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HomeMy WebLinkAboutCabot Creamery/LLBean 5K 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:. CABOT CREAMERY Whose place of business is: CABOT CREAMERY - LL BEAN FLANNEL 5 K 280 SCHOOL STREET PERSON(S) IN CHARGE: W, 19 UIR—IM ♦, Permit Expires: October 07, 2018 Food Fee: $0.00 License Number: T-19 WAIVED BOARD OF HEALTH MichaeCMcCCean, Chairman i h7 l / FOR BOARD OF IIEALTH 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: cce 2) Establishment Address: ) / 6 d 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: ry 5) Appiicant/Owner Name & Title: 6) Applicant/OwnerAddress: l 7) ApplicantlOwner Telephone No: r L C 8) Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: i Telephone No: 2 ' _, 2 Emergency Telephone No: 10) Event Attending Date(s): Event Name: L L e Event Location: M o Se - Event time: 11) Check one ❑ Food Truck L�l Caterer LG �.. Other:y1 4 13) Water Source: wil" I=11111 VT osz21 -,/35fl 1 s+. ro k o ea-6,94 e� 6 ee e , (�o A, Fax: c9 12) Solid waste disposal plan: we t) t'�� 6�- po<e 04", 14) Sewage disposal plan: 15 ) Please give A brief description of the food to be served: `, � d !i c,L d e Cti) e f 6� ttf 1` � pre pe- ka, ed e-C,edJ.a. ' 6-41eeSC Food Protection Questionnaire for Catered Events Date of Event: [ Location of Event: List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refri e ated Cooking Reheating cho. Food Manager Certification Person Trained On Site? ❑ Yes RIo Allergen Awareness Menu Label Present? ❑ Yes fio No List {9all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 °F? C rho c i <04 / 2 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. pe{ 16 ) Food will be prepared: ❑ Onsite for immediate consumption p Onsite and held at proper hot/ cold holding temperatures 1 p Q JAr Offsite and held at proper hot/ cold holding temperatures s. --fra +- 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 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 obtai copies of 105 CMR 590.00 d the lederal 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 paidstate ytaxes �required under law. 20) Social Security Number or Federal ID: �) � 21) Signature of Individual or Corporate Name: r,624 c�' {eG 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. �z Signature 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:1Userslsleite\I) sktoplScott's DocumentslFood Establishments- Temp1TAX CERTIFICATION FORM.doc i )ly a lo,(i I te 7K (,>ffl if ll tj A ccidtli is g 600 cha Workxsl Cbmpensalm bm"aw Anns; mant rhasusses QjAbani InAniarimi (11chse 111-iitt h�'l,"HAY UlhupkThHdB,v WANg Ounpact ylkiphybridgwo 1AT 1 Wastafr MiorkArce Moons JAK, Address: 61 Depot Street, First Floor City/State/Zip Lyndonville, VT 05851 Phone: 802-751-aloe aCt° lanplwv W C Ink dw a ppw# me boo L X i arl an omplovni, with (flill aink, ow"d A a j 3 660 F7 , 'Fie- J/00 A",ee-re'vel p 6V4 r- � r) A wi W pallmamsp and how no enijklovy,s woikilqhit ow ill any ciqjhlcil�, (No i"ollip, iniou'lillyS, 3, We am U empWan And in oWns WT awmWed Hovir right C. 15, §1 ( IL am! we Iwo, Stamm byVA"n, v,iT no nyNywo (No* hers cmny hownwc vNj 11knes Ty, MMA 1 NOW Wit coo, Who VIC HIM Call, 1 MAW 111ripolory slerl'inf4 A W,;ijM,H qxymop low AmolvAcei�lafic AW,,Q, hot we 01,016,u Won vq"; ov d "MMY =q"Wass Noy A vy"d mono Mt law an employer that is providing workers' compensation insta'ancefor my employees. Below istilepolicyinformation. War XL Wwwwc Amm&v Im- blaulill'a 1lihfir 3: 30rilvit" `iujic 106 MySwWalp: Emom VA 194) PIo! cy 4i, or sr i ! -u-ts, Lic. rt - R W D9,1"t s ! " N 05 - §vOu it under N,fc I joil t5,% (it' "MA c i 52 t�all lo�ltd to on, i laa),ohietl of"o oll ival p0m,"Aic', ct 0 ne up to S 50100 andiva unno year inqm Ownun " ", as c, H waH in, It on wri or a sj op wom K MIR amt, a on, of MP to WOOD it slat gainy the 0 %dor fly advW1 dolt a my nrolis ytiwnw m ntay No hit" arb'd 10 the M. co, MA f"'n mimalw'Cnvyiilg Cy,,lt I" JY, tOW tillWO J)"Wis With Mush-v nfirtfrvti 11tWdw wan't- illulw out cvu7vvf WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insurer: P O L I C Y N O. RWD9435435-05 XL Insurance America, Inc. 505 Eagleview Boulevard, Suite lo0 Exton, PA 19341 A Stock Insurance Company 1. Name and Address of Insured: Employbridge Holding Company 1040 Crown Pointe Pkwy # 1o40 Atlanta, GA 30338 NCCI Risk ID#: 917730881 Renewal of: RWD9435435-04 NCCI Carrier Code: 10480 Legal Entity: Corporation Other workplaces not shown above: See SCHEDULE OF NAMED INSUREDS AND LOCATIONS 2. The policy period is from 01-31-2018 to 0131-201912:01 A.M. standard Time at the Insureds mailing address. WC000001A Edition 1/08 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1.000.000 each accident Bodily Injury by Disease $1,000 Qgp policy limit Bodily Injury by Disease $1 000 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT: Ohio, North Dakota, Puerto Rico, Washington & Wyoming AND ALL STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE D. This policy includes these endorsements and schedules: See SCHEDULE OF ENDORSEMENTS 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium See EXTENSION OF INFORMATION PAGE WC 00 00 01A 0198T Moral Council on Compensatlon Insurance. Page 1 Edition 1/08 ®2007 XL America, Inc. WORKERS COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY Deposit Premium: Total Estimated Annual Premium Minimum Premium: Premium Adjustment Period: Annual Servicing Office: 190 South LaSalle Street, Suite 3900 Chicago, IL 60603 Date of Issue: 02-14-2018 Countersigned by Producer Name and Code No: 04420 Lockton Companies 444 UV. 47th Street Suite 900 Kansas City, MO 64112-1906 A& INSURANCE WC 00 00 01 A Edition 1l08 WC 00 00 01A 01987 National Council on Compensation Insurance, Page 2 Edition 1108 © 2007 XL Amerioa, Inc. Mansfield Board of Health Request for Fee Waiver for Food Permit Datef'[� r We t (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 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. WOther: Gzre Gt_ C tJ jai'' r V e— �Bo 10Lerc eA- f aC aameSS Thank you, Signature Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: Jane Doucette From: Ann Zetterstrom <azetterstrom@cabotcheese.com> Sent: Tuesday, September 25, 2018 11:56 AM To: Jane Doucette Subject: temporary food service permit request Cabot Creamery Attachments: SKM_C45818092511490.pdf Jane, Attached is our request along with the waiver form Best, I_T Ann Zetterstrom 193 Home Farm Way Waitsfield, VT 05673 P:802-496-1351 �ii� tl1 B The following request has been processed to the designated department. Your Name Ann Zetterstrom Email azetterstrom(�i.,cabotcheese.com Phone +1802-496-1351 Department, Board or Town Manager Committee you wish to contact Comments/Questions Good Afternoon, We are going to be sampling cheese at the Flannel )K on October 7, Sometimes if you are just sampling a permit is required. What are the regulations for your department? Best, Ann Website Contact Us Form, Town of Mansfield 2