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Home My WebLink AboutNE Sportservice/XFinity #5 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 FOOD ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 306A 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 PORTABLE PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-9 BOARD OF HEALTH wlichae(NeC(ean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-9 i 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 - a' 2) Establishment Address 885 SOUTH MAIN STREET -LOWER WOODSIDE PORTABL� `- 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. 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: j885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-2900 24 Hour Emergency No: (506) 261-2900 FAX: i(508)261-7799 -- - - - E-mail: SKELLY(a)DELAWARENORTH.COM Alt E-Mail: BSALANSK@DELAWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: E-mail: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWP 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 10/1/2001 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) �j 20) Location: iV, Permanent Location 22) Establishment Type Moblie Moblie Start Date: j Retail ( Sq. Ft) Moblie End Date: ISI Ji Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: Annual 11 Seasonal Seasonal Dates: Temporary Temporary Start Date: Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 [] Food Service - Institution ( Meals/Day) Caterer $25.00 Milk & Cream $10.00 j Mobile Food & Consession $75.00 �-� Manufacture Frozen Desserts/Ice Cream - - $25.00/freezer -j Pushcart $25.00 # of Pushcarts: 0 [.J Residential Kitchen $100.00 [.j Retail Food $100.00 -j Retail Snack Food $25.00 i, Tobacco Products $25.00 Temporary End Date: Hot PHF Cooked and Cooled or Hot Held Temporary Time: Preparation of PHFs For Hot And Rain Date: i PHF and RTE Foods Prepared For Highly 23) Food Operations Definitions: PHF - Potentially hazardous food (tlmeRempereture controls required) Sale of Raw Animal Foods Intended Non-PHFs - non -potentially hazardous food(no time/lemperature controls required) '.(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) -.I Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations BURGERS, DOGS, SAUSAGE, BOTTLE WATER PHFCooked To Order I `_I, Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Preparation of PHFs For Hot And Cold Holding For Single Meal Service 11 i PHF and RTE Foods Prepared For Highly ---- -- ---- 1 Susceptible Population Facility l Sale of Raw Animal Foods Intended __. _ to be Prepared by Consumer I iVacuum Chillook gR ng r { A Variance Use of Process Requiring ' Customer Self -Service and/or HACCP Plan (including bare hand -- -1 Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale I' control) _j Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date --- -- -' To be by the Board of Health or Reconditioned Food completed --__-- ----___-- Total Permit Fee: $125.00 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 copies of 10fiCMR 590.000 and the(Mderal Food Code. f\ 24) Signature of Applicant: \ `" , Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowled and belief, and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3466949 26) Signature of Individual or Corporate Name: Iv"�' W (.1 tr!{..-a^(� �s ",r 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 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 - LEFT FIELD FOOD PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-10 BOARD OF HEALTH MichaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-10 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 CENTERS «O;7 - - - - - .- -c- Lu 2) Establishment Address 885 SOUTH MAIN STREET - LEFT FIELD 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.: 24 Hour Emergency No.: (609) 2614900 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. Vl 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: 1(508) 261-2900 24 Hour Emergency No: (509) 251-2900 FAX: I(508) 261-7799 E-mail: SKELLY@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 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 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate I 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location j 22) Establishment Type L ] Caterer $25.00 Mobile Mobile Start Date: I -J Retail ( Sq. Ft) Ll Milk & Cream $10.00 Mobile End Date: IJP Food Service up to 100 or ��I j_ ] Mobile Food & Consession $75.00 Mobile Comments: '�, up to 10' PHF display $125.00 -- Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: I 1 Food Service up to 101 -200 $25.00/freezer IJ' Annual or up to 25' PHF display $150.00 i Pushcart $25.00 # of Pushcarts: 0 Seasonal I_. Food Service up to 201 +-_.J Residential Kitchen $100.00 or 25'+ PHF display $275.00 '�, Retail Food $100.00 Seasonal Dates: ..I I.. 1, Temporary i_i Food Service -Institution ,_) Retail Snack Food $25.00 Temporary Start Date: ��i ( Meals/Day) (-j Tobacco Products $25.00 I, Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions. PHF- Potentially hazardous food (timeRemperature controls required) j Non-PHFs - non -potentially hazardous food(no tlmeRemperature controls required) '(Check all that apply): 1 RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre Packaged Non PHFs ] PHFCooked To Order I 1 Hot PHF Cooked and Cooled or Hot Held �.. - - Sale of Commercially Pre -Packaged PHFs --- -- - - I Preparation of PHFs For Hot And { for More Than a Single Meal Service - Cold Holding For Single Meal Service j, PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ry g --- -- --- --I r.-.1 Intended Susceptible Population Facility -, Reheating of Commercial) g y Sale of Raw Animal Foods to be Prepared by Consumer _ � i i Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours - _- - - ---1 ------ -- - - h_1 Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- 1, Customer Sell -Service and/or HACCP Plan (including bare hand Perishable Foods Only _ Ice Manufactured and Packaged for contact alternative, time as a public health - PRetail Preparation of Non Sale control) ons Other Food Operations and Packaged for Juice) awOrUndercooked Food Of i ' I Offers Rle RetSanufactured Animal in BURGERS, DOGS, BOTTLED WATER [. Offers RTE PHF in Bulk Quantities - - - I _-, Prepares Food/Single Meals for Catered Events or Institutional Food Service i i Retail Sale of Salvage Out -Of -Date — _ -- -- --- --I or Reconditioned Food To be completed by the Board of Health - - __---- ----_ _- 5.00 2!---'... Payment is due with application 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 a��,,nnd the f eral Foo Code. 24) Signature of Applicant: d �r-'l"' •�r✓'�/lL.,th 1 �� l1 d Pursuant to MGL Cl sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-F 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: 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 LOTSIDE PORTABLE PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-11 BOARD OF HEALTH .MichaeC9vlcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-11 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 LOTSIDE 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.: BETH (716) 858-5000 EXT. 5162 24 Hour Emergency No.: (508) 261-2900 BETH 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: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: I(508) 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: I(508) 261-7799 - E-mail ISKELLY@DELAWARENORTH.COM Alt E -Mail ,BSALANSK(a)_DELAWARENORTH.COM (LICENSING) - - - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No FAX: 24 Hour Emergency No� E-mail: Food Establishment Information 1 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 10/1/2001 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) �1 20) Location: ;/I Permanent Location Mobile Mobile Start Date: Mobile End Dale: Moblie Comments: 21) Length of Permit: V Annual Seasonal --- - - Seasonal Dates: Temporary - -- -- Temporary Start Date: Temporary End Date: Temporary Time: R ' D 22) Establishment Type ❑ Retail ( Sq. Ft) I,J 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 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 _-1 Retail Food $100.00 .] Retail Snack Food $25.00 �❑ Tobacco Products $25.00 1 am ate. 23) Food Operations Definitions PHF- Potentially hazardous food(time/temperature controls required)'. Non-PHFs - non -potentially hazardous food(no time/lemperature 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 PHFCooked To Order �I Hot PHF Cooked and Cooled or Hot Heid Sale of Commercial/ Pre -Packaged PHFs Commercially g - -- - - i Preparation of PHFs For Hot And for More Than a Single Meal Service - - Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Deliveryof Packaged PHFs g - -'�, - --- -- I Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared b Consumer Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours I Customer Self -Service of Non PHF and Non - Perishable Foods Only I Preparation of Non-PHFs Customer Self -Service Retail Sale Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Other Food Operations ❑Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin FRIES, BOTTLED WATER, FOUNTAIN SODA ! __ _ --- ---- --- --- - r ' Offers RTE PHF in Bulk Quantities t' ! 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 590.000 and tWfederal Food Code. N t t 24) Signature of Applicant: Pursuant to MGL Ch,62C, sec. 49A, I certify and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Nar M under the penalties of perjury that I, to my best knoWtollige and belief, have filed lax 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 E .MV1611j111CIiU/31011RIi 17:401917 PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-12 BOARD OF HEALTH MichaeCMeCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS 12 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening (late) 1) Establishment Name NEW ENGLAND SPORTSERVICE INC. @ THE XFINITY CENTS 26 2017 2) Establishment Address 885 SOUTH MAIN STREET - UPPER LOTSIDE 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.: BETH (716) 858-5000 EXT. 5162 24 Hour Emergency No.: (508) 261-2900 BETH 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. VA Corporation Name Title Address An Individual - A Partnership Other legal Entity__ -- - - _- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) - - -- — - _ - 1 Name & Title: (STEPHEN KELLY, GENERAL MANAGER I Address: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No 1(508) 261-2900 24 Hour Emergency No: (506) 261-2900 FAX: (508)261-7799 E-mail: SKELLY(cDDELAWARENORTH.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 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 10/1/2001 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): -------- -------- ] Preparation of PHFs For Hot And 20) Location:; Permanent Location 22) Establishment Type Cold Holding For Single Meal Service ` Caterer $25.00 Moblie Moblie Start Date:'I, j_-] Retail ( Sq. Ft) to be Prepared by Consumer I!--- Milk & Cream $10.00 Mobile End Date: [] Food Service up to 100 or Ice Manufactured and Packaged for - Mobile Food & Consession $75.00 Mobile Comments up to 10' PHF display $125.00 Juice Manufactured and Packaged for ��; [_.', _ Manufacture Frozen Desserts/Ice Cream -- 21) Length of Permit: �. ] Food Service up to 101 -200 -- $25,00/freezer /- J Annual � t 25' PH or up o PHF display $150.00 1 ,Pushcart $25.00 # of Pushcarts: 0 Seasonal III-. Food Service up Pot 01 + I] Residential Kitchen $100.00 or 25'+ PHF display $275.00 -' Retail Food $100.00 Seasonal Dates: - Temporary - _ Food Service - Institution ', Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) 'I Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions:PHF - Potentially hazardous 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 furtherprocessing) I Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations FULL MENU -] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held j -------- -------- ] Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility .. to be Prepared by Consumer _'', Vacuum Packaging / Cook Chili -- 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 ��; [_.', Offers Raw Or Undercooked Food Of Retail Sale l Animal Origin _. Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, or Reconditioned Food Prepares Food/Single Meals for Catered Events or Institutional Food Service 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 applica le law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal o d Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that , to my best knowledge nd belief, have filed all tate 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 - GRAB & GO PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-13 BOARD OF HEALTH Michae(McC(ean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-13 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date l `" P � 2011 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET - GRAB & GO 3) Establishment Mailing Address (if different) 250 DELWARE AVENUE BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC., 6) Applicant Address 250 DELWARE 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 DELWARE 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 I Address: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: 1(508) 261-2900 24 Hour Emergency No: (506) 261-2900 FAX. 1(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: I E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN I DEP Public Water Supply No: (If applicable) 16) N0. Of Food Employees: 350 17) DAYS/HOURS: VARIES BY EVENTS 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 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: ;V! Permanent Location 1 22) Establishment Type j Mobile Mobile Start Date: i__', Retail ( Sq. Ft) Mobile End Date: V Food Service up to 100 or Mobile Comments: ! up to 10' PHF display $125.00 21) Length of Permit: '.J', Annual Seasonal Seasonal Dates: ��. Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 j..,i Food Service - Institution ( Meals/Day) STEPHEN KELLY i i _ 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 I..j Retail Snack Food $25.00 [ ] Tobacco Products $25.00 23) Food Operations Defin ns: PHF -Potentially hazardous to (..... mperature 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 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 PHFCooked To Order 1 Preparation of PHFs For Hot And Cold Holding For Single Meal Service ( 1 Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale 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 Vacuum Packaging / Cook Chill J Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Other Food Operations Juice Manufactured and Packaged for I '', Offers Raw Or Undercooked Food Of '.. Retail Sale Animal Origin PREPARED SALADS, SANDWICHES, 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 To be completed by the Board of Health,I Total Permit Fee: $125.00 '., Payment is due with application waived III 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: cq ' h-- L- — 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-; 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 LOTSIDE FOOD PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-14 BOARD OF HEALTH .MlchaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-14 FOOD ESTABLISHMENT PERMIT APPLICATION , (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENjER2 2) Establishment Address 885 SOUTH MAIN STREET -LOWER LOTSIDE 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.: 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 a An Association or partner. VI A Corporation Name Title Address I An dual A Partnership ship - - - - - 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: 1,(508) 261-2900 24 Hour Emergency No: (508)261.2900 FAX: (508) 261-7799 --- E-mail SKELLY@DELAWARENORTH.COM - Alt E -Mail: BSALANSK(a@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 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 10/1/2001 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) jJ 20) Location: [VI Permanent Location 22) Establishment Type [ - Caterer $25.00 Mobile Mobile Start Date j Retail ( Sq Ft) Milk & Cream $10 00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 11 Pushcart $25.00 # of Pushcarts: 0 -�i Residential Kitchen $100.00 _-1 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food dimeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timaAemperature 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 -1 Customer Self -Service of Non PHFand Non - Perishable Foods Only 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 Ice Manufactured and Packaged for 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 Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Preparation of Non-PHFs I Mobile End Date: I iJl Food Service up to 100 or ''. Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: Food Service up to 101 -200 J. Annual or up to 25' PHF display $150.00 Seasonal ',._] Food Service up to 201 + of 25'+ PHF display $275.00 Seasonal Dates: '. Temporary --.- Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: To be completed by the Board of Health I Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 11 Pushcart $25.00 # of Pushcarts: 0 -�i Residential Kitchen $100.00 _-1 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food dimeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timaAemperature 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 -1 Customer Self -Service of Non PHFand Non - Perishable Foods Only 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 Ice Manufactured and Packaged for 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 Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Preparation of Non-PHFs Sale I control) _ -..IRetail Other Food Operations _._ j Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of, Retail Sale i Animal Origin FULL MENU _ [ 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 I ` 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 590.000 and the federal Food Code. 24) Signature of Applicant; = - kA2 ;Z5 (A }-iAL...--cL` 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: 04-2 26) Signature of Individual or Corporate Name: and belief, helve filed all state tax returns 37 1y ,a 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 LOTSIDE PORTABLE PERSON(S) IN CHARGE. STEPHEN KELLY, GENERAL MANAGER Permit Expires; December 31, 2018 Food Fee: $125.00 License Number: XFS-15 BOARD OF HEALTH Michae(NcCtean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-15 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening datj,;(', g 20111 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET -LOWER LOTSIDE 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.: 1»61858-6000 EXT. 5162 BETH 24 Hour Emergency No.: 15081261-2900 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 i I Address: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: j(508) 261-2900 24 Hour Emergency No: (508) e61-2900 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: !, Address: II 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 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 10/1/2001 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): iV! 20) Location: 'ly; Permanent Location 22) Establishment Type Moblie Mobile Start Date: _-'II Retail ( Sq. Ft) Mobile End Date: Mobile Comments: 21) Length of Permit: iJ Annual ] Seasonal VI 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 Seasonal Dates: Temporary __j Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Caterer $25.00 Milk & Cream $10.00 [] Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream —I $25.00/freezer Pushcart $25.00 tl 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 (time/lemperature controls required) Ali Non-PHFs - non -potentially hazardous food(no tlme/temperature controls required) ',(Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs l Sale of Commercially Pre -Packaged PHFs j Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours ''. Customer Self -Service of Non PHF and Non - Perishable Foods Only '. Preparation of Non-PHFs Other Food Operations _] PHFCooked To Order r.J Hot PHF Cooked and Cooled or Hot Held, ----- I Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service ] PHF and RTE Foods Prepared For Highly ---- ---- Sale of Raw Animal Foods Intended Susceptible Population Facility _] to be Prepared by Consumer Vacuum Packaging / Cook Chill 'I use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for I contact alternative, time as a public health. Retail Sale control) _ ; Juice Manufactured and Packaged for ` -_`: Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BURGERS, DOGS, SAUSAGE, BOTTLED iI -- - WATER ,Offers RTE PHin Bulk Quantities ' Prepares Food/Single Meals for I Catered Events or Institutional Food Service I I Retail Sale of Salvage, Out -Of -Date ---- -- _. or Reconditioned Food To be completed by the Board of Health -_-- --_-- _-_-- --I' 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 590.000 and the federal Food Code. 24) Signature of Applicant: y' ' V, G-' 'u Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best lko4dge and belief, have filed all state tax returns and paid state taxes required under law. 25) Sal Security Number or Federal ID: 04-3466949 ��ti 26 Signature nature of Individual or Corporate Name: t 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 - LOTSIDE FRIED DOUGH PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-16 BOARD OF HEALTH Michae(MCCCean, Chairman - - - -, FOR BOARD OF HEALTH USE ONLY Permit ,# Issued XFS-16 FOOD ESTABLISHMENT PERMIT APPLICATION DEC DECD 16 (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CENTER I 2) Establishment Address 885 SOUTH MAIN STREET - LOTSIDE FRIED DOUGH 3) Establishment Mailing Address (if different) 250 DELEWARE AVENUE BUFFALO, NY 14202 4) Establishment Telephone No (508) 261-2900 5) Applicant Name & Title: NEW ENGLAND SPORTSERVICE, INC. 6) Applicant Address 250 DELEWARE 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 DELEWARE 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 i 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: SOUTH MAIN STREET, MANSFIELD, MA 02048 -- — - __ Telephone No: (508) 261-2900 24 Hour Emergency No: (508) e61-2900 - ---- FAX E-mail: is KELLY(aDDELEWARENORTH.COM Alt E -Mail: 'BSALANSKPDELEWARENORTH.COM (LICENSING) 13) District Or Regional Supervisor (if applicable) Name & Title: ail: 24 Hour Emergency No: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 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 10/1/2001 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: V1 Permanent Location 22) Establishment Type - j Moblie Moblie Start Date: LJ Retail ( Sq. Ft) Moblie End Date: l Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: Food Service up to 101 -200 iV1 Annual or up to 25' PHF display $150.00 Seasonal Food Service up to 201 + Seasonal Dates: - ! Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date. 23) Food Operations i li(Check all that apply): j or 25'+ PHF display $275.00 Food Service I ( I_ Institution Meals/Day) Caterer $25.00 I� Milk & Cream $10.00 1 F-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 Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous foodino time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) I Sale of Commercially Pre -Packaged Non -PRFs °. Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs -1, Reheating of Commercially Processed Foods for Service Within 4 Hours - Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations FRIED DOUGH, BOTTLED WATER 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 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 _-1 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand -_-_- and contact alternative, time as a public health Ice Manufactured and Packaged for '. Retail Sale---.. -..- I control) ---_- -.. [1 Juice Manufactured and Packaged for',',-_', Offers Raw Or Undercooked Food Of Retail Sale Animal Origin j [ 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: $125.00'. 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 copies- 05 CMR 590.000 and (75�eYederRI Food Code -y 24) Signature of Applicant: ill A C tai Pursuant to MGL Ch.62C, sec. 49A, I ce under the penalties of perjury that I, to my bestnn wledge and belief, have fled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-34669494p�, L, `// / 26) Signature of Individual or Corporate Name: I � 1C/°'" 1..�� 61V (i A 4_'/-'r 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 SERVICE 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 - BOSE PERSON(S) IN CHARGE: STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-17 1=Z9d1:7 Z•] �:1�e1 �Y:I MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-17 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NEW ENGLAND SPORTSERVICE, INC. @ THE XFINITY CEN$tir f 2) Establishment Address 885 SOUTH MAIN STREET - BOSE _ 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.: BETH (716) 658-5000 EXT. 5162 24 Hour Emergency No. (508)261-2900 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. l 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: 1885 SOUTH MAIN STREET, MANSFIELD, MA 02048 - - - Telephone No: 1(508) 261-2900 24 Hour Emergency No: (508) 261-2900 FAX: 1(508) 261-7799 E-mail: SKELLY(cDDELAWARENORTH.COM Alt E -Mail: iBSALANSK@DELAWARENORTH 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: STEPHEN KELLY If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 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): Vi 20) Location: iJ1 Permanent Location 22) Establishment Type I Moblie Moblie Start Date: 1-� Retail ( S Ft) j 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 LI, Retail Snack Food $25.00 [- ] Tobacco Products $25.00 23 Food Operations Definitions: PHF- Potentially hazardous food (time/temperalure controls required) p ! 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 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 PHF and RTE Foods Prepared For Highly ! -------,--_! Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours to be Prepared by Consumer J Vacuum Packaging /Cook Chill ---- i 1 Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- L] Customer Self Service and/or HACCP Plan (including bare hand Pere hable Foods Only --- _ - - _ - -.- j Ice Manufactured and Packaged for control)t alternative, time as a public health I, ] Preparation of Non-PHFs- Retail Sale Other Food Operations L] Juice Manufactured and Packaged for 1 I Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin FULL MENU ; ---- _-_-- ---- - - -- OffersRTE PHF in Bulk Quantities 1 Prepares Food/Single Meals for _ Catered Events or Institutional Food Service Retail Sale of Salvage. Out -Of -Date condit oned Food orReTo 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 590.000 and4he federal Food Code. I I 24) Signature of Applicant: ' 9 ,t `'`1 ` �L�1,1.�-L' "? .. 1 2-1-2 C c� Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my be 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: "✓ W L F -e \ /-Y'L t/1 ,�L"��;7( �;) �., q ." Moblie End Date: yI Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: Food Service up to 101 -200 J' Annual or up to 25' PHF display $150.00 ,Seasonal __'I Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates - -------___— _-- -- [; Food Service - Institution Temporary Temporary Start Date: ( Meals/Day) Temporary End Date: !, !' Temporary Time: Rain Date:-.-. -.-.... __. j 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 LI, Retail Snack Food $25.00 [- ] Tobacco Products $25.00 23 Food Operations Definitions: PHF- Potentially hazardous food (time/temperalure controls required) p ! 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 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 PHF and RTE Foods Prepared For Highly ! -------,--_! Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours to be Prepared by Consumer J Vacuum Packaging /Cook Chill ---- i 1 Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- L] Customer Self Service and/or HACCP Plan (including bare hand Pere hable Foods Only --- _ - - _ - -.- j Ice Manufactured and Packaged for control)t alternative, time as a public health I, ] Preparation of Non-PHFs- Retail Sale Other Food Operations L] Juice Manufactured and Packaged for 1 I Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin FULL MENU ; ---- _-_-- ---- - - -- OffersRTE PHF in Bulk Quantities 1 Prepares Food/Single Meals for _ Catered Events or Institutional Food Service Retail Sale of Salvage. Out -Of -Date condit oned Food orReTo 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 590.000 and4he federal Food Code. I I 24) Signature of Applicant: ' 9 ,t `'`1 ` �L�1,1.�-L' "? .. 1 2-1-2 C c� Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my be 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: "✓ W L F -e \ /-Y'L t/1 ,�L"��;7( �;) �., Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Xfinity Temporary Food Permit Type: 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:. LIVE NATION WORLDWIDE INC. DBA XFINITY CENTER Whose place of business is: LIVE NATION WORLDWIDE, INC. DBA THE XFINITY CENTER SAMPLING PERMIT 885 SOUTH MAIN STREET Permit good for 12/31/2018 1. Only non -PRFs, pre-packaged will be distributed. 2. The permit fee will be based on the previous year's vendor days. 3. The Xfinity Center shall report weekly on the vendor attendance. License Number: XT -23 Food Fee: $250.00 BOARD OF HEALTH MichaeCMcCCean, Chairman Date received: Date Inspected: Approved By: Permit# Issued XT -23 ----- ----- --- Z' !-'—, - - - --- - - ----------- - -------- XFINITY CENTER TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 7 days prior to planned event) 1) Establishment '-----"-,, fishmentNama`: "-' ' --- N --- W--ORLDWI,D-E,,INC.D-B,A-T-H,-EX-FI,N]T-Y- C-,-E'NT,E-"R,, 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) MANSFIELD, MA 02048 4) Establishment Telephone No: 5) Applicant Name & Title: 6) Applicant Address 7) Applicant Telephone No.: (608)452-8028 8) Owners Name & Title (508) 339-2331 RACHEL ABEND, SPONSORSHIP COORDINATOR 886 SOUTH MAIN STREET, MANSFIELD, MA 02048 --- --- 11 ---------------- 24 Hour Emergency No.: (5081452.8028 ----------- LIVE NATION WORLDWIDE INC. DBA XFINITY CENTER 9) Owner Address (if different from applicant): 5870W. JEFFERSON BLVD., STUDIO H, LOS ANGELES, CA annir, 1 10) Establishment Owned By: 1-1 An Association V1 A Corporation 11 An Individual 1 -1 A Partnership C.1 Other legal Entity 12} Person --b-lr'e'---------- - ctly-Resp-o-ns-ibleFor Name & Title: Address: Telephone No: Emergency Phone IE -mall: - Alt E-mail: 11) If a corporation or partnership, give name, title, and home address of officers or partner. LIVE NATION, WORLDWIDE INC. 5870 W. JEFFERSON BLVD., STUDIO H, LOS ANGELES, CA ---------- - --------------- .......... ...... .. .. . Operations (owner, person in charge, supervisor, manager etc.) 13) District Or Regional Supervisor (if applicable) Name & Title: Address: - - - - - - - - - - Telephone No:_ f4- f fq FAX Emergency Phone (ft Email JEFFREY MANN@LIVENATION.0 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ax&,,� "'ryP /UAr„ {flprldwd .. C Signature of Individual or Corporate Name By; Co porate Officer (Mandatory, l(Applicable) "Social Security No. (Voluntary) or Federal Identifiration Number "This license will not be issued unless this certification clause is signed by the applicant. Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. ILWalthVue's UocumeatsTER= APPLICA17OWTAX CERTZICATION PORM.dee Me Commonwealth ofAfassachusetts Deparhnent of Indushdal Accidents I Congress Street; Suite 100 Boston, AM 0-9114-2017 im atnass,gov/dia Workers' Compensation InsuranceAffidadt General Businesses, TO BE FILED WITH THE PERMIT'T'ING AUTHORITY, A-nplicant Information PIease Print Ledb] Business/Organization Name: L�uG 1E \v -4 - Address: 'I'VO CtitL �Gw N Qvt w `jD7AL)Phone#: x,23 -1 Are you an employer? Check the appropriate box: 1, ® I am a employer with *> S1iD00 employees (full rod/ or part-time).* 2;0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption pore. 152, §1(4), and we have no employees, [No workers' comp. insurance required]' 4, Ll We are a non-pmfit organization, stafbd by volunteers, with no employees, [No workers' comp, insurance req.] Business Type (required): 5. ElRetail 6. RRestaurant/Bar/Bating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) S. ❑ Non-profit 9. Entertainment 10,[] Manufacturing 11.[] Health Care 12,❑ other___ *Any applicant that checks box &I most ho fill out dm section beloW showing Ihcb Workers' compensation policy infortnatian. **Iftbc eorpamleoffic= bavecxempled thcm:clvu, but 1hemrpor&6onhasolbucmployocs, aworkera'comp-mationpolicy is requirrdaodsuchm ' orpnbadon should check boxIiI. !am m employer that is propidtnglvorkers' compensation insurance for my employees, Beloiv is tltapolicy informakoir, Insurance Company Name: \Ka. a -- Insurer's Address; City/stateizip: S�lhww�l3wt ` t (OV 4 loC6 Policy It or Self -ins. Lie. 9- WL ['� (A `f ly, fo ' it P (-Li Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Sectiou 25A of MCTL P. 152 ran lead to the imposi6D13 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 fine of tip to $250A0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations ofthe DIA for instmancc coverage verification. Cdo hereby and correct tce�ur"rtifjr, u�nde-r [hepates mrd penal8es ofperjury Uot the infarntatfon provided above is true Sianatura: " -t4l� 4A,, Date' S n1,.,... u. 3Z xj,1(c) .,4,4%f -) Official use only. Do rot write in this area, to he completed by city or lawn official City or Town: Permlt/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4, Licensing Board S. Selectman's Office 6. Other Contact Person: Phone 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 - DECK 8 PERSON(S) IN CHARGE STEPHEN KELLY, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XMF-6 BOARD OF HEALTH MichaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XMF-6 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- DECK 8 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.: (608) 261-2900 SALANSKY 8) Owners Name & Title NEW ENGLAND SPORTSERVICE, INC. 9) Owner Address (If different from applicant) 250 DELAWARE AVENUE, BUFFALO, NY 14202 Owner's telephone number 7168585000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. V A Corporation Name Title Address An Individual A Partnership - 1 Other legal Entity---- 12) ntity-_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) e61-2900 FAX: I(508) 261-7799 E-mail: SKELLY(a-)DELAWARENORTH.COM - - - Alt E -Mail: BSALANSK(&DELAWARENORTH.COM (LICENSING) - - - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: j - FAX: E-mail: I- - Food Establishment Information 14) WATER SOURCE: TOWN ( 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 350 17) DAYS/HOURS: VARIES BY 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 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate i I Hot And of PHI's ForMeal Preparlding 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) Ji 20) Location: IV's, Permanent Location 22) Establishment Type Moblie Moblie Start Date: [] Retail ( Sq. Ft) Moblie End Date: [__] Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: [', Food Service up to 101 -200 '. IV], Annual , 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) Caterer $25.00 ❑ Milk & Cream $10.00 [_ Mobile Food & Consession $75.00 i --i Manufacture Frozen Desserts/Ice Cream $25.00/freezer ';...] Pushcart $25.00 # of Pushcarts: 0 -.'. Residential Kitchen $100.00 Retail Food $100.00 V, Retail Snack Food $25.00 Tobacco Products $25.00 Temporary End Date: Temporary rDime I Rain li 23) Food Operations ! Definitions: PHF - Potentially hazardous rood dime/lemperature controls required) , Non-PHFs - non -potentially hazardous tood(no time/temperature controls required) '',(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non -PRFs. _ T Sale of Commercially Pre -Packaged PHFs II 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 ked To Order IHot PHF Cooked and Cooled or Hot Held i I Hot And of PHI's ForMeal Preparlding More Than a Single Mal Serve n Cold Hofor ng Forr S gleion Service PHF and RTE Foods Pr pa ed For Highly -_-- [ ' Sale of Raw Animal Foods Intended i Susceptible Population Facility :. 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 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin BEER, WINE, BOTTLED WATER � I Offers RTE PHF in Bulk Quantities I r 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 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 gopies of 105 CMR 590.000 anq-the federal Food Codq) I ,\ 24) Signature of Applicant:- Pursuant to MGL Ch.62C, sec. 49A, C edify 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: Z11 2t 1\-I and belief, have fled all state tax returns `---t' r' C-+ / vv a ° C u u u u o° Y � w 3 m 3 3 3� a s •" Y m a �n �c u E a v « E o r m m o r m m a a m v y Y m a w w w m U LL 6 O O _N LL 6 ° O C O° O t ° N m O y n Y' Y Y Y Y Y Wa E a a W LL y 0 6 LL W LL O. W _ O ` C N N N N N N 0 a C 3 n n n a n a y N LL m LL a o D LL U •O •O V m m O W O D a ° O a a a a N 3 J d W W M W N O d d 0 0 d a LL l° LL y N 10 U �v N N G d W' CO .° �0 ym IYO tyo N N V i T Y C IL LL LL V a 3 3 0 9 Ul QI QI J J O C C J J LL (O H a d N N N N N N V D D a 0° W a LL LL IL N d 3 a a L a LL C C C C C C o °o 0 0 5 °o w v w a w w n °. '� 3 0 o E v o 0 0« y °° w w a w w w C C m m m n n •CC- CCCC U C J J J -.i m J J G M J J M C J {C V1 VI V1 1n VI 1A Yf lG 6 N N N N N N N yob d- N N N N N N N N N N M M M M M M M M M M V R O V O Al" t H O O O H O H H O O O o H O O O O O O O O E K a N O H O O O O O O O O H O O O O H O O O O O O O O O H a Ln N LnM N In M a to cy Ln N N u1 N H u'1 N H N N mN N H Ln� N N H N H N O O iy � N Ln N u1 N N N � N � N V1 N u1 N H Ln N o� O O o H O O H H O H O H H O O O O O H O O H H O m H m a � 3 m N n � x x x x O c x x x x x x x x x x x x x x x x x x x x x H O O O H O H H O O O o H O O O O O O O O E K N O H O O O O O O O O H O O O O H O O O O O O O O O H a Ln N LnM N In M Ln N to cy Ln N N u1 N H u'1 N H N N mN N H Ln� N N H N H N O O iy � N Ln N u1 N N N � N � N V1 N u1 N H Ln N O O O H O O H H O H O H H O O O O O H O O H H O N LL V O O O O O O O O O O 0 0 0 OOH00OOO TWO a a E N dV1 Ln N LnM N In M Ln N to cy Ln N N u1 N H u'1 N H N N mN N H Ln� N N H N H N O O iy � N Ln N u1 N N N � N � N V1 N u1 N H Ln N 0 O V a a c c m cr UJ v o Y U m c vi v m U Y E N m av Y E OJ m v a Y U m c N v v = Z O1 o w Y U m c N v L Y U m G N a, N = Z N o Ql �! Ol o w m U °' v U 2 N o w Y U C t/1 v N = Z w °o w N U N o° m U °' = m Y U C t/1 v Y U C Vf 'Y v L Y U C of m v m V Q/ a o Y U C VI 'm v Y U C vi 'Y v N U_ Z 0! a o W U_ L N s o m U 0 0 0 0 w w r r r u u U C � u m m = 'm \ m 'm \ m 'mm \ 00O 0m E G0 C m L v co y> L o V E V c m Q) Y C ccm C U a o LL ii Y m w v CoD 11 Y m w C° u o LL LL Y m C' -o o w 6 N a Z) M O N a � m C= o E v cc E G to o a s a o E E U -moo °0 °t -0 N 3 aco 'O OI 3 vm o E v 3 cc C G am a vv Wm °o Y ami a it Y aci V d. Y a"i 0 0 LL v LL J N DO v LL J c (U OasO LL v_ lL � J av m0c C o 0. N UJ a o h O/ 0 CL D ;-m o E J m w J CC E C O H N M d' mto I, oo m O H N M V Ln to H N M L(7 l0 i� W Ql H H H H H H H H H H N N N N N N N u N N w v N a O W c N O O a O O O O H N H N H H H H H H N Vl M D-' Ln N Ln N Ln 0 O N Vl V1 Vl V1 V1 0 V) VI In N O O O O. N O O O O O O O O O O O O O O m n ci ci v a s �r Zr r Zr cr v w o Ln O N H O 0 0 4 0 Y 0 4 0 4 0 W 0 4 0 W 0 F 0 W 0 m H m c -I 0 0 0 0 � VI m m m m m m m m m m m m m m m m m m m W LL m N X X X X X X X X X w G w C w G w C w C w G w G w C w C w C u N N w v N a O W c N O O a O O O O H N H N H H H H H H N Vl M D-' Ln N Ln N Ln 0 O N Vl V1 Vl V1 V1 0 V) VI In N O O O O. N O O O O O O O O O O O O O O m n ci ci �y N Ln N O N H O O N O H o 0 0 0 0 0 0 0 0 0 0 � W LL e -I a O O O O O O H OO O O O O O O O O O O 2' N u N N w v N a O W c E L a Ln N Ln N Ln 0 O N Vl V1 Vl V1 V1 0 V) VI In N N N N N N N N N N N N N N N m 0 ci ci �y N N N O V a u uu u U U U V u U U U U U 0 cr c _U Z Z m m Z = m m m m m m m m m m m 0 W a) c VI c VI c N c VI c VI c VI c VI c VI c Vf c VI c V N VI J Q C'm'mmmmmm'm w w w w w w w w w w w O O O O Ll a r m U L O L L w iD •y w V w 09 w h w F w H w H w H w H U N = m Y w w w w w w O C U m O Y Y Y Y Y Y 0 o o CO m m O_ U E = t+ O_ U U U U U w LL d J 50 O G G m 0_ a a s m E o a a 3 m w w w w w w w 'in BVI T) w C J J m G z cm w C m m m m m m O O G LL m a w w w V1 VI V) V1 VI VI H c y w w m w iz a a a -o a s w Q L L v v i 'u, m„ m c c c c c c c a w w C C o 0 0 0 0 0 0 o w O O O w 0 O N w w w w w w O CO JO co J J Co _ J a w o_ V) Vl V) VI 0 Wm O H N m CI' ul W r 00 m O H N mrtt' N N M M M M M m M m m M Gj' d' 7 V u N N w v N a O W c 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 Y_ 00 ti 0foo E .--i N O N O ^ O 140 O O o 0 0 O .--I N \ @ N N N ,n N m ey m N V1 @ N N N N ut N N N 0in N 0 O N lt1 �t7 `^ N 0 0 '^ N 0 N VI � O O c -I o o .--� N o H o .--� N o o O o O � 0 0 @ N a N I x x x x w w c x x x x x x x x x x x x x x x x x x x x x Y_ 0foo E .--i N O v 140 O O o 0 0 O .--I a N N ,n N m ey m N N N N N N ut N N N 0in N 0 O N lt1 �t7 `^ N 0 0 '^ N 0 N VI Y O O c -I o o .--� N o H o .--� N o o O o O � 0 0 N LL U O O O O O O O 0 O O O O O O. 0 0 0 0 O O O O O a a lo Y_ E v O. .F O N N ,n N m ey m N N N N N N ut N N N 0in N 0 O N lt1 �t7 `^ N 0 0 '^ N 0 N VI Y N O U a a C c a @ @ �_ 3 o L1 Y U @ c@ VI w L Q Y_ E U1 @ Z u w VI 0 Y_ E N @ Z u w 1/� 0 .L U @ c VI a@+ w L w ,U 2 0! a O O Y U @ c VI YY w L Y U @ c vl w L w U_ Z U/ a O O w V Z@ N s O O r U O. w U_ Z 01 O 1O Y u @ c vl Y w L w U_ Q/ O W w V_ Z@ N 0 O L U O- —_ @ O Y U @ t�If Y w L Y U @ VCI a@-+ w L Y V @ N +@+ w L w U N a O Y U .@ N +@+ w L Y U @ VCI a@� w L w U N a O w U 01 s O 12 t U O p_ 0 0 t r r u u u L L C 'Y u a 0 J o E @ Z 1UJ ' c0 G Vt t' U @ x c ti w c] a o U � @ H E03 E 0 U w G c@ C o 4 m V� a o Y d' L w° co LL Y m K v a 11 Y M w a@ o tOi w 6 O L w a � d w v -o o L w a w @ ' c O E J a @ N c E G L m@ O v w N 0 o vi E E°° o w h 0 �j o > a@ o LL w O L w 3 JO .O t@@ a w O L w 3 J @ @ ' w a-0 O E @ w 3 c c G> w a0 v w a N 0 �j o 00 Y v L w a w Y c V Y u, a o LL _a w Il J L w m a w 1.1 , J c w N o LL a w LL ,� J w s @ 0 a -0 ate+ O w a � o 0 LL -o Y O J N s D w Y @ v @ O E J a @ w J c c G =UN :;ULn t0 1� W O N N M V 0 w N W 01 O H N M � llt lD YC_ G � N O O O O N O O O O O O O O O O O O O O �Ln a N � N 0 N 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O v v v v cr v <t v v a LD U w w w w o ti 0 o 0 0 0 0 0 0 0 0 0 0 0 0 O O O O O O d' N v Y mY Y Y Y Y Y Y Y Y Y N _U U_ U U U U U U U U U U U U U U 6 C � Z G m m N m m m m m m m `1 H Ol O) Ol m 01 Ol 01 VC1 VCI a ti x x x x x x x x x c c c c c c C c c C c I C c YC_ G � N O O O O N O O O O O O O O O O O O O O �Ln a N � N 0 N 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O LD U 0 0 0 O O O c -I O O O 0 0 0 O O O O O O d' N v Y mY Y Y Y Y Y Y Y Y Y N YC_ G Ln N Ln N Ln Ln N 0 O N Ln 0 �Ln N N N N N O U Y N v Y mY Y Y Y Y Y Y Y Y Y U _U U_ U U U U U U U U U U U U U U 6 C � Z G m m m m m m m m m `1 H N N VC1 VCI H VCI UCI t�If tC/1 VCf VC1 VCf N L N) Ami N) J -O "O m m m m m m m m m m m +-+ O 0 ++ d O O a+ +• s- a+ r.+ ++ ++ ++ Y ++ a+ m w w w w a m ,^ i `w � m vi 0/cu N M -tV1 LD C 0 � C C C C C M m N C Ol OJ Ol O/ O) 'O N U N w F H H H U N y N m O C Y U m` m= m a Y Y iU+ O O O C tO d U O LL d J x QO c m m m m m m m `t E w w N O1 C naso bo w bo w C z vi of m O) C J m m m m m m m O 0 LL m'� -0 O/ 0) A 1% N N N VI VI H C O/ O1 m W 1.1 '6 "O "O "O -O 'O 0/ N 3 3 0 v v 4f t L o 0 0 o O o o 75 O c N O O O C O1 O N N N N N N N O O] J C m J J m _ J d K V) N V1 VI N Vf J U 00 01 o N N m V0 lD f` CO o N N m ct V W N N m m m M m m m m m n It It v a v v It 42 C 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 0,0 P 6-62 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. RAHcaltWaoe's Docuzom(sTERMIT APPWCATIONMAX CERTIFICATION FORM doe The Commonwealth of Massachusetts Department oflndustrial Accidents 1 CongressS&ee4 Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE FILED WITH THE PERAUTCING AUTBORITY, Applicant Information Please Print LeZibly Business/Organization Name: New England Snortcprvirp Toy— @ Xfinit3LCentes Address:85 South Main Sweet City/State/Zip: Mansfield, MA 02048 Phone#: 508-261-2900 Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with 280 employees (full and/ S. ❑ Retail or part-time).* 6.❑Restawant/Baz/BadngEstablishment 2. ❑ ]am 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. S. ❑ 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, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance ru1.] 12.❑ Other •Airy applicant that clocks box Ni must alto fill out thesection below showing theirworkera' compensadun policy information. ••It tbo corporate officess have mccapied themselves, bus the corporation has other c aployaes, a workers' compensation po6ry is rxtuired and mch an organization should checkbox M. ! am an employer that is providing workers' compensation insurance for my employees. Below fs rhe policy fnformadorc Insurance Company Name: New ilampAbirp Lrimiranrp Company Insuror'sAddress: 2704 Commerce Drive, Suite B CitylState/zip; Harrisburg, PA 17110 Policy#or Self -ins. Lic, #- WC 013778773 Expiration Date.-_-L0/01/20l8 Attach a copy of the workers' compensation policy declaration page (showing 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 fine 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. information provided above is true and correct Offraial use only. Do not mite In this area, to be completed by city or town official City or Town: Peradt(Licanse # Issuing Authority (circle one): 1. Board of Health 2. Bui3ding Department 3. City/fowa Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone NEW HAMPSHIRE INSURANCE COMPANY 13080 250 0 LAWAREtA20 QPA O OES INCORPORATED SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE • WC990610 0006752-0o WC 013-77-8773 055-04-1017-00 An AIG Company EXECUTIVE OFFICES: HARSH USA INC. WORKERS COMPENSATION AND EMPLOYERS 6500 SHERIDAN DRIVE LIABILITY POLICY INFORMATION PAGE SUITE 114 CORPORATION RENEWALPO 011 4006 OTHER WORKPLACES NOT SHOWN ABOVEI SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990810 11e42 POLICY KWO nes A.M. nendem two th. Insvred.. m.mna•ddm• FROM 10101/17 70 ..10/01/18 mm 3 A. Workers Compensation Insurance: Part One Of the policy applies to the Workers Compensation Law of the steles listed hen: MA WI B. Employers Unblilty Insurance: Part Two of the policy applies to the work in oath state listed in Item 3A. The limits of out liability Under Part Two are! Bodily Injury by Accident S 1 .000.000 oath accident Bodily Injury by Diseases $ 1 , 000.000 policy limit Bodily Injury by Distant, f 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies io the elates, If any, listed hero: AK AL CT DC DE Hi IN KY HE NE NM OR SD UT VT O. This policy Includes those endorsements and schedules: SEE EXTENSION OF ITEM 3.0. OF THE INFORMATION PAGE - W C990612 ITEM a Thu premium for this policy will be determined by our Manuals of Rules, ClaselReHlobe, Rates and Rating Pbme. All Information required below In subject to vef leatlon and change by audit. oesel9tallom Orde Nwrbv old t$AeMrMgon A.t. hr Het aFae. Eylmrded Fwrhm A"" 3 your mum, &I Arvwd 3 Year SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7764 TAXES/ASSESSMENTS/SURCHARGES $33,576 ESPweacONSTANTIC)MIE WHERI!"PUCAewaaraTAlct $ MA MINIMUM PREMIUM $900 WI 70TA1.1e11MATEDUNUALF01MIUM $1,215,579 M Iodcled bdwv, Imelm edjuetmads of pemhen!hell be made ❑ Emni-Amudly ❑ Qltrtedy ❑ M=1my 01PONTORIMmM $1,215,573 P 11102/17 BOSTON 04 i•.ue a.t• Inulnornee Autiv,le.d R•Pn..Malin WCOODDOIA 3W (RWd WOO) vv a ° m V U U V O° 2 0 « m m � N m m m m� E '° f0 m m 2' a m a w a a• a« N 'm° Y w m w w m m s ° °o o c°. o° o° r m m c z ,0 w u m m m m m m U LL 6 O O N_ LL 1 O O t' O° O° 10 m A a d Y Y Y Y Y Y % O a N 6 V O1 a E a a W a y C E LL W LL 6 d L O� C m m m m m m m C O d No N N J d E N J OI d ° N W d J W O J G y C 3 6 6 a a a a a y LL m LL aa a LL V a a m m p y 0 a a 9 0 a a a a q ?+ N W W W W W W Y c a o a a a ° °o v a°° m o o v o o E �i m o 9 m m m m N m m o y 0 V i N Y C 1L 4L Il 41 N N « y y y J J« G C J J a �i C y {L a a a a a a a W a0 a0 d 0 O p Y« Y IY IY IY W N p a 6 N OI O i• 9 9 u w C QO y Q C Am m m OL 6 c` 0 0 0 0 0 O d W W W W W 0. 6 C L J p p C G d o o O V V U U U V Y O Ob N M O m w N w m O N N M a m N P� Op 01 O A N M a YI 6 P� W 6 O A N M O YI b 01 N N c 00 w w w w w w w w E L � N O O O O ci O O O O O O O O O O O O O O d N N w o ti N N N N V1 O N H O w o 0 w 0 w 0 w 0 w 0 w 0 w 0 w 0 0 N\ O O O O ry a+ N N N N N N N N N N N m N LL m m m m m m m m m m � U O O O O O O H O O O O m N x x x x x x x x x m c N c aJ c al c a/ c N c al c al c a) c Ql c c E L � N O O O O ci O O O O O O O O O O O O O O d N N N N N N N V1 O N H O O H O H O O O O O O O O O O O ry a+ N LL � U O O O O O O H O O O O O O O O O O O O � N c E L a Q ON N N N O N V1 iJ7 tf) tf1 to V1' l!1 to tl1 O N N N N N N N Qt ry a+ N O U a Y W W Y ai a)Y Y Y Y Y Y Y Y Y Y Y h V V_ u U_ V_ V V U U U U u U u u U o m _U m Z m m m m m m m m m m m 0 C C m = C C C C C C C C C C C U ai 11 N N � VI L N M 'm 'm 'm 'm Q E O O A+ Q O O O L v O O N O O N 0_1 (U v v `J ` d v w N V - a U `w L L O v -I N M 0 O Cm 4 C G G C C C .Op m Y N F H H F H u m N a1 a1 a! al a) m Lpp U JO a O t ry d Y Y Y Y Y m v-. m m O o o n u u u u u u L m p c 3 a n a m om. m m no. 3 m al a! OJ a) al N al v a :o a m ,.� Z �n '�n ro ai N N N c a m m m m m m m c Y o 4+ 0 cc G C LL 00 O '++ -0 a) 7@ N to N N N N N VI H Co m aIc ai w .(c+ o :o :a�l y m c cI cI c( cI a . 3 3 vYal $iNi UUUUUU Oc nnnnnnJO DQV I 00 m O a-1 N m d' 0 tD h 00 m O c -I N M V u1 O N N m M m M M M m m M M -zt a a a v v c