The URL can be used to link to this page

Home My WebLink AboutEpicurean Feast - 100 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 100 HAMPSHIRE STREET PERSON(S) IN CHARGE: RUSSELL QUEENAN Permit Expires: June 01, 2010 License Number: FS-19 Food Fee: $100.00 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 100 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 No.: FS-19 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 (Annlinetion must be submitted at least 30 days before the planned openinq date) 1) Establishment Name: EPICUREAN FEAST @ TYCOXENDALL 2) Establishment Address 100 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 BEAL, DISTRICT MANAGER 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (978) 375-4899 24 Hour Emergency No.: (508) 542-4424 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 O 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 �h�trk 'C < < Y�ct %6 C c l i kA to ��i� kCx f -CEI,ti k tt t( tt e��l� � s k Ct;c> 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: FAX: d ClTn�o-, Ol6/v yV o 24 Hour Emergency No: 13) District Or Regional Supervisor (if applicable) Name &Title: / +n cA i2e1ct , Address: /� ( � �/ IkV — Telephone No: T 24 Hour Emergency No: Y'! FAX. z V7V 377 y15'9 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: MON-FRI 7 AM-1:30 PM 18) Name of Person In Charge Certified in Food Protection Management: RUSSELL P QUEENAN 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): V 20) Location: W Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Moblie Comments: up to 10' PHF display $75 21) Length of Permit: ❑J Annual ❑ Seasonal Seasonal Dates: j Temporary Temporary Start Date: Temporary End Dale: Temporary Time: Rain Date: ❑�/ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 254 PHF display $125 [J] Food Service - Institution 300 Meals/Day) ❑ Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 n 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, mums which need no further processing) ❑� Sale of Commercially Pre -Packaged Non-PFHs PHFCooked To Order W Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And Cold Holding For Single Meal Service W 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 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 ❑ Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation 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: $100.00 Payment is due with application ❑ waived I, the undersigned, attest to the accura e informatiory ovided in t i application and affirm that the food establishment operation will comp ith 105 CPR 590 (f0 and all of r applicable law. I have bee_n.instructed by the board of health on how to obta npies of 10 MR 0.000 and t federal Food Code. 24) Signature of Applican Pursuant to MGL Ch.6 , sec A, I certify and t ties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes re under law. 25) Social Security Number or Federal ID: 04-2273500 26) Signature of Individual or Corporate Name: 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: 100 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: OWNER OF BUSINESS: (978)897-3719 LPM HOLDINGS CO., INC. TELEPHONE OF OWNER: (978) 897-0660 FEDERAL ID/SS NUMBER: 04-2273500 FEE: $2.00 PERMIT NUMBER: FS- SIGNATURE: DATE: