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HomeMy WebLinkAboutEpicurean Feast - 15 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: 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 @ TYCOXENDALL 15 HAMPSHIRE STREET PERSON(S) IN CHARGE: RUSSELL QUEENAN Permit Expires: June 01, 2010 License Number: FS-21 Food Fee: $75.00 Milk & Cream W BOARD OF HEALTH Dr. Raymond Martin, Chairman ) LIM U R q � � q � k [ ; 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. 1n iU * Signature of Individu4 or Corporate Name (Mandatory) By: rporate er ( datoryJ f applicable) 0� - -31c, ** 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 IV www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: L PT 40 14 1AN CO Address: Q c1 /Ylo, i -1 S d- W a y ()a(' Phone #: Are y9a an employer? Check the appropriate box: (full and/ Business Type (required): 5. [:]Retail I am a employer with . t2� employees or part-time).* 6. [*estaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no y, ❑ Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. S. ❑ Nan -profit 3. ❑ [No workers' comp, insurance required] 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 no employees. [No workers' comp, insurance required]* 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑-6ther (25O&'s(?R 0 with no employees. [No workers', comp. insurance req.] *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 #l. _ I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: [ k-t 1~ In Insurer's Address: 00 � 4Lk i City/State/Zip: Policy # or Self -ins. Lic. # L � o -`) U ( i lG (i; lC ` r9 Expiration Date: I W ` , io 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 certify, under the pains and penalties ofperjuiy that the Information provided above is true and correct. Phone #: Ylv-P9 1-0LLe Official use only. Do not write In this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone www.mass.gowma ACORD CERTIFICATE OF LIABILITY INSURANCE DATE MWO""Y yy 5/8%2009 "' PRODUCER (508)583-1106 FAX: (508)583-6478 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION NLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Fredericks & Geraxdi Insurance Agency, Inc.. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1575 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 3067 Brockton MA 02304 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:MA Retail Merchants WC INSURER 8: LPM Bolding Co. Inc.dba Currier & Chives, INSURER C: Encore Pxty Rental, Epicurean Feast Food INSURER D: 24 Main Street INSURER E: Maynard MA 01754 OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY VE BEEN REDUCED BY PAID CLAIMS. INSR ADD TYPE OF INSURANCE POLICY NUMBER PDATEYEFFECTIVE MI DNY) PDATE EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ PREMISES ERENT" rrence $ COMMERCIAL GENERAL LIABILITY MED EXP (Any one rson $ CLAIMS MADE OCCUR PERSONAL & ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JET LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea nclEent) $ ANYAUTO BODILYINJURY (Perperson) $ ALL OWNED AUTOS SCHEDULEDAUTOS HIREDAUTOS NON-OWNEDAUTOS BOOILYINJURY (Per accident) $ PROPERTYDAMAGE (Per accident) $ GAR AGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA A -CC $ ANYAUTO $ AUTOONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE $ DEDUCTIBLE $ RETENTION A WORKERS COMPENSATION AND WWCC T' X TORVLpM IITS OER E.L. EACH ACCIDENT $ 1,000,000 EMPLOYERS' LIABILITY ANY PROPRIEfORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? 014000502016109- MA 1/1/2009 1/1/2010 E.L. DISEASE -EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 It yes, demnt,e under SPECIAL PROVISIONS below MA HIRED EMPLOYEES OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS r RRT'IFIr.ATR Nnl nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of Mansfield EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 6 Park ROW 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT Mansfield, MA 02048 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Q Dianne ACORD 26 (2001108) OACORD CORPORATION 19UU IMCn9R,mn.,— Pane 1 nf9 Commonwealth of Massachusetts Town of Mansfield 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 15 HAMPSHIRE STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 License,/do.: FS-21 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 1) Establishment Name: EPICUREAN FEAST @ TYCO/KENDALL 2) Establishment Address 15 HAMPSHIRE STREET — 3) Establishment Mailing Address (if different) 24 MAIN STREET MAYNARD, MA 01754 4) Establishment Telephone No: (508) 261-8000 5) Applicant Name & Title: KIMBERLY A BEAL, DISTRICT MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD MA 01754 375-4899 24 Hour Emergency No.: 1978> 897-5754 7) Applicant Telephone No.: (978 ) — 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: 11) If a corporation or partnership, give name, title, and home address of officers [I An partner. An Association Title Address V A Corporation Name t) _l . �_ 1a71 t3"t id�Psalk �Cec oi�i�'iS1 (Y11 iui�S � An Individual u� 'S 0 A Partnership ', Sc ice Carr 1 r Sc ❑ Other legal Entity t Pic 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: �uiI `` �� M Address: lam; li(i C�— Gli�rlde�n aMi� ©��lv' Telephone No: 5 24 Hour Emergency No: 5@mom FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: S•� m 6ea , 7� Address: � c� %yl� pd Sd p'YffA Aa(J M a —O)O I Telephone No: � j;i� y a `�� — v 24 Hour Emergency No: SG •�. Zs FAX: 9 i�6 `17 37/01 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: 5 17) DAYS/HOURS: MON-FRI 7 AM-7:30 PM 18) Name of Person In Charge Certified in Food Protection Management: ALICE ARAUJO 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: ❑J Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Moblie 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) ❑d 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 0./ 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 Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous lood(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑d Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order 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 Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) _ ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ 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 I, the undersigned, attest to the accuracy of the information pro ' this application and affirm that the food establishment operation will comply wjtl�-10� CMR 590.00 nd all er applicable law. i have been instructed by the board of health on how to obtain qo ies of 105 CMR 59 . 00 the federal Food Code. 24) Signature of Applicant: Pursuant to MOIL Ch.62C, ec. 4 certify unde p and paid state taxes requi nder law. 25) Social Security Number or Federal to: 04-2273500 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all slate tax returns t1 `list Cii74 .Nl 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 list of each year. NAME OF BUSINESS: EPICUREAN FEAST @ TYCO/KENDALL ADDRESS: 15 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: (978) 897-5754 OWNER OF BUSINESS: LPM HOLDINGS CO., INC. TELEPHONE OF OWNER: (978) 375-4899 FEDERAL ID/SS NUMBER: 04-2273500 FEE: $2.00 PERMIT NUMBER: FS- SIGNATUR€: r q DATE: /�/xd. I --- --