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HomeMy WebLinkAboutNE Sportservice/XFinity #1 12/31/2018Commonwealth 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: XFINITY RETAIL SNACK 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOTSIDE TENT 4 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-25 BOARD OF HEALTH MichaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-25 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET - LOTSIDE TENT 4 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSIG, 12TH FL. BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 250 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No.: (716) 858-5162 24 Hour Emergency No.: (716) 367-0736 GM CELL 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. 9) Owner Address (If different from applicant) 250 DELAWARE AVENUE, BUFFALO, NY 14202 Owner's telephone number 7168585000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual _ A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title STEPHEN KELLY Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: I(608) 261 2900 I -- — FAX. (508) 2617799 E-mail: �SKELLY(q_)DELAWARENORTH - CO - M Alt E-Mail: BSALANSK@DELAWARENOF 13) District Or Regional Supervisor (if applicable) Name & Title. Address: Telephone No: ' FAX: 24 Hour Emergency No: (716) 367-0736 GM CELL .COM 858-5000 X5162 24 Hour Emergency No: E-mail: Food Establishment Information i 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No (If applicable) _. _16) No. of Food Employees 17) DAYS/HOURS: VARIES BY EVENT ---------- 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: 1 Permanent Location 22) Establishment Type Mobile Mobile Start Date: Retail ( Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: Food Service up to 101 -200 VI Annual or up to 25' PHF display $150.00 "I Seasonal I_ Food Service up to 201 + --- or 25'+ PHF display $275.00 Seasonal Dates: I_ Food Service - Institution i I_.1 Temporary Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: STEPHEN KELLY ALLERGEN 4/24/2022 ❑ Caterer $25.00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 - Manufacture Frozen Desserts/Ice Cream - $25.00/freezer j 1 Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 ❑ Retail Food $100.00 Retail Snack Food $25.00 [.] Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food ihme4empermure controls required) Non-PHFs non -potentially hazardous food(no time/temperature controls required) (Check all that apply). RTE- ready to eat foods (Ex. sandwiches salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non PHFs _r[ ] PHFCooked To Order r '� Hot PHF Cooked and Cooled or Hot Held -- ---- -- -- 1 —- for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs j Preparation of PHFs For Hot And Delivery of Packaged PHFs _.J Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations Cold Holding For Single Meal Service [] PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill ----- ❑ Use of Process Requiring A Variance [- ] Customer Self -Service and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin [ Offers RTE PHF in Bulk QuantitiesPrepCateares ed Events or Food/Single Meals Institutional Food Service ] Retail Sale of Salvage, Out -Of -Date ____ _ or Reconditioned Food To be completed by the Board of Health III -- __-- -_-- Total Permit Fee: $25.00 Payment is due with application i waived I, the undersigned, attest to the accuracy of the information provided in this application and 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. 24) 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 paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Delaware North- Sportservice March 12, 2018 Via Certified Mail Town of Mansfield Conservation Commission 6 Park Row Mansfield, MA 02048 Re: Notice of Intent — Abutter Notification Letter To Whom It May Concern: Enclosed please find a Notice of Public Hearing. The Mansfield Board of Selectmen will hold a public hearing at the Town Hall, 6 Park Row, Mansfield, MA, on Wednesday, March 28, 2018 at 6:30 p.m. Our company, New England Sportservice, Inc., has submitted an Amendment Application for an Alteration of Premises regarding our food and beverage operations at Xfinity Center, 885 South Main Street, Mansfield, MA. New England Sportservice, Inc., would like to extend the Golden Courtyard All Kinds of Alcoholic Beverages license to include the entire premise, and if approved, relinquish our Beer and Wine Malt Beverage permit. Very truly yours, NEW ENGLAND SPORTSERVICE, INC. Be A.Salansky Lead Licensing Paralegal Enclosure Town of Mansfield Notice of Public Hearing In accordance with the provisions of Massachusetts General Laws Chapter 138 Section 12 as amended the Mansfield Board of Selectmen will hold a public hearing at the Town Hall, 6 Park Row, Mansfield, MA, on Wednesday, March 28, 2018 at 6:30 PM on the application of New England Sportservice, Inc. Stephen Kelly, Manager, for an Alteration of Premises for All Alcohol Common Victualler license at their facility located at 885 South Main Street. Anyone interested in or wishing to be heard on said application should appear at the date and time specified. Mansfield Board of Selectmen Frank DelVecchio, Clerk The Sun Chronicle March 14, 2018 s_ Delaware 51 North _ Sportservice March 12, 2018 Via Certified Mail Town of Mansfield Conservation Commission 6 Park Row Mansfield, MA 02048 Re: Notice of Intent — Abutter Notification Letter To Whom It May Concern: Enclosed please find a Notice of Public Hearing. The Mansfield Board of Selectmen will hold a public hearing at the Town Hall, 6 Park Row, Mansfield, MA, on Wednesday, March 28, 2018 at 6:30 p.m. Our company, New England Sportservice, Inc., has submitted an Amendment Application for an Alteration of Premises regarding our food and beverage operations at Xfinity Center, 885 South Main Street, Mansfield, MA. New England Sportservice, Inc., would like to extend the Golden Courtyard All Kinds of Alcoholic Beverages license to include the entire premise, and if approved, relinquish our Beer and Wine Malt Beverage permit. Very truly yours, NEW ENGLAND SPORTSERVICE, INC. G-Ck Beth A.Salansky Lead Licensing Paralegal Enclosure Town of Mansfield Notice of Public Hearing In accordance with the provisions of Massachusetts General Laws Chapter 138 Section 12 as amended the Mansfield Board of Selectmen will hold a public hearing at the Town Hall, 6 Park Row, Mansfield, MA, on Wednesday, March 28, 2018 at 6:30 PM on the application of New England Sportservice, Inc. Stephen Kelly, Manager, for an Alteration of Premises for All Alcohol Common Victualler license at their facility located at 885 South Main Street. Anyone interested in or wishing to be heard on said application should appear at the date and time specified. Mansfield Board of Selectmen Frank DelVecchio, Clerk The Sun Chronicle March 14, 2018 Commonwealth 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: XFINITY RETAIL SNACK 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - RIGHT FIELD LAWN, PACKAGE BEER PORTABLE PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-14 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-14 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET -RIGHT FIELD LAWN, PACKAGE BEER PORTABLE 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE., ATTN: LICENSING 12TH FL. BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name &Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 250 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No.: (781) 858-6162 24 Hour Emergency No.: 280 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. 9) Owner Address (If different from applicant) 250 DELAWARE AVENUE, BUFFALO, NY 14202 Owner's telephone number 7168685000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers '_.'I An Association or partner. A Corporation Name Title Address An Individual A Partnership Other legal Entity_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: ISTEPHEN KELLY Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: 280 FAX: I(508) 261-7799 E-mail: SKELLY(&DELAWARENORTH.COM Alt E-Mail: IBSALANSKI(a)DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: OWNERS NUMBER (716) 858-5024 Hour Emergency No: FAX: I E mail. Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: VARIES BY CONCERTS 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate '.. 19) Person Trained in Anti -Choking Procedures (If 25 Seals or more) 20) Location: IJi Permanent Location 22) Establishment Type Moblie Moblie Start Date: ❑Retail ( Sq. Ft) Moblie End Date: [ ] Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: ❑ Food Service up to 101 -200 j Annual or up to 25' PHF display $150.00 ❑ Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 201 + or 25'+ PHF display $275.00 [,_ J Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 i.,.J Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer J Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 1 1 Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timefiemperature controls required) :(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) J Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs 1, Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non Perishable Foods Only j❑ Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meat Service (.] Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale [._.� Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for tJ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities I ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service J Retail Sale of Salvage, Out -Of -Date or Reconditioned Food 7Payment pleted by the Board of Health -- ---- -- - — — it Fee: $25.00 s due with application i waived _. ... I, the undersigned, attest to the accuracy of the information provided in this application and 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. 24) 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 paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Commonwealth 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: XFINITY PUSHCART 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - BEER, WINE, MIX-A-RITA CARTS PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-1 BOARD OF HEALTH .Michael' McClean, Chairman - FOR BOARD OF HEALTH USE ONLY Permit # issued XP-1 FOOD ESTABLISHMENT PERMIT APPLICATION x- 4` r aA �10W (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET -BEER, WINE, MIX-A-RITA CARTS 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 250 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No,: (716) 858-5000 EXT. 6162 BETH 24 Hour Emergency No.: (508) 261-2900 SALANSKY 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. 9) Owner Address (If different from applicant) 250 DELAWARE AVENUE, BUFFALO, NY 14202 Owner's telephone number 7168585000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual A Partnership - - Other legal Entity__ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ISTEPHEN KELLY, GENERAL MANAGER Address: I885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: 1(508) 261-2900 24 Hour Emergency No: (508) 261-2900 - FAX I(508) 261-7799 E-mail: SKELLY@DELAWARENORTH.COM _- - - - Alt E-Mail: BSALANSK@DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) - Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information -- 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN Supply1 DEP Public Water No: (if applicable) vARIEs wITH EVENTs _ 16) No. of Food Employees:. 350 17) DAYS HOURSI 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (I( 25 Seats or more): IV] 20) Location: [] Permanent Location -._I Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: JI Annual Seasonal Seasonal Dates: _1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ] Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 i- Food Service - Institution ( Meals/Day) Caterer $25.00 ❑ Milk & Cream $10.00 [_. ! Mobile Food & Consession $75.00 - Manufacture Frozen Desserts/Ice Cream - $25.00/freezer IV] Pushcart $25.00 If of Pushcarts: 3 Residential Kitchen $100.00 J Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no tlme/temperature controls required) '(Cheek all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) j Sale of Commercials Pre -Packaged Non-PHFs i y-- g I [ PHFCooked To Order Sale of Commercially Pre -Packaged PHFs 1, Preparation of PHFs For Hot And jI I_J Delivery of Packaged PHFs Cold Holding For Single Meal Service -! Reheating of Commercially - --i i i Sale of Raw Animal Foods Intended to be Prepared by Consumer Processed Foods for Service Within 4 Hours Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill - Customer Self -Service of Non PHF and Non- Self-Service s eq (ncl h HACCP Plan (including bare hand Customer Perishable Foods Onlyand/or and Packaged for public contact alternative, time as a ublic health - Preparation of Non PHFs Retail Sale control) Other Food Operations s L Juice Manufactured and Packaged for P g OffersRaw or Undercooked Food Of t-i Retail Sale Animal BEER, WINE, BOTTLED WATER Offers RTE PHF in Bulk Quantities --- - I Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out-Of-Dateor To be by the Board Health Reconditioned Food completed of ----- - ---- Total Permit Fee: $25.00 Payment is due with application j waived I, the undersigned, attest to the accuracy of the information provided in this application and 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.t, I 24) Signature of Applicant: Pursuant to MGL Ch.62Q sec. 49A, I certify on( and paid state taxes required under law. 25) Social Security Number or Federal ID: 04- 26) Signature of Individual or Corporate Name: the penalties of perjury that I, to my 3466949 . and belief, have filed all state lax returns Jane Doucette From: Beth Salansky <BSalansk@delawarenorth.com> Sent: Monday, December 11, 2017 2:50 PM To: Jane Doucette Subject: Xfinity health renewals Hello, Ms. Doucette: Please mail the renewals directly to me at corporate HQs as follows: Beth Salansky Delaware North Attn: Licensing, 121" Fl. 250 Delaware Avenue Buffalo, NY 14202 Thanks, Beth Beth Salansky Lead Licensing Paralegal Delaware North 250 Delaware Avenue Buffalo, NY 14202 T: 716 858 5162 F: 716 858 5056 www.delawarenorth.com The information contained in this electronic mail transmission is intended only for the use of the recipient(s) named above. It may contain proprietary, confidential or privileged information of the sender. If you are not the intended recipient, you are hereby notified that any disclosure, dissemination, distribution or copying of the information contained in this transmission is strictly prohibited. If you have received this transmission in error, please notify the sender immediately by reply electronic mail and delete the original message and any copy of it from your computer system. Knit Name Promises Uesimal felon license title license No license Cost. Xfinity Center Concessions Deck. 8 Mobile Food MF-6 $25.00 Xfinity Center Concessions Main Kitchen and Food Service XFS-1 $125.00 Commissary Establishment Xfinity Center Concessions Main Kitchen and Milk & Cream XFS-1 M&C ' $10.00 Commissary - M&C Xfinity Center Concessions Left Field F000 Food Service XFS-10 ; $125.00 Establishment Xfinity Center Concessions Upper Lotside Portable Food Service XFS-11 $125.00 Establishment Xfinity Center Concessions Upper Lotside -odd Food Service up to 100 XFS-12 $125.00 Xfinity Center Concessions Grab & Go Food Service up to 100 XFS-13 °. $125.00 Xfinity Center Concessions Lower Lotside Food XFS-14 ;r $125.00 Xfinity Center Concessions Lower Lotside Portable XFS-15 ,. $125.00 Xfinity Center Concessions Lotside Fried Coogh XFS-16 $125.00 Xfinity Center Concessions BOSE XFS-17 $125.00 Xfinity Center Concessions Lower Tent - Employee Food Service XFS-2 ., $125.00 Grill Establishment Xfinity Center Concessions Right Field Food Food Service XFS-3, $125.00 - Establishment Xfinity Center Concessions Upper Woodside Food Food Service - XFS-4 ,,:- $125.00 Establishment Xfinity Center Concessions Courtyard Food Service XFS-5c. $125.00 Establishment Xfinity Center Concessions Courtyard M&C Milk & Cream XFS-5 M&C -.- $10.00 Xfinity Center Concessions Upper Woodsid 9 Portable- Food Service XFS-6.,:.._. - $125.00 Establishment Xfinity Center Concessions Woodside Fried Dough Food Service XFS-7 ` $125.00 Establishment Xfinity Center Concessions Lower Woodside. Food Food Service XFS-8 -"" $125.00 Establishment Xfinity Center Concessions Lower Woodsid> Portable Food Service XFS-9 $125.00 Establishment Xfinity Center Concessions Beer, Wine, Mix ,rrita Mobile Food & XP-1 $25.00 Cart - ME Concessions Xfinity Center Concessions Minute Maid LemDrade. / Mobile Food & XP-2 $25.00 Water Cart - MF Concessions Xfinity Center Concessions Minute Maid Mobile Food & XP-3 $25.00 Lemonade/Water Cart Concessions Xfinity Center Concessions Minute Maid Mobile Food & XP-4 $25.00 LemonadeNdater Cart Concessions Xfinity Center Concessions Beer, Wine, Mix-a-rita Cart Mobile Food & XP-5 .,; $25.00 Concessions Xfinity Center Concessions Woodside Beer Portables Push Cart XRF-1 - $100.00 Xfinity Center Concessions Lotside Beer Portables Push Cart XRF-2., - $100.00 Xfinity Center Concessions Right Field Beer Push Cart XRS-1 " $25.00 Xfinity Center Concessions Minute Maid Lemonade / XRS-10t; ' $25.00 Water Cart Xfinity Center Concessions International XRS-11 `� $25.00 Xfinity Center Concessions Right Field Frozen Push Cart XRS 2 c $25.00 Xfinity Center Concessions Woodside Com.nissary Push Cart XRS-3,=-" $25.00 Xfinity Center Concessions Music Cafe Push Cart XRS-4 ;:' $25.00 Agency Submittai'_e;;xr Report �l Unit Name Promises DOSTrip Ulm license five License No License most Xfinity Center Concessions Centerfield Beer Push Cart XRS-5 $25.00 Xfinity Center Concessions Deck 4 Push Cart XRS 6 - $25.00 Xfinity Center Concessions Left Field Beer Food Service XRS i $25.00 Establishment Xfinity Center Concessions Left Field Frozen Food Service XRS-8 ~•:"-- $25.00 Establishment Xfinity Center Concessions Bullpen XRS-9 $25.00 Total: S2,770.00 License Count: 38 Aaency Submittal Letter R.eFert Commonwealth 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: XFINITY SNACK 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 W. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT1 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-16 BOARD OF HEALTH Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-16 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT1 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSING, 12TH FL. BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 7) Applicant Telephone No.: 250 DELAWARE AVENUE, BUFFALO, NY 14202 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No.: (716) 367-0736, GM CELL NEW ENGLAND SPORTSERVICE, INC. 250 DELAWARE AVENUE, BUFFALO, NY 14202 7168585000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers I An Association or partner. ill A Corporation Name Title Address An Individual A Partnership C 1 Other legal Entity____- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title. ISTEPHEN KELLY Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: FAX: E-mail: I Alt E-Mail: 08) 261-2900 24 Hour Emergency No: (716) 367-0736, GM CELL 261-7799 Y@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No: OWNERS NUMBER (716) 858-5024 Hour Emergency No: FAX E-mail: 14) WATER SOURCE: Food Establishment Information 15) SEWAGE DISPOSAL: '.. DEP Public Water Supply No. (If applicable) No. of Food Employees: 280 - 17) DAYS/HOURS: VARIES BY EVENT 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. '.. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 1 20) Location: IV] Permanent Location 22) Establishment Type ❑Caterer $25.00 Moblie Moblie Start Date: ❑Retail ( Sq. Ft) Moblie End Date: [] Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: Annual Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 ' Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 o Manufacture Frozen Desserts/Ice Cream �— $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 [I Retail Food $100.00 ❑ Retail Snack Food $25.00 Tobacco Products $25.00 23)Food Operations Defimhons:PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous lood(no timelemperature controls required) '..(Check all that apply): I RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) _'I Sale of Commercially Pre -Packaged Non-PHFs I Sale of Commercially Pre -Packaged PHFs Deliveryof Packaged PHFs I,. Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self-ServiceofNon PHF and Non - Perishable Foods Only [] Preparation of Non-PHFs Other Food Operations [ I PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Self -Service Ice Manufactured and Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service L ] PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health [ ] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities (i_] Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food by the Board o(Health Lbempleted rmit Fee $25.00 is due with application [ I waived _ I, the undersigned, attest to the accuracy of the information provided in this application and 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. 24) 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 paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Commonwealth 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: XFINITY SNACK 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT 2 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-17 BOARD OF HEALTH Michae(wlcCCean, Chairman L -- FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-17 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT 2 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSING, 12TH FL. BUFFALO, NY 1420002 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. - 6) Applicant Address 250 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No.: (716) 858-5162 BETH 24 Hour Emergency No.: 8) Owners Name &Title 9) Owner Address (If different from applicant) Owner's telephone number NEW ENGLAND SPORTSERVICE, INC. 250 DELAWARE AVENUE, BUFFALO, NY 14202 7168586000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers C l An Association or partner. l A Corporation Name Title Address An Individual A Partnership - - -- - 12) Person Directly Responsible For Daily Operations (owner, person in charge, su Name & Title: ISTEPHEN KELLY Address: !885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: I(508) 261-2900 24 Hour Emergency No: FAX I(508) 261-7799 1 E-mail: SKELLYPDELAWARENORTH COM Alt E Mail: BSALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: I E-mail: manager etc.) 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) NO. of Food Employees: 280 17) DAYS/HOURS: VARIES BY CONCERT 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate STEPHEN KELLY 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: [] Permanent Location 22) Establishment Type ❑ Caterer $25.00 ! i Mobile Mobile Start Date: -( J Retail ( Sq Ft) I Milk &Cream $10 00 - Moblie End Date: Mobile Comments: 21) Length of Permit: ] Annual ] Seasonal Seasonal Dates: 'i. , Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ] Food Service up to 100 or up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $276.00 ❑ Food Service - Institution ( Meals/Day) ❑ Mobile Food & Consession $75,00 Manufacture Frozen Desserts/Ice Cream -� $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) !(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) -i Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs J Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours I_ 1 Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility 1_ I Vacuum Packaging / Cook Chill _] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities I [._] Prepares Food/Single Meals for Catered Events or Institutional Food Service I Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $25.00 Payment is due with application ❑ waived -___.. ___... _.____--_— _ I, the undersigned, attest to the accuracy of the information provided in this application and 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. 24) 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 paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: m a N O � O m ,ti m a � 3 m N w d ei X X X X C X X X X X X X X X X X X X X X X X X X X X + o O O. 0 O o 0 o N 0 0 0 0 o ti 0 0 0 s O O O o 0 0 0 0 o i o 0 0 0 H 0 0 0 o 0 0 0 0 0 H a O O H H 0 H 0 o ci rl o. o c-I c-1 0 0 0 O O a o O H H o ut LL 0 0 O O O o O 0 0 0 0 O O 0 O O H o O 0 0 O 0 O O O V_ E v a w ° N N ui M �n M i.n N Ln N Ln N ui N 0 N 00 N tit O . N . N . N 00 N ci N N N N N `y �n N �y N O 0 U a a c c ° L1 a Y C VI m t m L Y E U1 @ U_ w j> U vi a Y E N @ U_ Z U v� a m L: VI w UI ° Y m C V1 Y m C VI w U_ U1 o w U_ 2 U! o @ V w U N o OaO Y U m c vl w = N a o w U U1 a o 'C m U 3 = @ Y U m C VI •. Y U m C N s V u m C N w = N Y U m c V1 Y U m C V1 w V U1 a w U_ N a°a O m U j°- 0 0 0 0 w t t t V U V awe � aw. c 0 '+. m o a0i E c° C t m V m R m x v m °o U E E ° u •cm G 0 00 -0 m (D o 0 ° a ++ L nn cc 1.1 ++ L no m c m w 11 Y L no w a o LL v oov L w n n w m 0 o v L w n n � w a 0 E w C c G L� 0 m w a_ •vf 0 o 0 E w a VI 0 0 -° o LL w a ° o w 3 O w\ .a m o a w °0 o w 3 O w -0 c 0 E a) C c G y w -0w t- 0 a O�j w a D o m Y U w w VLU ` Y G U Y U w` 0 ov a_ w I.l J m a_ w 11 • J c o _a w 11 ` J M t 0 - aow o° n n D 0 LL v L n n \ a 0 E aJmL w c c G 41,14 O H N M V lD h 00 m O H N M "It to w a-1 N M Lo 1� m Ol H �-1 �-1 �-1 c-I Ho r-I c-1 ci `-1 H "IN N N N N N �m 6 y 3 3 3 3 3 3 3 3 3 3 _ x x n E d 0 N N N T ti `y N N y N N N N y y N N N y N N N y y N O N y N N N N N y N N N N N N y y N N y N N N N N N N N O M N N N N ry N VI N N N ✓� N N N N VI V1 U E E c v v v a v v s v v s v s v s E E a .2 .z 0 0 o 0 0 0 0 M 1 101 1 a Y o m ~ Ey° 0 81 4 i qgqg o o o° t ryry z v v-' v oa 3 4n Y.91 � ei N M y vl h m m rNY „m1 epi N e1p-I n-1 H N N N N N N N N N N T T M Mp T M M T M V V y y 3 V V Commonwealth 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: XFINITY RETAIL SNACK 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT 3 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-18 BOARD OF HEALTH MichaelMcCt-ean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-18 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT 3 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSING, 12TH FL. BUFFALO, NY 14202 4) Establishment Telephone No (508)261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 250 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No.: (716) 858-5162 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No.: (716) 367-0736 GM CELL NEW ENGLAND SPORTSERVICE, INC. NEW ENGLAND SPORTSERVICE, INC. 7168585000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual A Partnership Other legal-- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title STEPHEN KELLY Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No I(508) 261-2900 24 Hour Emergency No: (716) 367.0736 GM CELL FAX: I(508) 261-7799 E-mail: SKELLY@DELAWARENORTH.COM IBS-ALANSK(d,)D-ELAWARENORTH.COM Alt E Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No. OWNERS NUMBER (716) 858-5024 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) 16) NO of Food Employees 280 17) DAYS/HOURS: VARIES BY CONCERTS 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. 1 Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: LVj Permanent Location [ ] Moblie Mobile Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: 1 Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $125.00 [] Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) ] Caterer $25.00 ] Milk & Cream $10.00 ] Mobile Food & Consession $75.00 ] Manufacture Frozen Desserts/Ice Cream $25.00/freezer ] Pushcart $25.00 # of Pushcarts: 0 ] Residential Kitchen $100,00 Retail Food $100.00 _] Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous food( timeAemperature controls required) Non-PHFs non -potentially hazardous tood(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- L. Perishable Foods Only Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $25.00 Payment is due with application ❑ waived 1, the undersigned, attest to the accuracy of the information provided in this application and 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. 24) 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 paid slate taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Commonwealth 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: XFINITY RETAIL SNACK 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:. NEW ENGLAND SPORTSERVICE, INC. Whose place of business is: NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT4 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-19 BOARD OF HEALTH Michae(McC(ean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-19 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address NEW ENGLAND SPORTSERVICE, INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - SECOND STAGE PACKAGE TENT4 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSING, 12TH FL. BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 7) Applicant Telephone No. 250 DELAWARE AVENUE, BUFFALO, NY 14202 (716) 858-5162 24 Hour Emergency No.: (716) 367-0736 GM CELL 8) Owners Name & Title 9) Owner Address (If different from applicant) NEW ENGLAND SPORTSERVICE, INC. 250 DELAWARE AVENUE, BUFFALO, NY 14202 Owner's telephone number 7168586000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1 An Association or partner. l A Corporation Name Title Address I An Individual I A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: STEPHEN KELLY - --- Address: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: I(508) 261-2900 24 Hour Emergency No: (716) 367.0736 GM CELL FAX I(508)261-7799 E-mail: SKELLY(a�DELAWARENORTH COM Alt E Mail BSALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: iOWNERS NUMBER (716) 858-5024 Hour Emergency No. FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: VARIES BY CONCERT 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 280 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of :. certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) 20) Location: C] Permanent Location L_] Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: W Annual Seasonal Seasonal Dates: i Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type [-I Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $125.00 [ ] Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 [_ I Food Service - Institution Meals/Day) ❑ Caterer $25.00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 ❑ Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 23) Food Operations Definitions.PHF - Potentially hazardous food(fime/temperature controls required) Non-PHFs - non -potentially hazardous food(no fimeRemperatare controls required) I(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self-service of Non PHF and Non Perishable Foods Only of Non-PHFs Other Food Operations ❑ PHFCooked To Order ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service 1 ❑Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 11 PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill -- ❑ Use of Process Requiring A Variance [� Customer Self -Service and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) ❑ Juice Manufactured and Packaged for [_] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage Out -Of -Date _ _ __.- _.. __— - _ _ or Reconditioned Food To be completed by the Board of Health ---__-- Total Permit Fee: $25.00 Payment is due with application waived I, the undersigned, attest to the accuracy of the information provided in this application and 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. 24) 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 paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: