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Home My WebLink AboutNE Sportservice/XFinity #2 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 - SECOND STAGE PACKAAGE TENT 5 PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-20 BOARD OF HEALTH NichaeCMcCtiean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-20 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 PACKAAGE TENT 5 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 BETH SALANSKY 24 Hour Emergency No.: (716) 367-0736 GM CELL 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers C i An Association or partner. I A Corporation Name Title Address An Individual 'A Partnership NEW ENGLAND SPORTSERVICE, INC. 250 DELAWARE AVENUE, BUFFALO, NY 14202 7168686000 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: STEPHEN KELLY, GENERAL MANAGER Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (716) 367.0736 GM CELL FAX: (508)261-7799 E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-Mail: 'BSALANSK(&DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) ....----_- Name & Title: I Address: Telephone No: FAX: 858-5000 X5162 24 Hour Emergency No: E-mail: 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 r19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) 20) Location: W Permanent Location 22) Establishment Type ail 1. I 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: h/1 Annual '. Seasonal - -----� Seasonal Dates: -j 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) STEPHEN KELLY ❑ 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 E] Retail Food $100.00 Retail Snack Food $25.00 [J Tobacco Products $25.00 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no hmeAemperature controls required) (Check all that apply) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) 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 _J Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held --------------- ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service _� PHF and RTE Foods Prepared For Highly ---- F J Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer Vacuum Packaging / Cook Chill -- F I Customer Self -Service El Use of Process Requiring A Variance 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 1-_1 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin O_ ffears RTRTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service leted y the oard of To or Reconditioned Food , ---i Pa�ment Permit with application n 25 owaived _IIII 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 690.000 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 to: 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 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 6 PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-21 BOARD OF HEALTH 34ichae(NcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-21 =: 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 - SECOND STAGE PACKAGE TENT 6 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) 85&5162 24 Hour Emergency No.: (716) 367-0736 Gros 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: 111) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address J' 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: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: 008) 261-2900 24 Hour Emergency No: (716) 367-0736 Prot CELL FAX: '(508) 261-7799 E-mail: !SKELLY@DELAWARENORTH.COM Alt E-Mail: BSALANSK(CDDELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: - Address: Telephone No: (716) 858-5000 X5162 24 Hour Emergency No: FAX: E-mail. Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 117) 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: Permanent Location 22) Establishment Type Moblie Moblie Start Date: �'I Retail ( Sq Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: Annual L j Seasonal Seasonal Dates: 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 $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 23) Food Operations Definitions PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous foodfno timertemperature 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 - Perishable Foods Only Preparation of Non-PHFs Other Food Operations j 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 Customer 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 Chili Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) _ J Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantifies ( i Prepares Food/Single Meals for Catered Events or Institutional Food Service -- ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be com feted b the Board of Health I - -- - - _ _-- Total Permit Fee: $26.00 -. 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: 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 BAR PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-26 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-26 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 886 SOUTH MAIN STREET - SECOND STAGE BAR 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSING, 12TH FL. BUFFALO, NY 14202 4) Establishment Telephone No (608) 261-2900 5) Applicant Name & Title NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 250 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No.: (508) 868-5162 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. 250 DELAWARE AVENUE, BUFFALO, NY 14202 7168685000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers J' 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, GENERAL MANAGER Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 t - Telephone No 1(508) 261-2900 24 Hour Emergency No: (716) 367•0736 GM CELL -- -- - - FAX: 1(508) 261-7799 E-mail: ISKELLY(&DELAWARENORTH.COM Alt E-Mail: IBSALANSK(a)DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: iOWNER NUMBER (716) 858-500 24 Hour Emergency No: FAX: I 1E mail 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 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. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of STEPHEN KELLY ALLERGEN 4/24/2022 certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: 1] Permanent Location 22) Establishment Type ❑ Caterer $25.00 _I Moblie Moblie Start Date: ❑ Retail ( Se Ft) Milk & Cream $1000 Moblie End Date: [ 1 Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 1 21) Length of Permit: d1 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) Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 Ll 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 (timeviemperature controls required) Non-PHFs non -potentially hazardous food(no timeaemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex sandwiches, salads, muffins which need no funherprocessing) i..._ __-___ _. _.. 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 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 Customer 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 / l:eeK Emil Use or rrocess megwnng m variance and/or HACCP Plan (including bare hand contact alternative, time as a public health I J Juice Manufactured and Packaged for ❑Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities li 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 Healfh 1 Total Permit Fee: $25.00 Payment is due with application L_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 RETAIL 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 - LOTSIDE TENT 1 PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-22 BOARD OF HEALTH .wlichae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-22 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 1 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 6156 BETH SALANSKY 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. VA 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, GENERAL MANAGER Address: I885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (716) 367-0736 GM CELL FAX: (508)261-7799 E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-Mail: BSALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: li Address: Telephone No: OWNER NUMBER (716) 858-500 24 Hour Emergency No: FAX: Email: 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: 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: [VI Permanent Location Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: LV Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: 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 ❑ Food Service - Institution ( Meals/Day) STEPHEN KELLY 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 [_] 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 (tlmeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timeAemperature 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 - 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 L _ J Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Customer Self-Service L.] 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 / Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Juice Manufactured and Packaged for j ['i, Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities 1 i_.i 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 fled 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 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:. Whose place of business is: NEW ENGLAND SPORTSERVICE INC., @ THE XFINITY CENTER 885 SOUTH MAIN STREET - LOTSIDE TENT 2 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-23 BOARD OF HEALTH MichaeC.McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-23- 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 2 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: 6) Applicant Address 7) Applicant Telephone No.: 24 Hour Emergency No.: (716) 367-0736 GM CELL 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers J 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: I885 SOUTH MAIN STREET, MANSFIELD, MA 02048 - - --- - - - Telephone No (608) 261-2900 24 Hour Emergency No: (716) 367.0736 GM CELL FAX: I(508) 261-7799 E-mail: ;SKELLY(&DELAWARENORTH.COM Alt E-Mail: 0SALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: rE-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL DEP Public Water Supply No: (If applicable) I _16) No. of Food Employees: 17) DAYS/HOURS: VARIES BY CONCERTS 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 . 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: _] 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 Annual or up to 25' PHF display $150.00 - ''. Seasonal i_. Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: ❑ Food Service - Institution _I Temporary Temporary Start Dale: ( Meals/Day) Temporary End Date: Temporary Time: TOWN 280 i I Caterer $25.00 j 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 j.--. Retail Food $100.00 ❑ Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous rood (timeRemperature controls required) Non-PHFs non -potentially hazardous food(no timeRemperature 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 T 1 PHFCooked To Order Hot PHF Cooked and Cooled or Hot HeldI -- - - Sale of Commercially Pre -Packaged PHFs - , - -- - ----- -- Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service I J PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs -- ---- Susceptible Population Facility --- — - -- - r ] Sale of Raw Animal Foods Intended . Reheating of Commercially to be Prepared by Consumer I� Vacuum Packaging / Cook Chill -I Processed Foods for Service Within 4 Hours --- ------ -!, Customer Self -Service of Non PHF and Non- - ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand - — ---- - [_] Customer Self -Service Perishable Foods Only F] Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations Juice Manufactured and Packaged for 1 g ! a w OrUndercooked Food Of Retail Sale Animal 1 Offers RTE PHF in Bulk Quantities [_ ] Prepares Food/Single Meals for i Catered Events or Institutional Food Service ! ]Retail Sale of Salvage, Out -Of -Date -- _„__ _.,: - or Reconditioned Food To be completed by the Board of Health 'I ---- ---- -_--- _ 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 fled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 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 - LOTSIDE TENT 3 PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-24 BOARD OF HEALTH 94 ichael McClean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-24 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 - LOTSIDE TENT 3 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSEING, 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 7188585000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. VI A Corporation Name Title Address I 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: 1(508) 261-2900 FAX: 1(508) 261-7799 24 Hour Emergency No: (716) 367.0736 GM CELL E-mail: ISKELLY@DELAWARENORTH.COM Alt E-Mail: �BSALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title. Address: Telephone No: (718) 858-5000 X5162 FAX: E-mail: 24 Hour Emergency No: 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: If more than 3 individuals are certified, complete list is on file. STEPHEN KELLY Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of STEPHEN KELLY ALLERGEN 4/24/2022 certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) LJ 20) Location: [] Permanent Location 22) Establishment Type (� ) Caterer $25.00 Mobile Mobile Start Date: [-] Retail ( Sq. Ft) ] Milk & Cream $10.00 Mobile End Date: li L] Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream i..) 21) Length of Permit: { �.] Food Service up to 101 -200 $25.00/freezer I... Annual or up to 25' PHF display $150.00 Pushcart $25.00 # of Pushcarts: 0 Seasonal i_J Food Service up to 201 + i --1 Residential Kitchen $100.00 Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations �!(Check all that apply): or 25+ PHF display $275.00 D. Retail Food $100.00 [� Food Service - Institution ❑ Retail Snack Food $25.00 ( Meals/Day) ❑ Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (tfineRemperature controls required) Non-PHFs - non -potentially hazardous Nadine timeRemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Lj Sale of Commercially Pre -Packaged Non-PHFs �,. ] PHFCooked To Order L,.J Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ----- -------- — — Sale of Commercially Pre -Packaged PHFs _ — _] Preparation of PHFs For Hot And [ ] PHF and RTE Foods Prepared For Highly Susceptible Population Facility -- - --- — — Delivery of Packaged PHFs . - ---al - -- -- - - -- Reheatingg o of Commercially Processed Foods for Service Within 4 Hours Cold Holding For Single Meal Service [] Sale of Raw Animal Foods Intended to be Prepared by Consumer [� Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) - -- - ----------- -- 1, Customer Self-service of Non PHF and Non- Perishable Foods Only Preparation of Non-PHFs - — ❑ Customer Self -Service _---- --n _ --_ - o L] Ice Manufactured and Packaged for Retail Sale Other Food Operations Juice Manufactured and Packaged for, Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin .-I Offers RTE PHF in Bulk Quantities L ) Prepares Food/Single Meals for Catered Events or Institutional Food Service LJ Retail Sale of Salvage, Out -Of -Date --------------� or Reconditioned Food To be completed by the Board of Health L Total Permit Fee: $26.00 Payment is due with application r 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 PUSHCAST 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 - MINUTE MAID LEMONADE/WATER CART PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-2 BOARD OF HEALTH Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XP-2 -` - P; ' f, FOOD ESTABLISHMENT PERMIT APPLICATION MY (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- MINUTE MAID LEMONADEIWATER CART 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 260 DELAWARE AVENUE, BUFFALO, NY 14202 7) Applicant Telephone No.: (716) 868-6000 EXT. 6162 BETH 24 Hour Emergency No.: (608) 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. I 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: 885 SOUTH MAIN STREET, BUFFALO, NY 14202 Telephone No: (508) 261-2900 24 Hour Emergency No: (908) 261.2900 FAX: (508) 261-7799 E-mail: ISKELLY@DELAWARENORTH.COM Alt E-Mail: BSALANSK(a)DELAWARENORTH.COM (LICENSING) - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: !i 24 Hour Emergency No: FAX: E-mail: i Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) __.16) NO of Food Employees 350 17) DAYS/HOURS: VARIES BY EVENTS 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) Ill 20) Location: Permanent Location 22) Establishment Type ..', Moblie Moblie Start Date: '--j Retail ( S Ft) Moblie End Date: I Moblie Comments: 21) Length of Permit: VI Annual _ i Seasonal Seasonal Dates: Temporary Temporary Start Dal Temporary End Data Temporary Tim( q. 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 a Milk & Cream $10.00 `._ Mobile Food & Consession $75.00'i i Manufacture Frozen Desserts/Ice Cream $25.00/freezer �! Pushcart $25.00 # of Pushcarts: 1 11 Residential Kitchen $100.00 I Retail Food $100.00 I Retail Snack Food $25.00 _1 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous rood (timeltemperature controls required) 1 Nan-PHF's - non -potentially hazardous food(no time4emperature controls required) ;(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) -I Sale of Commercially Pre -Packaged Non PHFs I ] PHFCooked To Order L] Hot PHF Cooked and Cooled or Hot Held -- - --- for More Than a Single Meal Service ] Sale of Commercially Pre -Packaged I Preparation of PHFs For Hot And -- - - -, Cold Holding For Single Meal Service [ I PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs _.. I Susceptible Population Facility -- -i I I Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- ',l Customer Self -Service Use of Process Requiring A Variance Perishable Foods Only _ _ and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations 1 Juice Manufactured and Packaged for -] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin FROZEN ICE, BOTTLED BEVERAGES -- - - Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for _ Retail Sale of Salvage, Out -Of -Date Catered �ents-orInstitutional Food Service or Reconditioned Food - To be b the Board$of Zalth ToPermit Fee: $25.00 -----_---- -� - _-- Y PP waived Payment is due with application r 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 1" 590.000 and the federal �& Code. ft 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify unc 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 best knowledge ana) belief, have filbd all state tax returns 3466949 ( `/`� (� ` 1 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 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 - MINUTE MAID LEMONADE/WATER CART PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December31,2018 Food Fee: $25.00 License Number: XP-3 BOARD OF HEALTH Michae(McCtean, Chairman FOR BOARD OF HEALTH USE ONLY Permit'# Issued XP-3iL I' FOOD ESTABLISHMENT PERMIT APPLICATION jr:k 2 8 ZTNU (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 - MINUTE MAID LEMONADEIWATER CART 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. 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 7168586000 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: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 I - Telephone No: (508) 261- 2900 24 Hour Emergency No. (508) 261- 2900 FAX: (508)261-7799 E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-Mail: BSALANSK@DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 350. 17) DAYS/HOURS: VARIES BY EVENTS 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: l Permanent Location I' 22) Establishment Type i ;Caterer $25.00 -', Mobile Mobile Start Date: I r ] Retail ( Sq. Ft) f Milk & Cream $10.00 Mobile End Date: Mobile Comments: 21) Length of Permit: IJ, Annual _. Seasonal Seasonal Dates: ;.-- 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 $160.00 Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) 11 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 1 Residential Kitchen $100.00 _J Retail Food $100.00!� L Retail Snack Food $25.00 Tobacco Products $25.00 D ( ition PHF Potentiall hazardous food (time/tem sisters controls re uiretl) 23) Food Operations a m ro s - y p q Non-PHFs - non -potentially hazardous leonine timeAemperature 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 PHFCooked To Order '�,'', ]Hat PHF Cooked and Cooled or Hot Held,, - --- --- Sale of Commercially Pre -Packaged PHFs ---- --- ----- i j Preparation of PHFs For Hot And for More Than a Single Meal Service _ LI ---- Cold Holding For Single Meal Service PHF and RTE Foods Prepare Delivery of Packaged PHFs _ .... -- �ForHighly �I Susceptible Population Facility --- --- I F me [ Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer 1 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours --- --- ---- -1. ------ --- - ] Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- i , Customer Self-service and/or HACCP Plan (including bare hand Perishable Foods Only-- - - I Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non PHFs _..i Retail Sale control)' Other Food Operations Juice Manufactured and Packaged for ', Offers Raw Or Undercooked Food Of Retail Sale Animal Origin FROZEN ICE, BOTTLED BEVERAGES _ C Offers RTE PHF in Bulk Quantities -- - --- ---- -- i Prepares Food/Single Meals for InstitutionalCatered Events or ice RetailSale of Salvage, Out -Of -Date ocondit Reconditioned Food To be completed by the Board of Health I Total Permit Fee: $25.00 L 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 Fo/odfycode. 24) Signature of Applicant: t '"� lA ;XLj�.---`� !XA Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my I*st knowledge and belief, have fled 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: 11� tivr'� A-V /✓k I 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 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 - MINUTE MAID LEMONADE / WATER CART PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-4 BOARD OF HEALTH .MichaeC-%1cCCean, Chairman Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No of Food Employees: 350 17) DAYS/HOURS: VARIES BY EVENT 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 19) Person Trained in Anti -Choking Procedures (If 25Seats or more) 1/1 20) Location: IJI Permanent Location 22) Establishment Type -', Moblie Moblie Start Date: �] Retail ( Sq. Ft) Moblie End Date: I_-'i 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 STEPHEN KELLY Caterer $25.00 f Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer '�� Annual or u to 25' PHFdisplay $150.00 Pushcart $25.00 # of Pushcarts: yi! Seasonal i_. Food Service u to 201 + p Residential Kitchen $100.00 or 25'+ PHF display$275.00 Retail Food $100.00 Seasonal Dates Temporary - - �_. Food Service -Institution I" ', Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) -I, Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous rood (time/temperature controls required) Non-PHFs - non -potentially hazardous lood(no tlme/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 - 1 Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations FROZEN ICE, BOTTLED BEVERAGES 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 j and/or HACCP Plan (including bare hand _I Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) Juice Manufactured and Packaged for '....i Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ! Prepares Food/Single Meals for l Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date _. or Reconditioned Food To be completed by the Board of Health 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 Customer - - Total Permit Fee: $25.00 Payment is due with application i...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,cf 105 CMR 590.000 apd the federal Food.Code. i 24) Signature of Applicant: �- 2- .2..b 1 2 G t i Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my est knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Signal Security Number or FederaCorporate ID: 04-3466949 u l�l ""' +� C � ""` ' 3 26 Signature of Individual or Cor orate Name: �-i, "f'