Loading...
HomeMy WebLinkAboutMargaritaville Foods - 5/25/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Comeast Temporary Food Permit In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. TOM KEANE, CEO Whose place of business is: MARGARITAVILLE FOODS, LLC @ COMCAST CENTER 885 SOUTH MAIN STREET Permit good for: JUNE 25 & 27, 2009 2 PM TO 7:30 PM License Number: MF-5T Food Fee: $50.00 BOARD OF HEALTH �h Dr. Raymond Martin, Chairman Date received: FOR BOARD OF HEALTH USE 9 � L, u Date Inspected: Appr0 IBY3ON 0 8 ZOAr Issued COMCAST TEMPORARY FOOD ESTABLISHMENtR9RffITjICATION (Application must be submitted at least 46 hours prior to planned event) 1) Establishment Name: Comcast Centre/Tweeter Center Jimmy Buffett Concert 2) Establishment Address 885 South main Street Mansfield MA 02048 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 5 0 8- 3 3 9- 2 3 31 5) Applicant Name & Title: Paul Morgan Tour Manager 6) Applicant Address 31420 Old Town Springs Road Chaumont NY 13622 7) Applicant Telephone No,: 215-859-2069 24 Hour Emergency No.: 215-859-2069 8) Owners Name & Title Tom Keane CEO 9) Owner Address (If different from applicant): 123 Water street Suite 4 SW Exeter NH 038 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, An Association and home address of officers or partner. C�FA Corporation Eric Martin An Individual 6800 Lakewood Plaza Drive ❑ A Partnership Orlando FL ❑ Other legal Entity 32819 iz/ Person uirecuy mesponsioie Por uany uperanons (owner, person in charge, supervisor, manager etc.) Name & Title: Paul Morgan Address: 31420 O d Town Springs :1,o.d Chaumont NY 13622 Telephone No: 215-859-2069 I FAX: Emergency Phone 215-859-2069 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: Emergency Phone 7 Food Establishment Information 14) WATER SOURCE: On Coach 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) On Coach 16) DAYS/HOURS:6/25 6/27 2 to 7.30 PM 17) No. of Food Employees: 4 18) Name of Person In Charge Certified in Food Protection Management: Paul Morgan squired as of f0111200t in accordance with 105 CMR 590.003(A) Please attach copy of certificate 20) Location: 22) Establishment Type [ Mobile Food Temporary(Snack Size ❑ Permanent Location Sampling of Produds,Comcast) $25 Temporary per day (for the event) with a cap of $100.0� Temporary Dates: 21) LENGTH OF PERMIT: 2 Days 6/25 and 6/27 23) Food Operations Definitions: PHF - Potentially hazardous food (timeltemperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no tim0amperature controls required) RTE - ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no further processing) Safe of Commercially Pre -Packaged Nan-PHFs [2� PHFCooked To Order Q Hat PHF Cooked and Cooled or Hot Held Q Safe of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot Rnd for More Than a Single Meal Service Cold Holding For Single Meal Service ❑ Reheating of Commercially Processed Foods Q Juice Manufactured and Packaged for for Service Within 4 Hours Q Customer Self -Service Retail Sale ❑ Customer self -Service of Non PHF and Non- ❑ Ice Manufactured and Packaged for Perishable Foods Only Retail Sale Q Preparation of Non-PHFs Other Food Operations To be completed by the Board al Health Total Permit Fee: Payment is due with application I, the undersigned, attest to the a racy of the information provided in this application and affirm that the food establishment operation will co I with CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obta' pi of 1 5 CM13AW0.000 and the federal Food Code. 24) Signature of Applicant: I I t Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury iNit I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law, f 25) Social Security Number or Federal ID: `�� �6Z 1 0 �� 4� +� 26) Signature of Individual or Corporate Name: en(Ao-,d Ar. . A V1 Ili �i? O Ix-JS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lepibly Business/Organization Name: i tV a(,t i t6{.Vf l l,.Q_ Fp© S � ) Address: f Z� WC(Z4- S t S [I �Lf-s W City/State/Zip: f)G k t P i } NH 03M Phone Are you an employer? Check the appropriate box: F{ Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. []Retail 2. ❑ or part-time).* I 'a 6. ❑ Restaurant/Bar/Eating Establishment amsole proprietor or partnership and have no employees working for me in any capacity. 7, ❑ Office and/or Sales (incl, real estate, auto, etc.) [No workers' comp. insurance required] S• ❑ Non-profit 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 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, I LEI Health Care with no employees. [No workers' comp. insurance req.] 12.YOther _bjdau,, -Any applicant that checks box # I 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 insurance far my employees. Below is the policy information. Insurance Company Insurer's Address: 5 !390 [lt to A vSl, v City/State/Zip: V qn N U YS C Policy # or Self -ins. Lic. # x w C-. hyLY i 2 2, Expiration Date: ® S 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 c�ertn,r-<+ 0, under the pains and penalties of perjury, thattheinformation provided above is true and correct Signature• &,U' .tn+A •— �lton V Date: 5I27/CIr'! Phone #-. Z 03i '7%Z—�aiic��1 _..__._.. OffWal 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 Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact www.mass.gov/dia ACORA CERTIFICATE OF LIABILITY INSURANCE OP ID D2 DATE(MWDDIYYYY) MARGE-Z 1 06 01 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Momentous Insurance Brokerage HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5990 Sepulveda Blvd, Suite 550 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Van Nuys CA 91411 Phone:818-933-2700 Fax:818-933-2701 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: @ixmazva eaves xvaaxanco Co. Margaritaville Holdings LLC INSURER B: Margaritaville Foods, Eric Forward Lf,C INSURER D; 6800 Lakewood Plaza Drives INSURER D: Orlando FL 32819 V V V Gl�NVG3 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMEDABOVE FOR THE POLICY PERIODINDICATED. 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS. INSR LTR rMUSURN TYPE OFINSURANCE POLICY NUMBER DATE MWOO D0.TE MM/OD LIMITS GENERALLIASII-ITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑ OCCUR EACH OCCURRENCE PREMISES eoxurence) $ MED EXP (Any one Person) $ PERSONALAADVINJURY $ GENERALAGGREGATE $ OEN'LAGGREGATELIMIT APPLIES PER: PoLICY JRO LoC PRODUCTS-CCMPIOPAGG $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEDULEDAUTOS HIREDAUTOS NON-OWNEDAUTOS COMBINED SINGLE LIMIT (Ea acadent) $ BODILY INJURY (Per Person) $ BODILYINJURY (Pe,acddenl) $ PROPERTY DAMAGE (PIN ardent) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC AUTOONLY; AGO $ $ EXCESSNMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ A WORKMCOMPENSA71ONAND EMPLOYERS' LIABILITY ANY PROPRIETORIETORIPARTNERlEXECUTNE OFFICER/MEMBER EXCLUDED? Byes desaibP under SPECIAL PROVISIONS below XKC80973582 05/07/09 05/07/10 X TORV LIMITS ER E.L.EACHACCIDENT $1000000 E.L.DISEASE-EAEMPLOYEE $lOOOOOO EL. DISEASE - POLICY LIMIT $10000DO OTHER DESCRWTION OF OPERATIONSI LOCATIONS 1 VEHICLES/ EXCLUSIONSADDED BY ENDORSEMENT I SPECIAL PROVISIONS EVID-01 I SHOLIMMYOFTHEABOVEOESCRIBEOPOUCIESBECANCELLEO BEFORETHEEXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENOEAVORTO MAIL 30 DAYS WRITTEN NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL EVIDENCE OF INSURANCE IMPOSE NO OBUGATK)N OR LIABILITY OF ANY KIND UPON THE INSURER, ITSAGENTS OR REPRESENTATIVES. 25 (2001108) 1ORA 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 Officer (Mandatory, ifApplicable) 2,� _ L[ A> 10 LO' "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: H"IthVMe's Documents\TAX CERTIFICATION FORM.doc /\ \) . 0z �\ / § § 04 \ \\ .0 ) mow/ \{G \ `\ ) k m076 \ ) - - } \ \ _ - 1.2 0 ~ �� kOD - >)3°/2$ (� QD' fA wr