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Home My WebLink AboutNE Sportservice/XFinity #4 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 BAR PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-13 BOARD OF HEALTH MichaerMCCCean, Chairman See the attached map for location FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION -(Application must be submitted at leasT30days before the planned opening date) 1) Establishment Name ; r New England Sportservice, Inc. @ Minity Center 2) Establishment Address 885 South Main Street Mansfield, MA 02048 It f j 5 3) Establishment Mailing Address (if different) 250 Delaware Ave., Attn: Licensing, 12th Fl., Buffalo, NY 14202 4) Establishment Telephone No (508) 261-2900 J 5) Applicant Name & Title: New England Sportservice, Inc. 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 An Association or partner. KI A Corporation Name Title Address ® An Individual Please see the attachment. M A Partnership H Other legal Entity rz/ r-erson uirecuy mesponsime ror Ljairy uperauons towner, person in cnarge, supervisor, manager eic.) 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@delawarenorth.com Alt E-Mail: bsalansk@delawarenorth.com 13) District Or Regional Supervisor (if applicable) Food Establishment Information 14) WATER SOURCE: Town DEP Public Water Supply No: (If applicable) 15) SEWAGE DISPOSAL: Town 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 r 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 19 20) Location: X Permanent Location 22) Establishment Type (] Caterer $25.00 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 ® Food Service up to 101 -200 Eii Manufacture Frozen Desserts/Ice Cream $25.00/freezer 21) Length of Permit: Annual or up to 25' PHF display $150.00 Food Service up to 201 + Pushcart $25,00 # of Pushcarts: Residential Kitchen $100.00 Seasonal Seasonal Dates: or 25'+ PHF display $275.00 ®Retail Food $100.00 ❑ Food Service - Institution Retail Snack Food $25.00 Bar 2nd Stage A Temporary Temporary Start Date: ( Meals/Day) Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: hazardous food (time/temperature controls required) 23) Food Operations Definitions: PHF-Potentially Non-PHFs - non -potentially hazardous lood(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 0 PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service o- - o . MUD C - � s . Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only of Non-PHFs Other Food Operations Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale (p1d PHF and RTE Foods Prepared For Highly Susceptible Population Facility CI Vacuum Packaging / Cook Chill ® Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑j Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ❑'r Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application [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 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 Ynowledge 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: New England Sportservlce, Inc. Attachment to Question 11 Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. operating at Xfinity Center 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 Willow Wood Park South, Amherst, New York 14226 Attachment to Question 11 Town of Mansfield Food Establishment Permit Application New England Sportservice, Inc. operating at Xfinity Center 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 Willow Wood Park South, Amherst, New York 14226 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 - LEFT FIELD LAWN PACKAGE BEER PORTABLE PERSON(S) IN CHARGE: STEPHEN KELLY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XRS-15 a97_1:11 RX012:I E909:I MichaeCwlcCCean, Chairman See the attached map for location FOR BOARD OF HEALTH USE ONLY [Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application at leastdays before the planned opening a e 1) Establishment Name New England Sportservice, Inc. @ Minity Center 2) Establishment Address 885 South Main Street, Mansfield MA 02048 3) Establishment Mailing Address (if different) MAY 04 250 Delaware Ave., Attn: Licensing, 12th FL, Buffalo, NY 14202 i 4) Establishment Telephone No (508) 261-2900 - --- - 5) Applicant Name & Title: New England Sportservice, Inc. 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 FI., 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. K] A Corporation Name Title Address An Individual Please see the attachment. 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: (716) 367-0736, GM Cell FAX: 508-261-7799 E-mail: skelly@delawarenorth.com Alt E-Mail: bsalansk@delawarenorth.com 13) District Or Regional Supervisor (if applicable) Name & i itle: Address: Telephone No: 24 Hour Emergency No: FAX: -- E-mail: - - _— -- 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 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 BEER PORTABLES PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: XRF-1 BOARD OF HEALTH Michael wMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRF-1 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 s, c 12 Ott)' 2) Establishment Address 885 SOUTH MAIN STREET - WOODSIDE BEER PORTABLES 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 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 01038 Tele hone No 115081 261-2900 24 Hour Emergency No: (508) 261-2900 p FAX: (508) 261-7799 E-mail: SKELLY(EDDELAWARENORTH.COM Alt E-Mail: IBSALANSK(cDDELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: BETH SALANSKY 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 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) iJ 20) Location: i✓. Permanent Location 'i,, 22) Establishment Type '.. Moblie Moblie Start Date: --', Retail ( Sq. Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates. Temporary Temporary Start 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 't _1 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', i Manufacture Frozen Desserts/Ice Cream $25,00/freezer Pushcart $25.00 # of Pushcarts: 0 ` Residential Kitchen $100.00 IV] Retail Food $100.00 i] Retail Snack Food $25.00 Tobacco Products $25.00 Temporary End Date: I,I Temporary Time: Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food (tima4emperature 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 Sale of Commercially Pre Packaged PHFs I 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 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 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service __I PHF and RTE Foods Prepared For Highly Susceptible Population Facility 1 Vacuum Packaging / Cook Chill ' Customer Self -Service - Use of Process Requiring A variance and/or HACCP Plan (including bare hand i Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) I Juice Manufactured and Packaged for 1, , Offers Raw Or Undercooked Food Of - Retail Sale I Animal Origin BEER, FROZEN DRINKS, BOTTLED WATER 7 Offers RTE PHF in Bulk Quantities F 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: $100.00 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 690.000 and the,(ederal Food Code. A I 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 ,.-, 26) Signature of Individual or Corporate Name: Tl•s L Le t c olt I I — that I, to my best knoldge 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 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 - LOTSIDE BEER PORTABLES PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: XRF-2 BOARD OF HEALTH .%IichaeC�lcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit'# Issued XRF-2 69, 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 BEER PORTABLES 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. 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 An Association or partner. I A Corporation Name Title Address ! An Individual A Partnership I- - — -- '� ,� 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: (508) 261.2900 FAX: I(508) 261-7799 E-mail: SKELLY@DELAWARENORTH.COM Alt E-Mail: BSALANSK@DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: i Telephone No: I FAX: 24 Hour Emergency No: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN I 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: 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): r- 20) Location: ) Permanent Location 22) Establishment Type r I Mobile Mobile Start Date: j Retail ( Sq Ft) Mobile 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 - _ Annual or up to 25' PHF display $150.00 �, Seasonal '�. ] Food Service up to 201 + -' or 25'+ PHF display $275.00 Seasonal Dates: ' Temporary it �.._i Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: Caterer $25.00 L_1 Milk & Cream $10.00 [ 1 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 j Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous rood(no timeRemperature controls required) II(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 BEER, FROZEN DRINKS, BOTTLED WATER PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service I Sale of Raw Animal Foods Intended to be Prepared by Consumer 1 Customer Self -Service I_J Ice Manufactured and Packaged for Retail Sale I. Juice Manufactured and Packaged f Retail Sale Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service', i PHF and RTE Foods Prepared For Highly Susceptible Population Facility 1 I Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Offers Raw Or Undercooked Food Of Animal Origin i Prepares Food/Single Meals for { Catered Events or Institutional Food Service i To be completed by the Board of Health -_--- - - Total Permit Fee: $100.00 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. f t 24) Signature of Applicant: , Pursuant to MGL Ch.62C, sec. 49A, I rtify under the p and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: 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 FOOD ESTABLISHMENT 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 -MAIN KITCHEN AND COMMISSARY PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December31,2018 Food Fee: $135.00 License Number: XFS-1 BOARD OF HEALTH Michae(McCCean, Chairman Milk & Cream 0 Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that. NEW ENGLAND SPORTSERVICE, INC. having a place of business at: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET -MAIN KITCHEN AND COMMISSARY in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: XFS-1 Board of Health NichaeCNcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit# Issued XFS-1 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening w049e 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET -MAIN KITCHEN AND COMMISSARY - - 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, LICENSING DIVISION, BUFFALO, NY 14202 7) Applicant Telephone No.: (716) 666-5000 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, LIC. DIV., BUFFALO, NY 14202 Owner's telephone number (716) 858-5000 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: �885 SOUTH MAIN STREET, MANSFIELD MA 02048 - - - i Telephone No: I(508) 261-2900 24 Hour Emergency No. (509) 261.2900 FAX: (508) 261-7799 E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-Mail: BSALANSKPDELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN L 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: 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) Fv_l '.. 20) Location: IV] Permanent Location 22) Establishment Type , Mobile Mobile Start Date: f 1 Retail ( Sq Ft) Moblie End Date: Mobile Comments: 21) Length of Permit: ; I Annual Seasonal --- Seasonal Dates: '.. Temporary - Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations ((Check all that apply): IVI Food Service up to 100 or up to 10' PHF display $125.00 STEPHEN KELLY Caterer $25.00 L Milk & Cream $10.00 _I Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 Food Service up to 201 + I_] Residential Kitchen $100.00 or 25'+ PHF display $275.00 -1 Retail Food $100.00 Food Service - Institution Retail Snack Food $25,00 ( Meals/Day) i Tobacco Products $25.00' Definitions: PHF - Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no rime/temperature 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 1 Delivery of Packaged PHFs a 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 MAIN KITCHEN & COMMISSARY [_ ] Food Service up to 101 -200 or up to 25' PHF display $150.00 j 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 Pr pared For Highly -- ---- I 1 Sale of Raw Animal Foods Intended Susceptible Population p y -- to be Prepared by Consumer Vacuum Packaging / Cook Chill Customer Self -Service 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 i j Offers Raw Or Undercooked Food Of Retail Sale "' Animal Origin ' Offers RTE PHF inBulk Quantities i-_] Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage Out -Of -Date -- --- -- - or Reconditioned Food f To be completed by the Board of Health _ - - Total Permit Fee: $135.00 '. Payment is due with application i waived !i 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. 1 have been instructed by the board of health on how to obtain.copiea of 105 CMR 590.000 ansl-ttre federal Food Code. I 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties and paid slate taxes required under law. 25) Social Security Number or Federal ID: 04 26) Signature of Individual or Corporate Name: N that I, to my best khowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER ADDRESS: 885 SOUTH MAIN STREET -MAIN KITCHEN AND COMMISSARY TELEPHONE AT LOCATION: (508) 261-2900 FAX NUMBER: (508) 261-7799 OWNER OF BUSINESS: NEW ENGLAND SPORTSERVICE, INC. TELEPHONE OF OWNER: (716) 858-5000 FEDERAL ID/SS NUMBER: 04-3466949 FEE: $10.00 PERMIT NUMBER: XFS-1 SIGNATURE: DATE: 1 2Z� rY U' 1 -1 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 FOOD ESTABLISHMENT 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 FOOD PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-3 BOARD OF HEALTH .MichaeC.McCCean, Chairman 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 FOOD ESTABLISHMENT 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 - LOWER TENT - EMPLOYEE GRILL PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-2 BOARD OF HEALTH Nichaet`NcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-2 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 886 SOUTH MAIN STREET -LOWER TENT -EMPLOYEE GI�I L 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. 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. JI 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 Telephone No: 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: I(508) 261-7799 - -- — - - - -- E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-Mail: BSALANSK(cDDELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: I Telephone No: 24 Hour Emergency No: E-mail: FAX: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: ' 17) DAYS/HOURS: VARIES BY 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: W�, Permanent Location i 1 22) Establishment Type Caterer $25.00 ! Moblie Moblie Start Date: l Rat 'I S Ft Mlk & C $10 00 Moblie End Date: Moblie Comments: 21) Length of Permit: �' j Annual -] Seasonal Seasonal Dates: i....1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations .(Check all that apply): ,... ai ( ) q. ream V Food Service up to 100 or _-; Mobile Food & Consession $75.00 up to 10' PHF display $125.00 1 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 J Pushcart $25.00 # of Pushcarts: 0 j Residential Kitchen $100.00 L_. Retail Food $100.00 Retail Snack Food $25.00 .I Tobacco Products $25.00 Definitions: PHF- Potentially hazardous food ftime/temperature controls required) Non-PHFs - non -potentially hazardous food(no lime/femperature 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 _. 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 1 Preparation of Non-PHFs I PHFCooked To Order Preparation of PHFs For Hot And , Cold Holding For Single Meal Service irk Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service 1 ! 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 j J 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) _ Other Food Operations (. ! Juice Manufactured and Packaged for 11 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BURGERS, DOGS, FOUNTAIN SODA Offers RTE PHF in Bulk Quantities 1 Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Dale - -- -- -- or Reconditioned Food 1 To be completed by the Board of Health -_-- - ---- - j '.. Total Permit Fee: $125.00 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 ] 0 MR�590.000 and the f eral Food Code. 24) Signature of Applicant: (- �-- I)rr. T"�---^r-'' ' ~I Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowled " d belief, have fit d all stile 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: FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-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 - RIGHT FIELD FOOD ,1,t,Lte ..1 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)868-5000 EXT.5162 BETH 24 Hour Emergency No.: SALANSKY (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 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 I Address: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No �(508) 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: (508) 261-7799 E-mail: SKELLY(cDDELAWARENORTH.COM Alt E-Mail: BSALANSK(a)DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: E-mail - 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 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 22) Establishment Type I Mobile Mobile Start Date: t Retail ( S Ft) Moblie End Date: Mobile Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates: _; Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: '.� Definitions: PHF - Potentially hazardous food (IimeRemperature 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) l 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 ' j Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) Caterer $25.00 U Milk & Cream $10.00 Mobile Food & Consession $75.00 -°, Manufacture Frozen Desserts/Ice Cream $25.00/freezer I. Pushcart $25.00 # of Pushcarts: 0 `._] Residential Kitchen $100.00 [.. Retail Food $100.00 1 Retail Snack Food $25.00 - i Tobacco Products $25.00 23) Food Operations ((Check all that apply): Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service -I - -' Cold Holding For Single Meal Service I I PHF and RTE Foods Prepared For Highly Deliveryof Packaged PHFs - r I� of --- - - Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer I I Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours an 'I, 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 Ice Manufactured and Packaged for contact alternative, time as a public health ''I, Preparation of Non-PHFs Retail Sale _ _ control) Other Food Operations i.-] Juice Manufactured and Packaged for, J Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BURGERS, DOGS, BOTTLED BEVERAGES I, Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for _ Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date ---- -- - I I, or Reconditioned Food To be -completed by the Board of Health -- Total Permit Fee: $125.00 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 106 CMR 590.000 and the federal Food Code' 24) Signature of Applicant: -2— D_ C' i Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best owledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: XFINITY FOOD ESTABLISHMENT 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 - UPPER WOODSIDE FOOD PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-4 BOARD OF HEALTH .Michaef,,1 cCCean, Chairman - FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-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 -UPPER WOODSIDE FOOD t 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) 868-5000 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. 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: 885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (sob) 261-2900 FAX I(508) 261-7799 l E-mail: ISKELLYPDELAWARENORTH.COM Alt E-Mail: I,BSALANSK(a)DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: 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: 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): IV] 20) Location: [✓] Permanent Location 22) Establishment Type [. Moblie Moblie Start Date: [] Retail ( Sq. Ft) Moblie End Date: [VI; Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: Annual Seasonal Seasonal Dales: '.. 1 Temporary Temporary Start Date: Temporary End 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 f..] 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 i.._i Retail Food $100.00 _] Retail Snack Food $25.00 Tobacco Products $25.00 Temporary Time: Rain Date: J1_.. 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) .(Check all that apply): ! RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commerally Pre -Packaged Non PHFs j j PHFCooked To Order IjI, Hot PHF Cooked and Cooled or Hot Held Sale of Commerc ally Pre Packaged PHFs -- - I j Preparation of PHFs For Hot And i for More Than a Single Meal Service _ 1 Delivery of Packaged PHFs - �. Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highll Sale of Raw Animal Foods Intended 1 Susceptible Population Facility I ]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- --- --- -- j j Customer Self -Service _ 1 Use of Process Requiring A Variance t 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) i I Juice Manufactured and Packaged for I j Offers Raw Or Undercooked Food Of'. Other Food Operations Retail Sale Animal Origin FULL MENU Offers RTE PHF in Bulk Quantities Pre Food/Sin le Meals for Prepares p g _.._ _. , 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: $126.00 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 1q5 CMR 590.000 and the fgdaral Food Code. f) , t 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best kno a and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Commonwealth of Massachusetts Town of Mansfield Board of Health. Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: XFINITY FOOD ESTABLISHMENT 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 - COURTYARD PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $135.00 License Number: XFS-5 BOARD OF HEALTH Michae[McCCean, Chairman Milk & Cream V Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: NEW ENGLAND SPORTSERVICE, INC. having a place of business at Town of Mansfield 6 Park Row Mansfield, MA 02048 NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET - COURTYARD in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: XFS-5 Board of Health NichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-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 XFINITY CENTER 2 Establishment Address _ 2`0)`f ) 885 SOUTH MAIN STREET -COURTYARD �`'" n 3) Establishment Mailing Address (if different) 250 DELAWARE AVENUE, ATTENTION: 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, LIC. DIV., BUFFALO, NY 14202 7) Applicant Telephone No.: (716) 858-5000 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, LIC. DIV., BUFFALO, NY 14202 Owner's telephone number (716) 858-5000 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 11 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: j(508) 261-2900 24 Hour Emergency No: (508) 251-2900 ! FAX I(508) 261-7799 E-mail: 'SKELLYODELAWARENORTH.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 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:1 Permanent Location 22) Establishment Type �._ I Mobile Moblie Start Date: I I-J Retail ( Sq. Ft) Mobile End Date: Mobile Comments: 21) Length of Permit: I Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: IV] 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 -.-1 Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) 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: 0 I, Residential Kitchen $100.00 Retail Food $100,00 j Retail Snack Food $25.00 -] Tobacco Products $25.00 Rain Date: _-- --__-- --�_-- - ---- 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs non -potentially hazardous food(no trme/temperature controls required) (Check all that apply): - RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) -', Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self-service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations FULL MENU & MILK & CREAM 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 Self -Service I Ice Manufactured and Packaged fc Retail Sale _.__-__ 1 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for ❑Offers Raw Or Undercooked Food Of Retail Sale Animal Origin I j Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service I J Retail Sale of Salvage Out -Of -Date --- - --:-.- or Reconditioned Food To be completed by the Board of Health �` _ - -- -_-- -- Total Permit Fee: $135.00 Payment is due with application 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMt3,590.000 and the fede!,@t Food Code. 1) 1 24) Signature of Applicant: �,j_�� '�"�-}-� �7.rr---C .-G-� ---.,✓max" Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and paid state taxes required under law. 25) Social Security Number or Federal ID: 04 E 26) Signature of Individual or Corporate Name: t2.ILo belief, have filed all state tax returns JV-cl Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER ADDRESS: 885 SOUTH MAIN STREET - COURTYARD TELEPHONE AT LOCATION: (508) 261-2900 FAX NUMBER: (508) 261-7799 OWNER OF BUSINESS: NEW ENGLAND SPORTSERVICE, INC. TELEPHONE OF OWNER: (716) 858-5000 FEDERAL ID/SS NUMBER: 04-3466949 FEE: $10.00 PERMIT NUMBER: XFS-5 SIGNATURE: {A DATE: 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 FOOD ESTABLISHMENT 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 - UPPER WOODSIDE PORTABLE PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-6 BOARD OF HEALTH Nichae(NcC(ean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-6 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) I 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTF�j 2) Establishment Address 885 SOUTH MAIN STREET - UPPER WOODSIDE PORTABLE 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 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 1 An Association i 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 Telephone No: (508) 261-2900 24 Hour Emergency No: (509) 261.2900 FAX: - ,(508) 261-7799 - E-mail: SKELLY@DELAWARENORTH.COM Alt E-Mail: !BSALANSK(&DELAWARENORTH.COM (LICENSING) - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: ii24 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 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 11 certificate j 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): d 20) Location: iJi Permanent Location 22) Establishment Type Caterer $25.00 1 _ Mobile Mobile Start Date: i ] Retail ( Sq. Ft) i_'1 Milk &Cream $10.00 Mobile End Date: iI Food Service up to 100 or I_.', Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 - ' M f t F D /I C 21) Length of Permit: i;�',, Annual Seasonal Seasonal Dates: i Temporary Temporary Start Date: Temporary End Date: Temporary Time: 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 L] Food Service - Institution ( Meals/Day) anu ac ure rozen easerta ce ream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 Ll Retail Food $100.00 _] Retail Snack Food $25.00 `..] Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions.PHF- Potentially hazardous food(time/temperature controls required) '.. Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) (Check all that apply): RTE- ready-fo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non PHFs I PHFCooked To Order -1 Hot PHF Cooked and Cooled or Hot Held - o - - ---i PHFs para -- - - r - Preparation of PHFs For Hot And I for More Than a Single Meal Service - Dell vet of Packaged PHFsackaged Delivery g Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly �-- - ---- ----- --- -I Sale of Raw Animal Foods Intended �. Susceptible Population Facility Reheating of Commercially _, to be Prepared by Consumer i_; Vacuum Packaging / Cook Chill ' Processed Foods for Service Within 4 Hours - - ----------- ---- ---i Customer Self Non PHF Non- --- -- --- Customer Self Use of Process Requiring AVariance -Service of and IF -Service and/or HACCP Plan (including bare hand' Perishable Foods Only -- i�.1 Ice Manufactured and Packaged for contact alternative, time as a public health !i ' Preparation of Non-PHFs Retail Sale ) Other Food Operations Manufactured and Packaged for I Offers RawOrUndercooked Food Of Retail Sale - 1 FRIES, BOTTLED WATER, FOUNTAIN SODA I - Prepare Events iir Institutional Food Service Offers RTE PHF in Bulk Quantities P g e Meals for 1, Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health - - - -- - -- -` Total Permit Fee: $125.00 1i 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 690.000 and the�federal Food Code. (I , 24) Signature of Applicant: gi _ -v -4-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: f ZCr 1t and belie . have fil d all state 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 FOOD ESTABLISHMENT 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 FRIED DOUGH PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-7 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-7 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 CENT IR r W 2) Establishment Address 885 SOUTH MAIN STREET - WOODSIDE FRIED DOUGH 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 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. �7 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: (508) 261-2900 FAX: (508) 261-7799 E-mail: ISKELLY(CDDELAWARENORTH.COM Alt E-Mail: iBSALANSK@DELAWARENORTH.COM 13) District Or Regional Supervisor (if applicable) Name & Title: Address: (LICENSING) Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information - T 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): FVl 20) Location: ❑r' Permanent Location 1 22) Establishment Type Mobile Mobile Start Date: [j Retail ( Sq. Ft) !, Mobile End Date: F ] 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 L..1 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: 'I. Temporary Time: !I Rain Date: 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 -.-I Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 23) Food Operations !, Definitions: PHF -Postially Rodfruature controls ont ! Non-PHF's -rion-potentially hazardous lood(no flmeAempereture controls required) - non -potentially hazardous mhue (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 Hot PHF Cooked andg Cooled or Hot Held '... Sale of Commercially Pre -Packaged PHFs Hot And Preparation of iSingle Fs rMeal Morele Than a Mel Service _. I Cold Holding For Service j PHF nrd RTE Foods Pr pared For Highly Delivery of Packaged PHFs - - _ -. I Sale of Raw Animal Foods Intended Susceptible Population Facility _. Reheating of Commercially _i to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ---- ------- ---- ---- 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 Perishable Foods Only a- _.-__ -- - _-i Ice Manufactured and Packaged for contact alternative, time as a public health ; Preparation of Non-PHFs Retail Sale _ control) Other Food Operations L] Juice Manufactured and Packaged for i _j Offers Raw Or Undercooked Food Of Retail Sale Animal Origin.... FRIED DOUGH, BOTTLED BEVERAGES F] Offers RTE PHF inBulk Quantities Prepares Food/Single Meals for _._ Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date 9 i or Reconditioned Food To be completed by the Board of Health - - !'I Total Permit Fee: $126.00 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 i 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-oL105 CMR 590.000 and+the federal Food Code. i , 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-F 26) Signature of Individual or Corporate Name: and belief, have filed all state 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 FOOD ESTABLISHMENT 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 - LOWER WOODSIDE FOOD PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December31,2018 Food Fee: $125.00 License Number: XFS-8 BOARD OF HEALTH MichaeCMCCCean, Chairman - FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-8 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 -LOWER WOODSIDE FOOD 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 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 CI An Association or partner. A Corporation Name Title Address An Individual j _ - 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) 251-2900 FAX (508) 261-7799 - E-mail SKELLY@DELAWARENORTH.COM Alt E-Mail: BSALANSK(&DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL. TOWN DEP Public Water Supply No: (If applicable) 1 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): W 350 20) Location: lei Permanent Location 1 22) Establishment Type E_I Caterer $25.00 -.'. Mobile Mobile Start Date: Retail ( Sq. Ft) 'r-'. Milk & Cream $10.00 Moblie End Date: Mobile Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: V 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 E ] Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) -1 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 (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 1 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 PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held : for ore Than a e Meal ln Preparation of PHFs For Hot And i Cold Holding For Single Meal Service FoodsForH � PHF and RTE Foods Prepared For Highly -i - Sale of Raw Animal Foods Intended Susceptible le Facility -- to be Prepared by Consumer I Vacuum Packaging / Cook Chill j ------ ---- --- j Use of Process Requiring A Variance CCP (including la to I i cesManufactured and Packaged for I alternative, time public heath Retail Sale control) Other Food Operations Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin FULL MENU ., Offers RTE PHFin 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: $125.00 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-.5,90.000 and the federal FoodrCode. r~ j i 24) Signature of Applicant: It- e LL4 Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and lief, have filed all state t x returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 E 26) Signature of Individual or Corporate Name: r `- � ( \�[/' 1 ) C �T t '�y i ( ) ')`-Yv, ,