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HomeMy WebLinkAboutCRN International - 5/31/2008TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD, MA 02048 PERMIT TO OPERATE A MOBILE FOOD TEMP 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: BARRY BERMAN, PRESIDENT Whose Place of Business is: CRN INTERNATIONAL, INC. Permit for MAY 31, 2008 only License Number: MF-10T Food Fee: $25.00 Milk & Cream: NO HEALTH Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued H r- ) 0 T FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: ?" 2) Establishment Address: ' S V"� Co, � JLI N iA o c� , 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: ✓J 5) Applicant Name & Title: " ' A 6) Applicant Address: C , AC , v — \Nc, 7) Applicant Telephone No.:0,� dy,y r��, 24 amour Emergency No.: ` 73 ) '-1 8) Owner Name & Title (if different from applicant): �l c 9) Owner Address (if different from applicant): - 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. ❑ An Association } D'A Corporation _ 'tt' ❑ An Individual c� 1 d ` c ❑ A Partnership i ❑ Other legal entity 12) Person Directly Responsible For Daily Operations (Owner, person In charge, Supervisor, Manager, etc Name & Title: Address: I Telephone No: 1S Fax Emergency Telephone No: - -7 1 - L) 13 District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: BLANK rO DPB ITAPPLICAMN JtT)e" Food Establishment Information 14.) Water Source t.f (;' 15) Sewage Disposal DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: C" (- 1` _ 17) No. of Food Employees 18) Name of Person In Charge Certified in Food Protection Management Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach co of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): 20) Location: 22) Establishment Type: ❑ Caterer ❑ Retail ( Sq. Ft) ❑ Food Delivery El Food Service - ( ) Seats El Residential Kitchen for Retail Sale HPermanent 7 (.ie'S El Food Service - Institution ❑Residential Kitchen for Bed &Breakfast Home Mobile (Dates) ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: ('P- 'r=-cj, ` (� ��.©i._�C'i, .i `"� (check one) l�Gt ❑Annual ❑seasoneUDates ❑Temporary/Dates/Tlmes 23) Food Operations: Definitions: PHF- Potentially hazardous food(time/temperature controls required) (check all that apply): Non-PHFs- non-potentiaV hazardous food (no tima4emperature controls required) RTE-rea -to-eattoods . Sandwich as, salads, muffins which need no further processm ❑ Sale of commercially Pre- ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And cold LJ PHF and RTE Foods Prepared For Highly Packaged PHFs Holding For Single Meal Service Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill be Prepared by Consumer ❑ Reheating of commercially ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control LJ Customer Self -Service of Non ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Only. ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Retail Sale Events or institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -Of --Date or Total Permit Fee: Reconditioned Food payment is due with application Other (Describe): I, the undersigned, attest to the accuracy of the information provided in this application and I 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 heafth on how to obtain copies of 105 CMR 690,000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state returns and paid state taxes required under law. 25) Social Security Number or Federal ID: r �" 6 — O -I (' � � - 26) Signature of Individual or Corporate Name: i i�7. Y�,t -(` c\ r 7yrt �\ea BLANK FOOD PE]Wr APPLICATION 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. Signature of Individual or Corporate Name By: Corporate Offi r(Mandatory, if pplicable) CC- - 1031 6w��- "Social Security No. (Voluntary) or Federal Identification 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. R: HmIthUane's Documents\TAX CERTIFICATION FORM.doc CSIN The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �^ Please Print Legibly Business/Organization Name: e, `� j V,- _ e Address: k-J � \Q, �j City/State/Zip: t,c-, fN Phone #: 'IC)') r) CO Are you an employer? Check the appropriate box: Business Type (required): I. EI am a employer with jJ employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* , U lye-;"( I1.❑ Health Care 4. ❑ We are anon -profit organization, staffed by volunteers, \ 1 with no employees. [No workers' comp. insurance req.] 12.❑'Other �N A �j mi- c, \$y e, `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. *'If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that isprovidine workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: T ��, � rK e y, , c l "� {-' wtsC"'r� t1 t..� tVC ?�nri l�l Insurer's Address: \ 5 r( �:A, C" \&2_C, City/State/Zip: Ux �� t (C� t C cf 1 Policy # or Self -ins. Lic. # .�) �, :`i c I C; 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 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. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.mass.gov/dia Phone May 27 2008 2:2GPM BELOWSKY 8r R950C. 203-709-9400 p.2 ACORD� CERTIFICATE OF LIABILITY INSURANCE T (MM/DoiYYYY) 70 PRODUCER (203) 795-1281 Belowsky 6 Associates Inc 472 Heston Post Road, *3 Po Box 986 THIS CERTIFICATE IS ISSUED AS A ONLY AND CONFERS NO RIGHTS IJICON ALTER THE CIOVERAGEICATE DOES NDT AFFORDED 8Y 05/27/2008 TTER OF INFORMATION THE CERTIFICATE HE pOL AMEND, EXTEND BELOW. orange CT 06477-0986 INSURED INSURERS AFFORDING COVERAGE INSURERA Tile Hartford NAIC 1k C R N International One Circular Avenue INSURER B. INSURER C: INSURER D: Hamden CT 06514— INSURER E: rtnuvonr_ec THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIC REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MA THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COI AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. kTED. NOTIMTHSTANDING ANY BE ISSUED OR MAY PERTAIN, IDITIONS OF SUCH POLICIES. INSR LTn AOO'L I SR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMMDfYY POUCY EXPIRATION DATE(MMUMNY) LIMITS AJX NERAL LIABILITY COLIMERCIAL GENERAL LIABILITY CLAIMS MADE 313BABF6447 12/23/2007 / / / / / / 12/23/2008 / / / / / / EACHOCCURRIE CE $ 1,000,000 PRM ISES Ea oc urrenoel $-3O0r000 MED FXPM on person)S 10,000 PERSONAL&AD INJURY S 1,000,000 GENERALAGGR 'ATE S 2,000,000 'LAGGREGATE POLICY LIMRAPPUeS PER: JECT LOC PRODUCTS -CO P—PAGG S 2, 000, 000 AOMOBILE LIABILITY ANYAUTO AILOV'MEOAUTOS SCHEDULEDAUTOS HIRED AUTOS NON-OWNEDAUTO$ 31UECUF5057 22/23/2007 / / ////BODILY 12/23/2008 //BODILY COMBINED SIN (Eo edcidanl) LIMIT $ 1,000,000 INJURY (PerPson) $ INJURY (P..1del1) $ PROPERTY DAMA (Per sWdenl) E $ CARAGELIABILITY ANYAUTO / / / / AUTO ONLY -EA 1 C CIDENT $ OTHERTHAN AUTO ONLY: EA ACC S _ AGG $ A EXCESSIUMBRELLA LIABILITY X OCCUR 7CIAIMSMADE DEDUCTIBLE RETENNON $ 31SBAPF6447 12/23/2007 / / 12/23/2008 / / EACH OCCU N E $ 4, 000,000 AGGREGATE $ 4,000,000 $ $ $ A WORKERS COMPENSATION AND EMPLOYBRS' LIABILITY ANY PROPRIETORIPARTNEMEXECUTVE OFFICEWMEMBER EXCLUDED? Ifyes, desulbe under SPECIAL PROVISIONS Dhow 31WBCIE4965 12/23/2007 12/23/2008 X I TORYLATIT- O R" E.L. EACH ACCIDE 4T $ 500, 000 E.L. DISEASE -EA MPLOYEE$ 500, 000 E.L DISEASE -PO ICYLIMIT $ 500,000 OTHER DESCRIPTION OFOPERATIONSILOCATIONONEHICLESIEXCLUSIONS ADDED BY ENOORSEYENT/SPECIAL PROVISIONS Additional Insureds: Clear Channel COMmunications, Capetar Radio Operating Company, NUNN FM anc parents, partners, subsidiaries, divisions and a££iliates; Tweeter Center for tha Performing Art LiveNation Worldwide, Inc, and their respective parents, partners, subsidiaries, divisions and affiliates. their respective S; DLC Corp.) WOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSIAB R WILL )W'W� NAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, RK Tweeter Center for the Performing Arts XemY11ME}EKxxyhG50@Mx' gyp ( ( Attn: Andrea Victoria 885 South Main St AUTHORILEO EPRESENT TNE- Mansfield MA 02048- ACORD 25 (2001/08) © CORD CORPORATION 1988 ql„ INSD251woe).G5 ELECTRONIC LASER FORMS, INC. -(800)327-0546 Page l of2 rq Nr O] 'NPe9 uo slleled � 'PePnloulsanleel6lNnaeg IN a W O WO 9-1 N iB