HomeMy WebLinkAboutLive Nation - 8/5/2008TOWN 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:
LIVE NATION
Whose Place of Business is:
COMCAST CENTER
Permit expires August 5, 2008
License Number. MF-307T
Food Fee: $25.00
Milk & Cream: NO
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
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: (ly�
2) Establishment Address:
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3) Establishment Mailing Address (ff different)
4) Establishment Telephone No: 2 j
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5) Applicant Name & Title:
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6) Applicant Address: 8 O --
7) Applicant Telephone No.:'T )u ..�3� _
� � 24 Hour Emergency No.: 4-% „ �-'
8) Owner Name & Title (if different from applicant): l
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
ErA Corporation
I t
Q3 [ C�Ce( )kr r.
❑ An Individual
❑APartnership
❑ Other legal entity
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12) Person Directly Responsible For Daily Ooerafions (Owner, person in charge, Supervisor. Manaaec etc.)
Name & Title:
Address:
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Telephone No:
�: 3 Fax:
Emergency Telephone No:
8 - �)4 . J-3 '
13 Distdct Or Regional Su ervisor f!applicable)
Name & Tltie:
Address:
Telephone No: Fax:
BLANK POOD PERMIT APPLICATION
Food Establishment Information
14.) Water Source
15) Sewage Disposal
DEP Public Water Supply No: (if applicable): �IVYA W-A�o
140A RU-11-
16) Days and Hours of Operation: }
17) No. of Food Employees
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 1(Y112WI 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): NO
1
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
Other (Describe)
21) Length Of Permit:
(check one)
❑Annual
❑Seasonal/Dates
p {)U f✓ �j f7
10 Tempg jry//DatesiTimes
� ( P' N1P,
23) Food Operations:
Defioidons:PHF - PotentleV hazardous food(Urnalemperature controls required)
(check all that apply):
Non-PHFs- non-potentleV hazardous food (no ameRemperafure controls required)
RTE- ready -to -eat foods Ex. Sandwlchss, salads mu/fins which need no fnMer rocessin
❑ Sale of commercially Pre-
Ll PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held for
Packa ed 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
Pa cka ed PHFs
Holdin For Sin le 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
El 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-Pedshable Foods
Retail Sale
Origin
Only.
Lj Preparation of Non-PHFs
Juice Manufactured and packaged for
Prepares Food/Single Meals for Catered
Retail Sale
Events or institutional Food Service
Lj urers r< I t rHr in tsulk ctuanmies Payment is due with application
To be com feted b Y the Board of Health
Retail Sale of Salvage, Out -Of -Date or
Reconditioned Food Total Permit Fee:
Other (Describe): P
1, 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 health on how to
obtain copies of 105 CMR 590,000 and the federpi food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.620, 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. 2
25) Social Security Number or Federal ID., ) J /LJ
d 6 6.7 'I q
26) Signature of Individual or Corporate Name:
BLANK FOOD PeRMI'r APPUCA77ON
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.
Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
1'�ij00(at(
"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.
RAHm1thV ne's Documents\TAX CERTIFICATION FORM.doc
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Form
Request for Taxpayer
Give form to the
(Rev. Janaary
2W3)
Identification Number and Certification
requester. Do not
o'lemn nt of the Treasury
Ir,loniG RCYCmII $eryiCC
send to the IRS.
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Narne
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Tweeter Center for the Performing Arts
a
cosiness name, if different front above
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DLC Corp d/bla Tweeter Center
Individual/
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II--11 r,7 Other � partnership Corporation
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Clteck appropriate Uox: Sole proprietor lY._I ❑ ❑
fxempt from backup
Elwithhold�nq
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cAddress
(number, street, and apt. or suite no.)
Requester's name and
address (optional)
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u._—....-------_-_----.-.._----'-----
36 Bay State Rd.
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-
City. state, and ZIP code
c
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Cambridge MA 02138
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LiSI account numbers) here (optional)
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AQMZJ lax ayP ItleOtltlCatlon Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). social security number
However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on
page $ For other entities, it is your employer identification number FIN). if you do riot have a number,
see How to get a TIN on page 3. or
Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number
to enter. 1 1 3 [_ 4 1 o 1 6 1 614 1 4141
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellction of debt, contributions to an individual retirement
arrangement (IRA), and generally, pay ents other than interest and dividends, you arc not required to sign the Certification, but you must
provide your correct TIN. (See the inllciions on page T)/J A
Sign ( signature of
Here U.S. person 0-
Purpose of Form
A person who is required to rile an information return with
the IRS, must obtain your correct taxpayer identification
number (TIN) to report, for example, income paid to you, real
estate transactions, mortgage interest you paid, acquisition
or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding,
or
3. Claim exemption from backup withholding if you are a
U.S. exempt payee.
Note: If a requester gives you a form other than Form W-9
to request your TIN, you must use the requester's form if it is
substantially similar to this Form W 9.
Foreign person. If you are a foreign person, use the
appropriate Form W-8 (see Pub. 515, Withholding of Tax on
Nonresident Aliens and Foreign Entities).
V—p Date ► (/ / zY � v-[
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the
terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a
provision known as a "saving clause." Exceptions specified
in the saving clause may permit an exemption from tax to
continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
You must attach a statement that specifies the following five
items:
1. The treaty country. Generally, this mustbe the same;
treaty under which you claimed exemption from tax as a
nonresident alien.
2, The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualities for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article.
Cat. No. 10231X Form W-9 (Rev. 1 2003)
Date Received
�rrrr�
FOOD ESTAWSH1AENT PERMI
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: C �� , _ - (t? l
A C—
2) Establishment Address: i
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: S O g 3 q a
5) Applicant Name & Title: s
6) Applicant Address:
NCW 4G. /)%
(v
7) Applicant Telephone No.: c(I _1 S 7 ( Y
24 Hour Emergency No.:
8) Owner Name & Title (if different from applicant):
Live N c)Ai d
9) Owner Address (if different from applicant): (1
3 I R C i V iL,
p �I; q
10) Establishment Owned By:
1 If a corporation or partnership, give ame, tHle, and ome address of
officers or partner.
1616
❑ AD Association
Corporation
I••�c�'1/1.St 1K, l G�-
�'r 1 �Z 0 V` 1�,�
❑ An Individual
❑ A Partnership
❑ Other legal entity
12) Person Directiv Responsible For Daily ODerations (Owner. oerson in charoe. Suoervisor. Manacer. etc.)
Name & Title:
m Ana ! l C` F j.
Address:
r, M9 M O b y
Telephone No:
(_S 520 -�29 , 3L3 Fax:
Emergency Telephone No:
13) District Or Regional Su ervisor (if applicable)
Name & Title:
Address:
Telephone No: Fax:
BLANK FOOD PERMIT APPLICATION
)4
Food Establishment Information
14.) Water Source
A/(R
15) Sewage Disposal /V
DEP Public Water Supply No: (if applicable):
Days and Hours of Operation: jJ I
c ooe
17) No, of Food Employees
18) Name of Person In Charge Certified in
Food Protection Management:
M
Required as of 1 tY1/2001 in accordance with 105 CMR 590.003(A) Please attach co
of certificate
19) Person Trained in Anti -Choking Procedures (if 25 seats or mare): 46 All
1-
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) V
{ Meals/Day)
❑ Residential Kitchen for Bed & Breakfast
Establishment
❑ Frozen Dessert Manufacturer
Other (Describe)
21) Length Of Permit:
S G MQ
(check one)
❑ Annual
❑Seasonal/Dates
Temporary/Datesf rimes
IIzi
23) Food Operations:
Definitions:
PHF— Potentially hazardous food(6me/temperature controls required)
(check all that apply):
Non-PHFs— non-potenliaV hazardous food (no timeltemperature controls required)
RTE -rea-to-eat foods Ex. Sandwiches, salads, muffins which need no further processl)
❑ 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
Packs ad PHFs
HoldingFor Single Meal Service
Susceptible Population Facili
❑ Delivery of Packaged PHFs
❑
Sale of Raw Animal Foods Intended to
❑ Vacuum Packaging/Cook Chill
be Prepared by Consumer
❑ Reheating of commercially
0
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
Lj Offers RTE PHF in Bulk Quantities To be completed by the Board of Health
Other (Describe):
Y (@e Say ri`kS o� ❑ Retail Sale of Salvage, Out -Of -Date or
j I
(i 1 Q Total Permit Fee:
Reconditioned Food Payment is due with application
�J 4(VA
Mp SPn�y�;
e'l t�/hi uh49is g6d,tattesttyo A accc`S oighe 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 health on how to
obtain copies of 105 CMR 590.000 and the federal Food Code. 4 ,
6 Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of p4dury thi�o my best knowledge and belief, have filed all state
returns and paid state taxes required under law.
Social Security Number or Federal ID: Key) Signature of Individual or Corporate Name: ( ye O-10 y /1 �
BLANKFOODPFB APPLICATION
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Ulf 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: k/ UML�,, (Pn+ct'
Address: % g y M a. n ]r
6
Are you an employer? Check the appropriate box:
1. ❑ 1 am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity,
o workers' comp, insurance required]
3. We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone#: SUS p 3j _ a333
Business Type (required):
[6.
. ❑ Retail
❑ Restaurant Bar/Eating Establishment
7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. EMtertainment
10.❑ Manufacturing
11.❑ Health Care
12,❑ Other
*Any applicant that checks box 91 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 is providing workers' compensation insurmue for my employees. Below is thepolicy information.
Insurance Company Nat
Insurer's Address:
City/State/Zip:
Policy # or Self -ins, Lie.
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.
1 do hereby certify, under the pains and penottles ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to he completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
www.mass.gov/dia
Phone
Page 1 of I
Jane Doucette
From: Victoria, Andrea [AndreaVictoria@LiveNation.com]
Sent: Sunday, August 03, 2008 3:57 PM
To: Jane Doucette
Subject: Rockstar Energy Drink
Hi Jane,
We have Rockstar Energy Mayhem Tour coming through on Tuesday 815. 1 just received their permit and check to sample Rockstar
Energy Drink. If I personally hand deliver this tomorrow to you, can we have the permit in time for Tuesday?
SO sorry it is so last minute. I hope you can make this happen for us!
Please let me know. Thanks! O
LTVE nRT[on
Andrea Victoria I Sponsorship Coordinatoi / Boston - Comcast Center & Bank of America Pavilion
0:: 508.339.3333 x.328 / 508,339,6669 fx
qndreavictoria@livenation.com
.:: 885 South Main St. I Mansfield, MA 1 02048
www.liveNation.cmm
:L!_11:
Scott Leite
To: AndreaVictoria@LiveNation.com
Cc: MarcAbend@Livenation.com; Jane Doucette
Subject: Rockstar Energy Drink
Good morning Andrea,
I regret that your request for a temporary food permit for Rockstar Energy Drink is declined, because you cannot submit
the required forms and check 48 hours prior to the event.
This is the second request in about 2 weeks to waive the 48 hour requirement.
I realize that GMR/Wrigley was an existing permit requesting additional dates, but it was not presented to us as anything
but Mariana Perez applying with no mention of GMR (the forms were also incomplete and no check was enclosed).
Several calls to her in an attempt to resolve the matter were not returned.
Please remember that this policy was put into effect for the very reason that you are asking exception to it and that when
the policy is adhered to, permits are always issued in a timely manner.
Yours truly,
Scott Leite,
Health Agent
Page 1 of 1
Jane Doucette
From: Abend, Marc [MarcAbend@LiveNation.comj
Sent: Monday, July 21, 2008 10:37 AM
To: Scott Leite
Cc: Jane Doucette; Victoria, Andrea
Subject: GMR/Wrigleys Sampling
Scott,
GMR was granted a health permit to sample Wrigley's (sealed) packages of gum. They put down specific dates
on the application. The fee that they paid was $175. (In the past, you and I had discussed a $25 fee for the
entire season. I am out of the loop on this now, and I understand that the fee may have gone up.)
Our rep. in New York tried to add another date and instead of contacting us here locally so that we could just let
you know of any additional dates, they started a new process too close to the date. They were denied because
they did not include a check and completely fill out the form. The information is all the same as it relates to any
previous and future sampling dates.
Is there any issue using the existing permit to allow them to sample the product at the Concert tomorrow
(7/22/08).
Thanks for your attention to this matter.
Marc
jave nRTIoni
Marc Abend I Regional Vice President -Mid Atlantic /Northeast
12: 508.339.3333 x321 / 508.339.6669 fx/ 508.725-2300 cell
^: marcabend�lalivenation.com
'.: 885 South Main Street, I Mansfield, MA 02048
www.LiveNatlOn.com
7/21 /2008
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