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Home My WebLink AboutNE Sportservice/XFinity #3 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: 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-5 BOARD OF HEALTH Michaet`McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XP-5 FOOD ESTABLISHMENT PERMIT APPLICATIONS „ eon (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.: t716) 858--5000 ExT.5162 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 7168685000 10) Establishment Owned By 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. V 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: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: I(508) 261-2900 24 Hour Emergency No: (506) 261-2900 FAX: (508) 261-7799 E-mail: ISKELLY@DELAWARENORTH.COM Alt E-Mail: IBSALANSK(&DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: I Address: Telephone No: FAX: 24 Hour Emergency No: - I E-mail.. - - - Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: , 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ICI j 20) Location: J; 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: I;J. Annual Seasonal-- --- - Seasonal Dates: --_.. Temporary Temporary Start Date: Temporary End Date: Temporary Time: I'Rain Date: j Food Service up to 101 -200 or up to 25' PHF display $150.00 [.j Food Service up to 201 + or 25'+ PHF display $275.00 L': Food Service - Institution ( Meals/Day) TOWN 350 STEPHEN KELLY Caterer $25.00 _. _....�I _. Milk & Cream $10.00 '.. Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream -` $25.00/freezer Pushcart $25.00 # of Pushcarts: - i Residential Kitchen $100.00 j Retail Food $100.00 Retail Snack Food $25.00 (.-.1 Tobacco Products $25.00 23) Food Operations III Definitions' PHF - Potentially hazardous food (timeRemperature 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 I _ PHFCooked To Order ! 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 Cold Holden For Single Meal Service - 9 g ' PHF and RTE Foods Prepared For Highly,. Delivery of Packaged PHFs ry 9 - Susceptible Population Facility ---- _.. _.i I_ Sale of Raw Animal Foods Intended -_ Reheating of Commercially 9 y to be Prepared by Consumer Vacuum Packaging / Cook Chill L, ProcesseFoods for Service -__ 4 Hours Use of Process Requiring A Variance CustomerdSelf-Service of Non PH and Non- J Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations i ] Juice Manufactured and Packaged for is 1 Offers Raw Or Undercooked Food Of Retail Sale AnimalOrin BEER, WINE, MIX-A-RITA CARTS r --- Offers RTE PHF in Bulk Quantities _Pre ares od/SinMeals for I CateredEvents or stitutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be com leted byle 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 590.000and the federal F000 Code. I I 24) Signature of Applicant—'2-d-r Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to moat 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: The Commonwealth of Massachusetts Department of IndushialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 r www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERhHTTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: New England Snnrtca v;re, Tno @d xf• rT r Address:885 qnurh Mnin Rt t City/State/Zip: Mansfield, MA 02048 Phone#: 508-261-2900 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 280 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑RestaurantBar/Safing Establishment 2: ❑ lam a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp, insurance required] 3, ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § t (4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I I. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12,❑ Other with no employees. [No workers' comp. insurancereq.] *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy ioformadon. "If the eorpomte officers have exempted thcauslves, but the corporation has other employees, a workcrs' compensation policy is required and such an organix.6m should check box#I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon. Insurance Company Name: New Hampshire Insurance f 3r insurer's Address; 2704 Commerce Drive City/State/Zip: Harrisburg, PA 17110 Policy# orSelf-ins.Lic.#-WC D13778773 Expiration Date: 10/01/2018 Attach a copy of the workers' compensation. policy declaration page .(sbowing the policy number and expiration date),.. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fxte of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cthel�ins.d pe I s ofperjury that the information provided above is true and correct 716-858-5000x5162 Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person; Phone#: www.mass.gomma AFRO® CERTIFICATE OF LIABILITY INSURANCE D100920 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: MARSH USA, INC. P FAX SHERIDAN SHERIDAN MEADOWS CORPORATE PARK NORTH oN o EM : _Nod: 6500 SHERIDAN DRIVE, SUITE 114 E-MAIL ADDRESS: WILLIAMSVILLE, NY 14221 INSURERSAFFDRDING COVERAGE NAICN INSURER A: NIA NIA INSURED NEW ENGLAND SPORTSERVICE, INC. INSURER B : New Hampshire Ins. Co. 23841 INSURER C : NIA NIA CIO DELAWARE NORTH COMPANIES INCORPORATED 250 DELAWARE AVENUE INSURER D : BUFFALO, NY 14202 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-008890320-39 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUER VWD -- POLICY NUMBER POLICY EFF MMIDDMYY POLICY EXP MMIDDNYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMSMADE1:1OCCUR DAM A ET R N ED PREMISES Ea occurrence $ _ _ MED_EXP (Any one person) $ PERSONAL B ADV INJURY $ AGGREGATE LI MIT APPLIES PE R'. AGGREGATE $ GEN'L POLICY n jEa LOC _GENERAL PRODUCTS -COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident)accident)$ HIRED F I NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ _ $ UMBRELLA LIAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE LED RETENTION$ $ S WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED4 (Mandatory inNH) NIA--"---- WC 013778766 1010112017 10101/2018 X I PER OTH- __, STATUTE ER - EL. EACH ACCIDENT $_ 1,000,000 E.L. DISEASE EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASEPOLICYLIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ADDED 101, Additional Remarks Schedule, maybe attached if more space is required) CONFIRMATION OF COVERAGE THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS OFFICE OF INVESTIGATIONS 600 WASHINGTON STREET BOSTON, MA 02111 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Annette M Borodzik ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ISSUED BY THE STOCK INS HHANCE COMPANY HE REIN CALLED THE COMPANY. COMPANYNEW HAMPSHIRE INSURANCE r r DELAWARE NORTH COMPANIES INCORPORATED 250 DELAWARE AVENUE BUFFALO, NY 14202.0000 SEE EXTENSION OF ITEM 1, OF THE INFORMATION PAGE • WC990610 0006752-00 WC 013.77-8773 055-o4-1017-00 AIG An AIG company EXECUTIVE OFFICES! MARSH USA INC. WORKERS COMPENSATION AND EMPLOYERS 6500 SHERIDAN DRIVE LIABILITY POLICY INFORMATION PAGE SUITE 114 CORPOERDA710N RENEWAL wT Ogcrt 4006 OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 I/SM 2 POLICY PERIOD 12.91 AM, slrndnd lime of the Imm.. d's mOlInaaddresa FROM 10/01/17 ro 10/01/18 Hall 3 A. Workers Compensation Insurance: Pert One of the policy applies to the Workers Compensation Law of the states listed here: MA WI B. Employers Liability Insurance; Part Two of the policy applies to the work In each state listed In Item &A'. The limits of our liability under Part. Two are: Bodily Injury by Accident $ 1 , 000, 000 each accident Bodily Injury by Disease $ 1 .000.000 policy limit Bodily Injury by Disease t 1.,.000, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, If any, listed here: AK AL CT DC DE HI IN KY ME NE NM OR SD UT VT D. This policy. Includes these endorsements and schedules: SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE- WC990612 ITEM The premium for this policy will be determined by our Manuel$ of Rules, Claselficallons, Rates and Rating Plane. All Information required below Is subject to verification and change by audit. Osedticallurn CAR Number Bantam game TDtal T U.Na allan Seto Pot $1 of Re• Estimated Remlum X Annual3Y. munerAllon N Annual El 3Year SEE EXTENSION OF ITEM 4, OF THE INFORMATION PAGE - WC7754 TAXESlASSESSMENTSlSURCHARGES $33,576 EXPENSE CONSTANT(EXCEPTWNERE APPLICABLE BYSTATE) $338 MA MINIMUM PREMIUM $900 WI TOTAL ESTIMATED ANNUAL PREMIUM 31,215,511 It Indicated balow, Imalm adjuSlmenie Of premium Shell be made: ❑ 5e1N-Annually ❑ Ouateay ❑ Monthly ORPOSITPIUMIUM $1, 215, 573 11/02/17 BOSTON 04 ryLv inur bob nsuina OlNee Authodnd RearseenlaHVP WC 0000 O1A 399ar (fWd 04100) TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. New England Sportservice, Inc Signature of Individual or Corporate Name 04-3466949 "Social Security No. (Voluntary) or Federal Identification Number al P 6-�2- By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. RMmIthVa 0s Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc New England Sportservice, Inc. Massachusetts Director Christopher J. Feeney Officer Carlos Bernal Richard R. Schneider Nicholas D. Liberto Glenn T. Hart Janice R. Trybus Title Director Title President Chief Operating Officer Vice President -Finance Treasurer Secretary/Clerk Feeney, Christopher J. Residence: 9734 Cobblestone Drive, Clarence, New York 14031 Bernal, Carlos. Residence: 4880 Cliffside Dr. W., Clarence, New York 14031 Trybus, Janice R. Residence: 505 Tremont Street, Unit 405, Boston, Massachusetts 02116 Schneider, Richard R. 76 Chapel Woods, Williamsville, NY 14221 Liberto, Nicholas D. 54 Deer Run, Orchard Park, NY 14127 Hart, Glenn T. 53 Williow Wood Park South, Amherst, New York 14226 4 s � w m � G ME w O w U w W U V z 7-4 '�"'1 -40 Un J W z W P4 J J Y W_ W N N V 0 O a) z Z w U � N U a, o 4 O �y Q ld 'w ' O A w 0 � wed dnx a o h 43 y � tl aware ��— th- il, 8.'�C_,5 _s /E- Town of Mansfield Selectman's Office Six Park Row Mansfield, MA 02048-2433 Re: Xfinity Center Concessions Renewal of Health Permits Dear Sir or Madam: 250 Delaware Avenue Buffalo, New York 14202 T 716 858 5000 www.delawa renorth.co rn December 22, 2017 'p Enclosed please find our renewal application for the Health permit(s) covering our operations at Xfinity Center Concessions. Also enclosed is our check # 01298976 in the amount of $2,770.00 covering the renewal fees. Upon re -issuance of the license/permit, please forward to: New England Sportservice, Inc. Attn: Beth A. Salansky Licensing Division 250 Delaware Avenue Buffalo, New York 14202 Should you have any questions, please contact me at (800) 828-7240, Ext. 5162. Very truly yours, New England Spportservice, Inc. Beth . Salansky License Administrator/Paralegal Enclosures cc: Stephen Kelly Agency Submittal Letter Report 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 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 BEER PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25,00 License Number: XRS-1 BOARD OF HEALTH Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit #Issued XRS-1 FOOD ESTABLISHMENT PERMIT APPLICATION f0 2 6 2 �( (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 BEER 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE ATTN: LICENSING DIVISION 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) 868-5000 ExT.5162 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. 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: STEPHEN KELLY, GENERAL MANAGER Address: 1885 SOUTH MAIN STREET, MANSFIELD MA 02048 Telephone No. (508) 261-2900 24 Hour Emergency No: (509) 261.2900 FAX: I(508) 261-7799 E-mail: ISKELLY(a,)DELAWARENORTH.COM Alt E-Mail: IBSALANSK(&DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishmen4 Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: VARIES BY CONCERT BEING HELD 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 350 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): i] 20) Location: ICI Permanent Location 22) Establishment Type Moblie Moblie Start Date: [1 Retail ( Sq. Ft) Moblie End Dale: Moblie Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: _.J Food Service up to 100 or up to 10' PHF display $125.00 I Food Service up to 101 -200 or up to 25' PHF display $150,00 -I, i°; Food Service up to 201 + or 25'+ PHF display $275.00 --- __-1 [-_ i Food Service - Institution ( Meals/Day) I__ ] 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 VI Retail Snack Food $25.00 _ 1 Tobacco Products $25.00 Rain Date: 23 Food Operations I Definitions: PHF- Potentially hazardous food (time/temperature controls p 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 furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order V Hot PHF Cooked and Cooled or Hot Held . ---- - --i - Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service _____ _. Cold Holding For gle Meal PHIF and RTE Foods Prepared Highly Delivery Packaged { fof le ulation lbe OonsFoods PackagPng Commercially mlertendede Reheating So Pe paredlby Vacuum /Cook Chill Processed Foods for Service Within 4 Hours -. Customer Self -Service of Non PHF and Non- -' I Customer Self -Service --- Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only I J 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 _l Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BEER, WINE, BOTTLED BEVERAGES 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 !i 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 oEJD5_CMR 590.000 and the fe¢ecal Food Code. A r 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 Q ,{f 26) Signature of Individual or Corporate Name: and belief, have filed all slate tax returns 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 FOOD 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 FROZEN PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-2 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-2 FOOD ESTABLISHMENT PERMIT APPLICATION 2,6 (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 FROZEN 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) 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 ,I An Association or partner. A Corporation Name Title Address An Individual A Partnership y - Other legal Entit ___ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: STEPHEN KELLY, GENERAL MANAGER i Address: 11885 SOUTH MAIN STREET, MANSFIELD MA 02048 Telephone No: !(508) 261-2900 24 Hour Emergency No: (eos) 261•2900 FAX: (508) 261-7799 E-mail: SKELLY(u)DELAWARENORTH.COM Alt E-Mail: IBSALANSK(cDDELAWARENORTH.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 DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: VARIES BY EVENT BEING HELD 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 350 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 1-..1 Moblie Moblie Start Date: Retail ( Sq Ft) Moblie End Date: Moblie Comments: 1 21) Length of Permit: V Annual Seasonal Seasonal Dates: Temporary ---- Temporary Start Date: Temporary End Date: LI 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 L Mobile Food & Consession $75.00 J Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100,00 Retail Food $100.00 IV: Retail Snack Food $25.00 I 1 Tobacco Products $25.00 Temporary Time: I Rain Date:- 23)Food Operations Definitions:PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs non potentially hazardous food(no timeRemperatum 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 I ] ] PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs i 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 ----- ----- - - Preparation of PHFs For Hot And for More Than a Single Meal Service I_. ---. Cold Holding For Single Meal Service 'I PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility 1 _.. _.-..... to be Prepared by Consumer i 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) — --- _-.I Other Food Operations I Juice Manufactured and Packaged for I ] Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin BEER, FROZEN DRINKS, BOTTLED WATER —_--- - 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 fedArai Food Code. n t I 24) Signature of Applicant: i Pursuant to MGL Ch.62C, sec. 49A, I certify un( and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-F 26) Signature of Individual or Corporate Name: the penalties of perjury that I, to my best knowWge and belief, have filed all state tax returns 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 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 - WOODSIDE COMMISSARY PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-3 BOARD OF HEALTH michaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-3 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 - WOODSIDE COMMISSARY 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) 868-soon 24 Hour Emergency No.: (508) 261-2900 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 f J A Partnership - -- - _:L 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 Telephone No: j(508) 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: �(508) 261-7799 E-mail: ISKELLY(a)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 1 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) �� 16) No. ofFood Employees: 350 17) DAYS/HOURS: VARIES BY EVENT BEIG HELD 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: L I Permanent Location 22) Establishment Type _l. Caterer $25.00 J Mobile Mobile Start Date: 11 Retail ( Sq. Ft) If if Milk & Cream $10.00 '_ 1 Mobile Food & Consession $75.00 Moblie End Date: Mobile Comments: 21) Length of Permit: IJ' Annual Seasonal Seasonal Dates: .: ,_ Temporary Temporary Start Date: Food Service up to 100 or up to 10' PHF display $125.00 r j 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) Temporary End Date: Temporary Time: Rain Date: - --. Manufacture Frozen Desserts/Ice Cream $25.00/freezer li I. J 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 1 Dehnitions. PHF - Potentially hazardous food turnMemperalure controls required) HIs - non -potentially hazardous food(no thmeltemperalure controls required) I(Check all that apply). RTENon-P ready -to -eat foods (Ez sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre Packaged Non PHFs..- j ' PHFCooked To Order - - - -- PHIF Cooked and Cooledl t H eld I for More Than a Single MeaHot Servor ice Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ry - - - - Susceptible Population Facility -- — - - -'. Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer _.. Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 HoursI. ''. --- - --i Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- Customer Self -Service and/or HACCP Plan (including bare hand j Perishable Foods Only -an _ n � I Ice Manufactured and Packaged for contact alternative time as a public health ' P !. '. Preparation of Non-PHFs i Retail Sale control) L- Juice Manufactured and Packaged g e for Offers Raw Or Undercooked Food Of Other Food Operations i Retail Sale Animal Origin BEER, WINE, BOTTLED WATER 'r I J Offers RTE PHF in Bulk Quantities I _ 'Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date j 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 10 MR 590.000 an the deral F od Cade. 24) Signature of Applicant: _ < — � �rt Z!J 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 1 26) Signature of Individual or Corporate Name: 4`� �. �Fs^,l� t/ r� GJ-�� \0 ��y� 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 event being held 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: X Permanent Location 22) Establishment Type Caterer $25.00 Mobile Mobile Start Date: Q Retail ( Sq. Ft) «l Milk & Cream $10.00 Mobile End Date: Food Service up to 100 or Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑-I Food Service up to 101 -200 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 21) Length of Permit: X Annual or up to 25' PHF display $150,00 0 Food Service up to 201 + or 25'+ PHF display $275.00 i;t] Pushcart $25.00 # of Pushcarts: Residential Kitchen $100.00 1 Retail Food $100.00 0 ❑E Seasonal Seasonal Dates: ety Food Service - Institution Retail Snack Food $25.00 x1 2 tents ❑-1 Temporary Temporary Start Date: ( Meals/Day) 0 Tobacco Products $25.00 Temporary End Date: Temporary Time: i Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no tima/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) n Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑i Hot PHF Cooked and Cooled or Hot Held t =: Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑'I PHF and RTE Foods Prepared For Highly Susceptible Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours Perishable Foods Only Preparation of Non-PHFs Other Food Operations to be Prepared by Consumer I ( Vacuum Packaging / Cook Chill and/or HACCP Plan (including bare hand - ck — - contact alternative, time as a public health Ice Manufactured and Packaged for Retail Sale control) [ED Juice Manufactured and Packaged for I r] Offers Raw Or Undercooked Food Of Retail Sale - Animal Origin in Bulk Quantities 0 Prepares Food/Single Meals for Catered Events or Institutional Food Service U Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health 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 kndwledge 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: New England Sportservice, Inc. Conanzonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment I i XFINITY RETAIL SNACK 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 - MUSIC CAFE PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-4 BOARD OF HEALTH MichaetMcCtean, Chairman t FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-4 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- MUSIC CAFE 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.: BETH (716) 868-5000 EXT. 6162 24 Hour Emergency No.: (508) 261-2900 '.. 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. 9) Owner Address (If different from applicant) 260 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 I An Association or partner. ICI A Corporation Name Title Address An Individual A Partnership Other legal Entity j - - 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, MANSFIELD, MA 02048 Telephone No: 1:(508) 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: l(508) 261-7799 E-mail: SKELLY(cDDELAWARENORTH.COM Alt E-Mail: BSALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title Address: i - - Telephone No: 24 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:.. 350. 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. III 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: i) Permanent Location 'I, 22) Establishment Type Mobile Moblie Start Date: i-..._I, Retail ( Sq. Ft) Mobile End Date: ', Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: 'tiff Annual Seasonal Seasonal Dates: Temporary -.. _.... Temporary Start Date: Temporary End Date: Temporary Time: _ Food Service up to 101 -200 or up to 25' PHF display $150.00 1,_ I Food Service up to 201 + or 254 PHF display $275,00 -i 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 ❑ Retail Food $100.00 IVI Retail Snack Food $25.00 '.. - 11. Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions. PHF - Potentially food (time/lem erl controls required) q Y P Non-PHFs - non- non -potentially hazardous /ootl(no hmeRem erature controls required) ...(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocess l li Sale of Commercially Pre -Packaged Non-PHFs ) ] PHFCooked To Order L J Hot-PHF Cooked and Cooled or Hot Held,, Sale ofCommerciallyPre-Packaged IF' Preparation of PHFs Hot And for ore Than a Single Meal Service _PHFs Holdingal Serendvice arucl be Foodt For Highly - Deliveryof Packaged PHFs Susceptible PopulationF Facility SCold ale of Raw Animal Foords Reheating of Commercially to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours - - -- - Use of Process Requiring di Variance -- ', Customer Self -Service of Non PHF and Non- - _ Customer Self -Service � and/or HACCP Plan (including bare hand Perishable Foods Only r 1 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 j Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BEER, WINE, BOTTLED BEVERAGES i Offers RTE PHF in Bulk Quantities _ 11 Prepares Food/Single Meals for Catered Events or Institutional Food Service _i Retail Sale of Salvage, Out -Of -Date Ali or Reconditioned Food To be completed by the Boardf Health Total Permit Fee: He Payment is due with application l-1 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-of105 CMR 590.000 and jh6 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 and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: and belief, have filed all state tax returns �y!Ce , U+C_ . 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 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 XFINTIY CENTER 885 SOUTH MAIN STREET- CENTERFIELD BEER PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-5 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-5 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 XFINTIY CENTER 2) Establishment Address 885 SOUTH MAIN STREET- CENTERFIELD BEER "aG 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTN: LICENSING DIVISION 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.: BETH (716) 858-5000 EXT. 5162 24 Hour Emergency No.: (508) 261-2900 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 f I An Individual A Partnership Other legal Entity --J -- - --- - _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) -_ Name & Title: STEPHEN KELLY, GENERAL MANAGER Address: 1885 SOUTH MAIN STREET, MANSFIELD MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: 1(508) 261-7799 E-mail �SKELLY@DELAWARENORTH.COM Alt E-Mail: IBSALANSK(&DELAWARENORTH.COM (LICENSING) - _ - 13) District Or Regional Supervisor (if applicable) Name & Title Haaress: Telephone No: 24 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: 350 - 17) DAYS/HOURS: VARIES BY EVENT BEING HELD 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: ICI Permanent Location P2) Establishment Type ( Caterer $25.00 Moblie Moblie Start Date: (-] Retail ( Sq. Ft) f--; Milk & Cream $10.00 Moblie End Date: Moblie Comments: 21) Length of Permit: ;lit Annual Seasonal Seasonal Dates: i.i, Temporary Temporary Start Date: Temporary End Date: Temporary Time: ( Food Service up to 100 or up to 10' PHF display $125.00 [.l Food Service up to 101 -200 or up to 25' PHF display $150.00 !_J Food Service up to 201 + or 25'+ PHF display $275.00 [l Food Service - Institution ( Meals/Day) Mobile Food & Consession $75.00 -- Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 j Residential Kitchen $100.00 Retail Food $100.00 'I Retail Snack Food $25.00 ',._a Tobacco Products $25.00 Rain Date: 23) Food Operations I, Definitions: PHF - Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/femperature controls required) (Check all that apply): RTE -readto-eat y foods (Ex processing) sandwiches, salads, muffins which need no furtherI --_ Sale of Commercially Pre -Packaged Non-PHFs --- _-___- J PHFCooked To Order --__-_ Hot PHF Cooked and Cooled or Hot Held I - — - I ; Sale of Commercially Pre Packaged PHFs --- --- - -- - Preparation of PHFs For Hot And for More Than a Single Meal Service - _ - Cold Holding For Single Meal Service I, PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs rY g ---- ---- -- -- Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Vacuum Packaging /Coo k Chill h Processed Foods for Service Within 4 Hours - I Customer Self -Service of Non PHF and Non- j Customer Self -Service Use of Process Requiring A Variance q and/or HACCP Plan (includingbare hand shable Foods Only Perishable - 111 --- -- Packaged for ' � Ice Manufactured and contact alternative time as a public health . Preparation of Non PHFs Retail Sale _. a control) Other Food Operations Juice Manufactured and Packaged for g Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BEER, WINE, BOTTLED WATER — -- II Offers RTE PHF in Bulk Quantities I Prepares Food/Single Meals for Catered Events or Institutional Food Service r J Retail Sale of Salvage, Out-Of-Dateor Reconditioned Food To completed by the Board$of e _-.. __--------------i 2alth Tot Permit pee 5 He 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 conies aL1.(15 CMR 590.000 and therfed'eral Food Codt , i 24) Signature of Applicant VA kA,, l�42 'L ' 1 2' ?� ( l Pursuant to MGL Ch.62C, sec. 49A, I certifynder the penalties of perjury that I, to my be nowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 i✓ 26) Signature of Individual or Corporate Name: ` _�'' L `��`� V ` I-,f �+' ' 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 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 - DECK 4 PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-6 BOARD OF HEALTH Michaet .-%4cCCean, Chairman Food Establishment Information 14) WATER SOURCE: TOWN 11 15) SEWAGE DISPOSAL: TOWN !i DEP Public Water Supply No: (If applicable) -_. �. 16) No. of. Food Employees: 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) �. 20) Location: [J] Permanent Location ) Establishment Type l -j Mobile Mobile Start Date: '.- j 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: j_] Food Service up to 101 -200 JAnnual or up to 25' PHF display $150.00 Seasonal Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: -- -- �'- Temporary Food Service - Institution ''� Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: IFj Caterer $25.00 _ _! Milk & Cream $10.00 I _] Mobile Food & Consession $75.00 -- Manufacture Frozen Desserts/Ice Cream I_-! $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 -'; Residential Kitchen $100.00 Retail Food $100.00 J, Retail Snack Food $25.00 Tobacco Products $25.00 't-. Rain Dale: 23) Food Operations Definitions: PHF- Potentially hazardous food (timeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) �i,(Check all that apply): RTE - ready-to-eal foods (Ex. sandwiches, salads, muffins which need no further processing) 'I, Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order I Hot PHF Cooked and Cooled or Hot Held _ ----- - i for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs ' Preparation of PHFs For Hot And Cold. Holden For Single Meal Service 9 9 i PHF and RTE Foods Prepared For Highly !. Delivery of Packaged PHFs ry 9 _ Susceptible Population Facility 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 - - - - - 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 Ice Manufactured and Packaged for contact alternative, time as a public health j Preparation of Non-PHFs Other Food Operations BEER, WINE, BOTTLED WATER Retail Sale ❑ Juice Manufactured and Packaged Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin Offers RTE PHF in Bulk Quantities 7 I I Prepares Food/Single Meals for Catered Events or Institutional Food Service I Retail Sale of Salvage, Out-0 f-D --- -- -- - or Reconditioned Food To be completed by the Board of Health - -- -- - - -_ Total Permit Fee: $25.00 Payment is due with application waived 1, the ccuracy of board of health on how to ill con, attest to the acopi it of 1 the information R 5 0.0.00 and a the fe this Food application affirm b that the food establishment operation will comply with 105 CMR 590.000 and all other plP able law. I have been instructed by the —r 24) Signature of Applicant: � � f -41� 5::- 1-2 � l Pursuant to MOIL Ch.62C, sec. 49A, I certify under the penalties of perjuryt'Chat I, to my best knowledg� and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949tt�' 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 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 855 SOUTH MAIN STREET - LEFT FIELD BEER PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-7 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-7- FOOD ESTABLISHMENT PERMIT APPLICATION &T.�l U 2017 - (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 855 SOUTH MAIN STREET -LEFT FIELD BEER 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.: BETH (716)858-5000 EXT. 5162 24 Hour Emergency No.: (608) 261-2900 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, GENERAL MANAGER Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (e08) 261-2900 FAX: 1(508) 261-7799 I - -- E-mail: SKELLY@DELAWARENORTH.COM Alt E-Mail: BSALANSK(cDDELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) 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 CONCERT 1 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): iJ 20) Location: [Jl, permanent Location ! 22) Establishment Type Caterer $25.00 `. Moblie Moblie Start Date: l.._ Retail ( Sq. Ft) 'I Milk & Cream $10.00 Moblie End Date: -`, Food Service up to 100 or l Mobile Food & Consession $75.00 Moblie Comments up to 10' PHF display $125.00 - - Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: !..] Food Service up to 101 -200 _I $25.00/freezer I JJ Annual or up to 25' PHF display $150.00 ' -1 pushcart $25.00 # of Pushcarts: p �! --I Seasonal L I Food Service up to 201 + j Residential Kitchen $100.00 or 25'+ PHF display $275.00 Seasonal Dates: i Retail Food $100.00 _.] Food Service - Institution r! Retail Snack Food $25.00 Temporary Temporary Start Date: ( Meals/Day) Tobacco Products $25.00 Temporary End Date: !I Temporary Time: Rain Date:-_- __- -_-- 23) Food Operations Definitions: PHF- Potentially hazardous food (timeAemperature controls required) Non PHFs non -potentially hazardous food(no fimeRemperature 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 Hot PHF Cooked and Cooled or Hot Held for More Than a. Single Meal Service Sale of Commercially Pre -Packaged PHFs -- -II Preparation of PHFs For Hot And Cold Holding For Single Meal Service �, in PHF and RTE Foods Prepared For Highly Deli ve of Packaged PHFs ry -- - { Sale of Raw Animal Foods Intended Susceptible Population Facility _ ! ! Reheating of Commercially to be Prepared by Consumer Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours __ ---- --- ---- -- Use of Process Requiring A Variance -' Customer Self -Service of Non PHF and Non- [ Customer Self Service J 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 Retail Sale I control) _ Other Food Operations BEER, WINE, BOTTLED BEVERAGES [..i Juice Manufactured and Packaged for;...'! Offers Raw Or Undercooked Food Of Retail Sale Animal Origin I. I Offers RTE PHF in Bulk Quantities r i Retail Sale of Salvage, Out -Of -Date or Reconditioned Food [1 Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health ". --- -- - Total Permit Fee: $25.00 !, Payment is due with application i. _.,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 copiesA105 CMR 590.000 and therfederal Food Code. n I I 24) Signature of Applicant: / - Pursuant to MGL Ch.62C, sec. 49A, I certi under the penalties of perjury that I, to my best and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-f 26) Signature of Individual or Corporate Name: and belief, have filed all state tax returns 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 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 - LEFT FIELD FROZEN PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-8 BOARD OF HEALTH Michael 9McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRS-8 FOOD ESTABLISHMENT PERMIT APPLICATION 0 C 2 2%11 (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- LEFT FIELD FROZEN 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.: BETH (716) 868-5000 EXT. 5162 24 Hour Emergency No.: (508) 261-2900 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 - i 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, GENERAL MANAGER Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (506) 261-2900 FAX: (508) 261-7799 1 E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-mail, BSALANSK(a)DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) 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 CONCERNT 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): ICI 20) Location: Ili Permanent Location ( 22) Establishment Type _I Moblie Moblie Start Date: [ ] Retail ( Sq. Ft) Moblie End Date: [...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 IV Annual or up to 25' PHF display $150.00 I._ I, Seasonal __ Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: ___.-------- - j Temporary _. Food Service -Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply):', STEPHEN KELLY [. J Caterer $25.00 Milk & Cream $10.00 Mobile Food & Consession $75.00 --I Manufacture Frozen Desserts/Ice Cream `' $25.00/1reezer [... I Pushcart $25.00 # of Pushcarts: 0 ] Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 ',...� Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) 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 _I Delivery of Packaged PHFs 'I Reheating of Commercially Processed Foods for Service Within 4 Hours _] Customer Self -Service of Non PHF and Non - Perishable Foods Only i Preparation of Non-PHFs Other Food Operations BEER, FROZEN DRINKS, BOTTLED WATER I Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service j PHF and RTE Foods Prepared For Highly Susceptible Population Facility _ !� I, ] Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand 'i. _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 Catered Events or Institutional Food Service Retail Sale of Salvage, Out-Of-Dateor Reconditioned Food '.', To be completed by the Board of Health - Total Permit Fee: $26.00 Payment is due with application r -r� waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that g y p pp at 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 copiesofz105�GMR 590.000 and the federal FOQd Code. 4 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 24) Signature of Applicant: `7F 23 d- i.'�—Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best and paid state taxes required under law. 25) Social Security Number or Federal ID: 04 26) Signature of Individual or Corporate Name: and belief, have filed all state tax returns p 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 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 - BULLPEN PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-9 BOARD OF HEALTH -IichaeCwlcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-9 FOOD ESTABLISHMENT PERMIT APPLICATIONIEC 2 6 20=1 (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 - BULLPEN 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.: BETH (716) 858-5000 EXT, 5162 24 Hour Emergency No.: (508) 261-2900 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 90) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation i 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: 1,885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: 'I(508) 261-2900 24 Hour Emergency No: (506) 261-2900 FAX (508) 261-7799 E-mail: SKELLY@DELAWARENORTH.COM Alt E-Mail: IBSALANSK(cDDELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: l 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: - DEP Public Water Supply No: (If applicable) 1'1 16) No. of Food Employees: 17) DAYS/HOURS: VARIES BY CONCERTS TOWN 350 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: IJi Permanent Location 22) Establishment Type -.!, Moblie Moblie Start Date: [j Retail ( Sq. Ft) Moblie End Date: L_] 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 I ) Annual or up to 25' PHF display $150.00 I.] Seasonal 1 Seasonal Dates: Temporary - Temporary Start Date: Temporary End Date: Temporary Time: 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 or 25+ PHF display $275.00 - Retail Food $100.00 -- -- (- Food Service - Institution ly � Retail Snack Food $25.00 ( Meals/Day) Tobacco Products $25.00 i I Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperatum controls required) Non-PHFs - non -potentially hazardous food(no limeltemperature 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 -PH Fs I PHFCooked To Order ] Hot PHF Cooked and Cooled or Hot Held -- -- --) ra - - - -- i for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs 1 ,Preparation of PHFsFor Hot And I _- _. _I Cold Holding For Single Meal Service 1 PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs _ -_ _ --..I Susceptible Population Facility -- 1 Sale of Raw Animal Foods Intended I __ _. Reheating of Commercially �' to be Prepared by Consumer i 1 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours -' Customer Self -Service of Non PHF and Non 1' Customer Self -Service ---- Use of Process Requiring A Variance i and/or HACCP Plan (including bare hand . Perishable Foods Only -- -- -- _.i contact alternative, time as a public health Ice Manufactured and Packaged for - Preparation of Non PHFs Retail Sale _ I control) - Other Food Operations Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale BEER, WINE, BOTTLED WATER - e i I Catered Events or Food/Single Meals Food Service I, I Offers RTE PHF in Bulk Quantities 1 �i...] Retail Sale of Salvage, Out -Of -Date or Reconditioned Food j 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 tho'federal Food CodeA t L _j Food Service up to 201 + 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best kno ledge and bel f, have filed all state tax returns and paid state taxes required under law. ,1 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate IN �4 L}} Commonwealth of Massachusetts Town of Mansfield Town of Mans)feld 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: XFINITY RETAIL SNACK 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: XRS-10 BOARD OF HEALTH michaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-10 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned openm ga(._q gae)„i a, ;.r f t r~usd 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET - MINUTE MAID LEMONADEIWATER CART ' I 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. 5162 24 Hour Emergency No.: 508) 261-2900 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, GENERAL MANAGER Address: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: 508) 261-2900 24 Hour Emergency No: 509) 261.2900 FAX: (508) 261-7799 - - E-mail: ISKELLY@DELAWARENORTH.COM Alt E-Mail: BSALANSKPDELAWARENORTH.COM 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 DEP Public Water Supply No: (if applicable) 16) No. Of Food Employees: 350 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 10/l/2001 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 Mobile Start Date: '. _'i Retail ( Sq. Ft) Mobile End Date:-- Food Service up to 100 or Mobile Comments: 21) Length of Permit: IV' Annual I Seasonal- - Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: up to 10' PHF display $125.00 i STEPHEN KELLY Caterer $25.00 Milk & Cream $10.00 - ! Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 1 Pushcart $25.00 # of Pushcarts: 0 '.. _ Residential Kitchen $100.00 _J Retail Food $100.00 J� Retail Snack Food $25.00 Tobacco Products $25.00 Temporary Time: Rain Date' 23) Food Operations Definitions.PHF-Potentiall azardofood(time/tem(erature controls required)9 Non-PHFs non-potentiallyhazardous food oo hme4em ensure 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 i ❑ PHFCooked To Order ....I Hot PHF Cooked and Cooled or Hot Held -' Sale of Commercially Pre -Packaged PHFs j Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs -- Cold Holding For Single Meal Service ! PHF and RTE Foods Prepared For Highly rY ---- - - - --- Susceptible Population Facility ! Reheating of Commercially i Sale of Raw Animal Foods Intended - Processed Foods for Service Within 4 Hours to be Prepared by Consumer Vacuum Packaging / Cook Chill '. Customer Self -Service of Non PHF and Non Customer Self -Service - - Use of Process Requiring A Variance] - and/or HACCP Plan (including bare hand Ice Manufactured and d Packaged for Perishable Foods Only -__-._ -- contact alternative, time as a public health Preparation of Non PHFs _- Retail Sale _.._ control) _. Other Food Operations j i . Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _ FROZEN ICE, BOTTLED BEVERAGES - 1 r [ Offers RTE PHF in BU ulk Quantities i Prepares Food/Single Meals for i Catered Events or Institutional Food Service ] Retail Sale of Salvage Out -Of -Date i_: --- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $25.00 Payment is due with application ii-'1 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.pf 105 CMR 590.000 and the federal Food Code. I I Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 254 PHF display $275.00 i Food Service - Institution ( Meals/Day) 24) Signature of Applicant: i Pursuant to MGL Ch.62C, sec. 49A, I ertify under the penalties of perjury that I, toA 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 _,r � i1�. 9 f 1, s A 26) Signature of Individual or Corporate Name: '(• 'V `,'�,"`jam L 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 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 - INTERNATIONAL PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-11 BOARD OF HEALTH Michaet'McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRS-11 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opemndte7 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET - INTERNATIONAL 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) 858-6000 EXT. 5162 24 Hour Emergency No.: (508) 261-2900 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. 9) Owner Address (If different from applicant) Owner's telephone number 7168585000 10) Establishment Owned By: !, 11) If a corporation or partnership, give name, title, and home address of officers 1 An Association or partner. VI 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 Telephone No: (508) 261-2900 24 Hour Emergency No: (508) 261-2900 - - --- - FAX: I(508) 261-7799 E-mail ISKELLY@DELAWARENORTH.COM Alt E-Mail: IBSALANSK(&DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name &Title: - Address: Telephone No: FAX: 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 CONCERT 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): IV] '.. 20) Location: iJI Permanent Location 22) Establishment Type '_ Caterer $25.00 Moblie Moblie Start Date:11 Retail ( Sq. Ft) I' -1 Milk & Cream $10.00 Moblie End Date: Moblie Comments: 21) Length of Permit: Annual _ Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Food Service up to 100 or up to 10' PHF display $125.00 -.'':, Mobile Food & Consession $75.00 i Manufacture Frozen Desserts/Ice Cream $25.00/freezer [ 1, Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 254 PHF display $275.00 Food Service - Institution ( Meals/Day) [_ Pushcart $25.00 # of Pushcarts: 0 I Residential Kitchen $100.00 f_ I Retail Food $100.00 ICJ 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 lood(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 Y Sale of Commercially Pre -Packaged PHFs Delivery ofPackaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non Perishable Foods Only Pre aration of Non-PHFs !_ PHFCooked To Order i Preparation of PHFs For Hot And Cold Holding For Single Meal Service I Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale [j 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 i 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 Undercooked Food Of Other Food Operations ___ Catered Events or Meals f Food Service Retail Sale Animal Origin BEER, WINE, BOTTLED WATER.11 Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities -.I Retail Sale of Salvage, Out -Of -Date r ---- -- or Reconditioned Food To be completed by the Board of Health Ali Payment is due with application 00 Total Permit Fee: $25. Pa Y PP 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 tjwfoderal Food Code. (\ , 24) Signature of Applicant: r 1"`y r - V`' 6 I Pursuant to MGL Ch.62C, sec. 49A, I ce ify under the penalties of perjury that I, to my best knowle ge 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 - GRAB N GO 2 PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-12 BOARD OF HEALTH MichaeCMcCCean, Chairman See the attached mar, for location FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION _—TAp—plic—aton —must be submt d at least 30 days before the planned opening date) 1) Establishment Name New England Sportservice, Inc. @ Minity Center _Z) —Establishment Address 885 South Main Street, Mansfield, MA 02048 77 3) Establishment Mailing Address (if different) 0 4 2GIB 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 MAY -1 4) Establishment Telephone No (508) 261-2900 1k 5) Applicant Name & Title: New England Sportservice, Inc.L�� 6) Applicant Address 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 7) Applicant Telephone No.: 716-858-5162 24 Hour Emergency No.: (716) 367-0736, GM cell Beth Salansky 8) Owners Name & Title New England Sportservice, Inc. 9) Owner Address (if different from applicant) 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 Owner's telephone number (716) 858-5000 x5162 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers H An Association or partner. KI A Corporation Name Title Address 19 An Individual Please see the attachment. H A Partnership El Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Stephen Kelly, General Manager Address: Telephone No: 885 South Main Street, Mansfield, MA 02048 508-261-2900 24 Hour Emergency No: (716) 367-0736, GM Cell 508-261-7799 FAX: E-mail: — skelly@delawarenorth,com Alt E-Mail: bsalansk@delawarenorth.com 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 DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 280 17) DAYS/HOURS: Varies by event being held 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): 0 - .l 20) Location: X Permanent Location 22) Establishment Type Caterer $25.00 dl Mobile Mobile Start Date: Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: ® Food Service up to 100 or - ® Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 I❑'9 Food Service up to 101 -200 0 Manufacture Frozen Desserts/Ice Cream $25.00/freezer _ 21 Length of Permit: 9 Annual or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 Pushcart $25.00 # of Pushcarts: Residential Kitchen $100.00 H Retail Food $100.00 Seasonal Seasonal Dates: Food Service - Institution X Retail Snack Food $25.00 Grab n Go 2 H Temporary Temporary Start Date: ( Meals/Day) i'1 Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: -- 23) Food Operations (Check all that apply): Definitions:PHF-Potentially hazardous food (timertempereture controls required) Non-PHFs -non-potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs❑`! PHFCooked To Order 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 Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs [=1J Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑! Reheating of Commercially Processed Foods for Service Within 4 Hours ❑'# 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) Q Offers Raw Or Undercooked Food Of Animal Origin Customer Self -Service of Non PHF and Non- Perishable Foods Only _____ ❑1 Customer Self -Service ;❑i Ice Manufactured and Packaged for Retail Sale E] Preparation of Non-PHFs Other Food Operations [] Juice Manufactured and Packaged for Retail Sale Prepares Food/Single Meals for Catered Events or Institutional Food Service ---- ies Offers RTE PHF in Bulk Quanti t TJ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: 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 berst 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: New England Sportservice, Inc.