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Home My WebLink AboutGMR Marketing, LLC - 7/16/2008TOWN 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: CAROLINE PETTY, EVP Whose Place of Business is: GMR MARKETING, LLC Permit good July 16, 18, 23/August 2, 6, 8/September 20, 2008 License Number. MF-88T Food Fee: $175.00 Milk & Cream: NO BOARD OF HEALTH ti• Dr. Raymond Martin, Chairman Date Received Date Inspected . Approved By Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: C 1 1 c 3) Establishment Mailing Address ('rf different) 4) Establishment Telephone No: ,::� 61 I to 5) Applicant Name & Title: (kplg 6) Applicant Address: - 1 v I A i 16 7) Applicant Telephone No.: _ -� - 24 Hour Emergency No.: 8) Owner Name & Title (if different from applicant): 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 partner. //(� ��o��r An Association t5wo 6, oo) V e A Corporation An Individual �,^� � Now � �f/V v'� VV', w' 5316 ❑ A Partnership ❑ Other legal entity 121 Person Directly Resnnnsihle For Daily nneratinn5 (Owner narsnn in nharne SunA.rvisnr Mananar atc 1 Name & Title: Address: (�I G I Telephone No: _ Fax: _ (i Emergency Telephone No: _ oc36I J 13) District Or Regional Supervisor ff applicable Name & Title: U Address: Telephone No: '' Fax: Y BLANK FOOD PERMIT APPLICATION Food Establishment Information 14.) Water Source k 1 I A- 15) Sewage Disposal DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation:N IN 17) No, of Food Employees 18) Name of Person In Charge Certified in Food Protection Management: N iA- Re uired as of 14r1/2001 in accordance with 105 CMR 590.003(A) Please attach c» 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 ❑ Food Service - ( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Bed & Breakfast Home ❑ Mobile (Dates) ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment / ❑ Frozen Dessert Manufacturer ,rOther (Describel),1l 21) Length Of Permit: (check one) ❑ Annual(iiS T I "o •_ L❑�Sea�nsopnal/Dates p Il�rolra�rriDatTs(fi es I400) 1'2j09� 001 088 gl �f�()� I� p �,r%r�)0 23) Food Operations: Definitions: PHF—Potentially hazardousfood(time/temperature controls required) (check alf that apply): Non-PHFs— non -potentially hazardous food (no 6meRemperature controls required) RTE — ready -to -eat foods Ex. Sandwiches, salads, muffins which need no further rocessin ) ❑ 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 ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Holdin For Single Meal Service Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill be Pre ared b 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 ❑ 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 Other (Describe): ❑ Offers RTE PHF in Bulk Quantities To be completed by the Board of Health El Retail Sale of Salvage, Out -Of --Date or Total Permit Fee: Reconditioned Food Payment is due with application 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 � a,$,�licabie law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food C�6d� 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the returns and paid state taxes required under law. perjury that I, to my best knowledge and belief, have filed all state 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: HLA FOOD PERMIT 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 o •porate Name *"Social Security No. (Voluntary) or Federal Identification Number 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. RMmIthUane's Documents\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UIV 600 Washington Street Boston, MA 02111 rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: jDO. —Mvkj U __JOY City/State/Zip: Phone #: /1/7�7 — Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ElRetail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (me]. real estate, auto, etc.) employees working for me in any capacity. rTNo workers' comp. insurance required] 8. ❑Non-profit 3.0 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.0. Health ^C/a�re'�,,q��[� with no employees. [No workers' comp. insurance req.] 12.N Other IA1NV' k�t/''11 n,6 A461VU, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. v 0 **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. lain an employer teat is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 cert' under the pai Z�/ d penalties ofperjurryy that the information provided above is true and correct. Signature:. . -i v Date: '�?_'col — hr/ Official use only. Do nol write in this area, to be completed by city or town official City or Town: 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 Phone www.mass.gov/dia ACORD,e CERTIFICATE OF LIABILITY INSURANCE DATE (MM/OD/YVYY O5/09/08 PRODUCER 1-313-259-2900�THIS�CERTIFICATE�ISISSUED AS A MATTER OF INFORMATION Wachovia Insurance Services, Inc. RIGHTS UPON THE CERTIFICATE E DOES NOT AMEND, EXTEND OR 300 River Place, Suite 2900 __--_ _.___.. Detroit, MI 48207 COVERAGE OMIAICOM GROUP INC. INSURERA:XL (GMR MARKETING, LLC) INSURERB: 437 MADISON AVENUE NSUflER C: NEW YORK, NY 10022 INSURERD: PTN/GO A n=0 NAIC # THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR DD' L POLICY NUMBEq POLICY EFFECTIVE POLICY EXPIRATION LIMITS I 'I GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE El EACH OCCURRENCE $ AM ET RENTED PREMISES Ea occumnce $ MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GENERALAGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS•COMP/OPAGG $ ' AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIREDAUTOS NON-OWNEDAUTOS COMBINED Ea.MdOM51NGLE LIMIT $ SODILYINJURY (Perperson) $ BODILY INJURY (Peraccitlent) $ PROPERTY DAMAGE (Peraxitlan0 $ GARAGELIABILITY ANY AUTO AUTO ONLY -EAACCIDENT $ OTHERTHAN EAACC AUTOONLV: AGO $ $ EXCESSAIMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACHOCCURRENCE $ AGGREGATE $ $ A WORKE SCOMASP ABIDTY EMPLOWORKERS COMPENSATION AND ANY PROPRIETOP/PARTNER/EXECUTIVE OFFICENMEMBER EXCLUDED? Ilyyas,tlescribe�ntler SPECIALPROVISIONSbelow OTHER RWC6200002 01/O1/08 --T Ol/Ol/09 K WC STATU- OTH- TORYLIMITS ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE• POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS [VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS Waiver of Subrogation in 'favor of the certificate holder if required by contract and where permitted by law. uvrr SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION PROOF OF INSURANCE ONLY DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R EPgESENTATIVE USA AP(1RD 9R PoDMIOnl -1 8757519 U ACORD CORPORATION 1988