HomeMy WebLinkAboutEpicurean Feast - 5 Hampshire- 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: RETAIL FOOD
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 @ TYCOXENDALL
5 HAMPSHIRE STREET
PERSON(S) IN CHARGE:
RUSSELL QUEENAN
Permit Expires: dune 01, 2010
License Number: RF-4
Food Fee: $50.00
Milk & Cream ❑O
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 @ TYCOXENDALL
5 HAMPSHIRE STREET
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
Lice'nse4o.: RF-4
Scottl.gitd, Health Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
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FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
RF-
FOOD ESTABLISHMENT PERMIT APPLICATION
(Aoolication must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
EPICUREAN FEAST @ TYCO/KENDALL
2) Establishment Address
5 HAMPSHIRE STREET
3) Establishment Mailing Address (if different) 24 MAIN STREET
MAYNARD, MA 01754
MAY 2 2 2009
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) 897-0660 ( 978) 897-5754 (508) 261-8215
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
W A Corporation
❑ An Individual
El Partnership
❑ Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
Ob2r� �< (}a ct ��\�ici�d to a%L(tI�\`,u.�y (`iIyi:�ifl:� �
LAk
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dvl Sj e� U S CE t s�S CCU- It
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
14 /
<USS�(/ J
Address:
/
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Telephone No:
oC� 100 -7 a 24 Hour Emergency No:
FAX:
13) District Or Regional Supervisor (if applicable)
Name & Title:
�)•,7I�
m2f I
Address:
Telephone No:
77g 37.E %crY 24 Hour Emergency No: 56h�f.
FAX:
q qfi ^ c
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: LINDA M ROTELLA
If more than 3 individuals are certified, complete list is on file.
Required 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): 0
20) location: [] Permanent Location
❑ Mobile Mobile Start Dale:
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)
❑ 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
l000d Service - Institution
[ too Meals/Day)
❑ Bakery $25
❑ Caterer $25
❑ Food Delivery $25
❑J Milk & Cream $2
❑ Mobile Food & Consession $50
❑ Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
i— Pushcart $25 If of Pushcarts:
iJ Residential Kitchen $25
❑J Retail Food $50
❑ Retail Snack Food $10
❑ Tobacco Products No Fee
23) Food Operations cognitions: PHF- Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order So� Hot PHF Cooked and Cooled or Hot Held
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service
❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
❑ Sale of Raw Animal Foods Intended Susceptible Population Facility
❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
❑ Use of Process Requiring di Variance
❑ Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only
❑ Ice Manufactured and Packaged for contact alternative, time as a public health
❑ Preparation of Non-PHFs
Retail Sale control)
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: $50.00
Payment is due with application ❑ waived
1, the undersigned, attest to the accuracy of the informate rovided i this application and affirm that the food
establishment operation will comply wi 05 CMR 590.
0 and all er applicable law. I have been instructed by the
board of health on how to obtai f 05 CMR
0.000 the federal Food Co
24) Signature of Applicant:
Pursuant to MGL Ch.62 ,'sec. 4?"V(certify under the
penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes req ire�der law.
25) Social Security Number or Federal ID: 04-2273500 g
'rkf
26) Signature of Individual or Corporate Name:
m J.G iq 4 ,)
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: 5 HAMPSHIRE STREET
TELEPHONE AT LOCATION: (508) 261-8000
FAX NUMBER: (978) 897-3719
OWNER OF BUSINESS: LPM HOLDINGS CO., INC.
TELEPHONE OF OWNER: (978) 375-4899
FEDERAL ID/SS NUMBER: 04-2273500
FEE; $2.00
PERMIT NUMBER: RF-
SIGNA'