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Home My WebLink AboutCourtside Pub - 6/1/2010Commonwealth 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: 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:. MICHAEL KENEALLY & PATRICK MADIGAN, RICHARD MADIGAN, SR. Whose place of business is: COURTSIDE PUB dba SETPOINT ATHLETICS 31 OXFORD ROAD PERSON(S) IN CHARGE: BRIAN COFFEY, MANAGER Permit Expires: ,June 01, 2010 License Number: FS-12 Food Fee: $75.00 Milk & Cream W BOARD OF HEALTH Dr. Raymond Martin, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: AEL KENEALLY & PATRICK MADIGAN, RICHARD MADIGAh having a place of business at: COURTSIDE PUB dba SETPOINT ATHLETICS 31 OXFORD ROAD in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 No.: FS-12 Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-12 FOOD ESTABLISHMENT PERMIT APPLICATION (ADDUCation must be submitted at least 30 days before the planned openinada _ . r2. Q 1) Establishment Name: COURTSIDE PUB dba SETPOINT ATHLETICS DC 2) Establishment Address 31 OXFORD ROAD kq,u 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 "V 4) Establishment Telephone No: (508) 337-3100 5) Applicant Name & Title: STEVE S HUBER & KIMBERLY GIANNOULOUDIS gdld,v CorG� y 6) Applicant Address 31 OXFORD ROAD, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 3373100 24 Hour Emergency No.: (508) 337-3100, (774) 2533851, (508) 648-8466 8) Owners Name & Title MICHAEL KEN EALLY QA t A kcK 0,40j(rAN 11L 1A21? MA I � A- 9) Owner Address (If different from applicant): M GREEN STREET, FOXBORO, MA 02035 d5l 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ❑ A Corporation Name Title Address ❑ An Individual MtCµAiL V-Vd L*4Y o rrtK iY� irPLt4r�S`. �7ix/�v2a Ww �r K �byv�ADl(7/deJ _ ❑O A Partnership L L o ❑ Other legal Entity P A I (2,'rG K tOA 0 1'(, A-J 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) b:?035 Name & Title: 80IUM/ Address: �70 .Suti„ /I'Y-- QUlf,lc`/� Telephone No: a 24 Hour Emergency No: FAX: 13) District Or Regional Supervisor (if applicable) tilft Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (if applicable) I 16) No. of Food Employees: 5 17) DAYS/HOURS: 7 DAYS 5 AM-1 AM 18) Name of Person In Charge Certified in Food Protection Management: BRD�-gyRLIEY If more than 3 individuals are certified, complete list is on file. S y e _-So� m f-A) as of 101112001 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: 0 Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Dale: ❑ Retail ( Sq. Ft) Moblie End Date: 0 Food Service up to 100 or Moblie Comments: up to 10' PHF display $75 21) Length of Permit: ❑ Annual ❑ Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ( Meals/Day) ❑ Bakery $25 ❑ Caterer $25 Food Delivery $25 ❑� Milk & Cream $2 ❑ Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 ❑ Tobacco Products No Fee 23) Food Operations (Check all that apply): Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ForHighly ❑Susceptible PHF and RTE Foods Prepared on Facili Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer - 0 Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ] Customer Self -Service of Non PHF and Non- Perishable Foods Only 0 Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale n Preoaration of Non-PHFs Other Food Operations ❑ 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 or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $75.00 ` Payment is due with application ❑ waived 1, 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 appligable law. I have been instructed by the board of health on how to obtain copies of 1 5 f 90.00Q and th edera ood Code. 24) Signature of Applicant: tF/'.4r Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of pertu hat I, to my best knowledge and belief, have filed all stale tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26-2121058 26) Signature of Individual or Corporate Name: `> L e,(.t-, A--sHC,z ) c- Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: COURTSIDE PUB dba SETPOINT ATHLETICS ADDRESS: 31 OXFORD ROAD TELEPHONE AT LOCATION: (508) 337-3100 FAX NUMBER: (508) 406-2245 OWNER OF BUSINESS: MICHAEL KENEALLY e P-<�4Aa V MA_OtCaAn) 'PA 7n tGl- IM Ate t G-A^I TELEPHONE OF OWNER: <68 SLt'3 • g 8qb FEDERAL ID/SS NUMBER: 26-2121058 FEE: $2.00 PERMIT NUMBER: FS-12 SIGNATURE: "— DATE: _( ,0c7 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. SC-T eO.ly i AT I-(LCj 1C S * Signature of Individual or Corporate Name (Mandatory) wit By: Corporate Officer (Mandatory, if applica e) gu. DID.ro513 ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. 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 Legibly Business/Organization Name: S¢ Pb,,-j i A i t-tC£ i 1( S P904 YYIArSy=11icc �l'o2rS('cEt! Address: 15 1 &1Z_e t rl 5-k (LE€-1— City/State/Zip:_FoXBOCZb AAA p-)D3S Phone #: Are you an employer? Check the appropriate box: Business Type (required); 1. ('l am a employer with 20 employees (full and/ 5. ❑ Retail or part-time).* 6. ®'Restaurant/Bar/Eating Establishment 2. ElI 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. g 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I LEj Health Care with no employees. [No workers' comp. insurance req.] 12.EeOther SPo�7Spc �X *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 # I. I am an employer that 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. # d'A W C L I S R 3 i a Expiration Date: Co ' 1-7-o'l 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 Phone #: 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 offlelal 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 Person: Phone #: www,mass.gov/dia 92 (Policy Provisions: WC 00,00 00 A) Is INFOI;rvfATION PAGE WEC WORI'I-RS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER:I RTPORD CASUALTY INSURANCE COMPANY 1n.RTPORD PLAZA, HARTFORD, CONNECTICUT 06115 NCCI Company Number: 14397 Company Code: 3 POLICY NUMBER: oz wEc I59292 Previous Policy Number: NEW HOUSING CODE: DW 1. Named Insi,red and Mailing Address: SET POINT ATHLETICS LLC (No., Str< ' lawn, State, Zip Code) 157 GREEN STREET FEIN Nuc•hrr: 262121058 FOXBORO, MA 02035 State Ide .lfication Number(s): UIN: The Named Insured is: LIMITED LIABILITY COMPANY Businc — med Insured: PHYSICAL FITNESS FACILITY NO P Other r s ;tit shown ab'oVe: 31 OXFORD STREET MANSFIELD MA 02048 2. Policy P�iiod: From 06/17/08 To 06/17/09 12:01 a.m., Standard time at the insured's mailing address. Produce - N ime. STARKWEATHER & SHEPLEY INS BK/PHS �.,e t+ a Ate' Suffix LARS RENEWAL 00 (SEE ENDT) 4401 MIDDLE SETTLEMENT RD RECEIVED NEW IIARTFORD, NY 13413 Produc,,,' ": 090570 JUN 23 2008 Issuinc `'"''- ': !Ir'F0RD 4401 MIDDLE SETTLEMENT ROAD, 2ND FLOOR STARKWVEATHER & SHEPLEY NE`9 IIARTFORD NY 13413 WESTWOOD MA O`O 467-8730 Total Estin. \nnual Premium: $2, 689 'posit Premium: Poll "'nimum Premium: $251 'MA (INCLUDES INCREASED LIMIT MIN. PREM:) Audit Perioc+ - " `UAL Installment Term: The policy i:, ing unless countersigned by our authorized representative. Countersigned by Authorized Representative Date Form WC 00 1 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Dn' o /o 8 Policy Expiration Date: 06/17/09 Uw COPY � 2 k j m /� . )2 � \/ f «% § _c }0 / . 2-4,4 -- {)) ) ; \ k \ \/ E) q f ! R \0 23 _ \ \\ � /\/ § §] \ \ G