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Home My WebLink AboutEpicurean Feast - 21 Oxford - 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:. LPM HOLDINGS CO., INC. Whose place of business is: EPICUREAN FEAST @ TYCO/KENDALL 21 OXFORD ROAD PERSON(S) IN CHARGE: RUSSELL QUEENAN Permit Expires: June 01, 2010 License Number: FS-18 Food Fee: $75.00 Milk & Cream ❑d 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: LPM HOLDINGS CO., INC. having a place of business at: EPICUREAN FEAST @ TYCO/KENDALL 21 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 Scott Leite, 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 FOOD ESTABLISHMENT PERMIT APPLICATION (Annllcatinn must he suhmitted at least 30 days before the planned ooenino date) 1) Establishment Name: EPICUREAN FEAST @ TYCO/KENDALL 2) Establishment Address 21 OXFORD ROAD 3) Establishment Mailing Address (if different) 24 MAIN STREET MAYNARD, MA 01754 4) Establishment Telephone No: (508) 261-8000 5) Applicant Name & Title: KIMBERLY BEAL, DISTRICT MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (978) 375-4899 24 Hour Emergency No.: (978) 897.5754 8) Owners Name & Title LPM HOLDINGS CO., INC. 9) Owner Address (If different from applicant): 24 MAIN STREET, MAYNARD, MA 01754 10) Establishment Owned By: ❑ An Association V A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address n I1��3 rk .4 . �. ace aaI NI Ce z' G% ' r (1tI da t fh 1 a r -� tt�rr ij `cc Cdac�2rsc u U ff , , .� 4t y f 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: v� r-2 tee. nun Address: '^ ,� V� �+i �j�l�n ✓1 �i �O Telephone No: qoo 7 q q 24 Hour Emergency No: 4 1 FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: J IVY) Address: t 111(4 U YJ744 Telephone No: Cr75-c g 24 Hour Emergency No: rn FAX: ` % 3 7/ 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 1 17) DAYS/HOURS: MON-FRI 7:00 AM-1:30 PM 18) Name of Person In Charge Certified in Food Protection Management: IRENE OGARA If more than 3 individuals are certified, complete list is on file. 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: ❑� Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑� Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) 0 Food Service up to 100 or up to 10' PHF display $75 ❑ 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-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) W Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order OV Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs W Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑d PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill Fvfl Use of Process Requiring di 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 Q Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the accu c�of tht establishment operation will co!mylf with 105 C board of health on how to obtp'6 copies of 105 24) Signature of ❑ Juice Manufactured and Packaged Retail Sale I ❑ Offers RTE PHF in Bulk Quantities I Pursuant to MGL Ch.6 C, sec. 49A, I ceftify under th6,p and paid state taxes r cared un aw. 25) Social Security Number or Federal to: 04-2273500 26) Signature of Individual or Corporate Name: Retail Sale of Salvage, or Reconditioned Food ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: $75.00 Payment is due with application ❑ waived 9vrded in this appp)�16ation and affirm that the food id all other appylicable law. I have been -Instructed by the and the fed&'al Food Cod of perjury that I, to my best knowledge and belief, have filed all state tax returns N 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: EPICUREAN FEAST @ TYCO/KENDALL ADDRESS: 21 OXFORD ROAD TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: (978) 897-3719 OWNER OF BUSINESS: LPM HOLDINGS CO., INC. TELEPHONE OF OWNER: (978) 897-0660 FEDERAL ID/SS NUMBER: 04-2273500 FEE: $2.00 PERMIT NUMBER: FS- SIGNAL I IL. 0 a M m 0 d Z Z 0 to w U. Oa, w d F.A IL tN w a w U m ''0• Y.� z w a w 0 d a s Z d z Z W wM W w r E N w k 0 O W Z 0 U N w H U U U UI d n u w.,^ S two ti