2018 Y, OSl7012018 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(&), 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 CONTACT Joseph Zenmilis Zemakis/Baker Insurance Agency PPIHCNa Ext: ONE 1508)752-7777 FAX . Not(508)752-8580 EMAIL Izemaitis@zemaitisbakeccom ADDRESS: 108 Shrewsbury Street INSURER(S)AFPORDING COVERAGE NAICa Suite 201 INSURERA: Ohio Casualty Insurance Co 24074 Worcester MA 01604 INSURED INSURER B: Continental Indemnity Co. 28258 INSURER C:_ Creedon And Company Inc INSURERD: -..- 39 Joimo Rd INSURER E INSURER F: v— Worcester MA 01604 COVERAGES CERTIFICATE NUMBER: CL1851001657 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. _ MSR LTR TYPE OF INSURANCE INSO Me POLICYNUMBER POLICY EFF 'POLIOIYYYY POLICYEXP Lr.IfODRYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR BK055313020 1011112017 10/11/2018 EACH OCCURRENCE S 1.000.000 PREMISES Ea oaurrence 5 300'090 GEN'L X OLD E%P dmy and Deism) 5 15,000 PERSONAL&ADV INJURY S 1,000,000 AGGREGATE WAIT APPLIES PER: POLICY F�] jE'CT'1:1 LDC OTHER' GENERAL AGGREGATE S 2,000,000 PRODUCTS - CONPIOP AUG 5 2,000.000 LIQUOR LIABILITY S 1,000,000 'S A AUTOMOBILE LIABILITY ANYAUTO OWNED X SCHEOULEO AUTOS ON LY AUOE HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY BA055313020 10MI12017 10/1V2018 COMBINED SINGLE LIMIT 1,000,000 BODILY INJURY IPer persomt BODILY INJURY P.,aoudehij S PROPERTY DAMAGE Perac.dent S Medical payments S 5,000 A X UMBRELIA HAS EXCESS LIAR X OCCUR CLAIMS -MACE US055313020 10/11/2017 10/11/2018 EACH OCCURRENCE S 5.000,000 AGGREGATE S 5,000,000 bEb I X RETENTION $ 10,000 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY FFtCEN EMBERIPARTNEWEXEWTNE OFFIOE.ry lh NER EXCLUDE09 (MandatorylnNHl It yes. descrme under DESCRIPTION OF OPERATIONS bebw NIA 37-833435-01-01 05/0312078 0510312C19 X STATUTE ERH E I. EACH ACCIDENT_ 1,000,p00 s -— EI,. DISEASE, EAEIl.PLOYEE S 1.000.000 E.L. DISEASE - POLICY LIMIT 1,000.000 $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarka Schedule, may be attached It more space is required) 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. AUTHORIZED REPRESENTATIVE / ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD PIN: FM-17-1668 CITY 'OF' WORCESTER, MA Department of Inspectional Services 25 Meade Street, Worcester, MA 01610 Phone:(508)-799-8539 FOOD ESTABLISHMENT PERMIT PERMIT EXPIRES: Mondav, December 31 2018 EFFECTIVE DATE: Monday January 01 2018 2018 PERMIT FEE: $250.00 In accordance with Regularions promulgated under authority of M.G.L. c. 94, ss 305A; c. 111, ss. 5 123A, 105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to: Name of Permit Holder JOHN W.S. CREEDON Address of Permit Holder 39 JOLMA RD, Name of Food Establishment CREEDON AND CO., INC. Address of Food Establishment 39 JOLMA RD OPERATIONS PERMITTED Food and Drink Establishment 1 - 100 Occupancy 1 Comments: Restrictions: Common Notes: Renewal of Permit: DURATION OF PERMIT Annual An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the expiration of the permit. Notification of Changes: This permit is non -transferable. A permit holder shall notify the CIS at least 30 days prior to any change. If this business is to close or there is a change in ownership, The DIS must be notified at least two weeks prior to closing and this permit must be returned to the DIS. Director of Housing and Health Inspections Post Conspicuously ig o v o ..,; y p d D D T � CA) - Nm v� uO 0'O n u D VI m N a s X p T 3 =a o o y o p m p DT a Z p 1� � o = o n 3 o � T � O v m ^ o � _ nX w v 3 m 0 _ � �w u « Q� z � z � � � CA con W-4 z W-4 P4 � � � \� s \ \\\\ \ /}} \ 6 3 / » tz &