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Home My WebLink AboutEpicurean Feast - 9 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 HOLDING CO., INC. Whose place of business is: EPICUREAN FEAST @ COVIDIEN-TYCO 9 HAMPSHIRE STREET PERSON(S) IN CHARGE: RUSSELL QUEENANXIM BEAL Permit Expires: June 01, 2010 License Number: FS-17 Food Fee: $100.00 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: LPM HOLDING CO., INC. having a place of business at: EPICUREAN FEAST @ COVIDIEN-TYCO 9 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 License No.: FS-17 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-17 FOOD ESTABLISHMENT PERMIT APPLICATION (Anntiration must be submitted at least 30 days before the planned openino date) 1) Establishment Name: EPICUREAN FEAST @ COVIDIEN-TYCO 2) Establishment Address 9 HAMPSHIRE STREET 3) Establishment Mailing Address (if different) 9 HAMPSHIRE STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 261-8000 5) Applicant Name & Title: LPM HOLDING CO., INC. 6) Applicant Address 24 MAIN STREET, MAYNARD, MA 01754 7) Applicant Telephone No.: (978) 697-0660 24 Hour Emergency No.: (978) 897-0660 ( 978) 897-5754 8) Owners Name & Title LPM HOLDING 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 n , t� ln��aJSa-= (�d�r�.arc�,ft�a Est .Q��1� yq , [ rgu � C _� �°c3ti�tL% "t}�t�C�r�hz; � ��( y d`he e 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: - Address: Telephone No: 6024 Hour Emergency No: ,j ce n ¢� FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: (< 49 Address: �' ✓fit, )^ Tr /' �k ^� I %sy Telephone No: �qy 24 Hour Emergency No: 5� , L FAX: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 12 17) DAYS/HOURS: 6:30 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): W 20) Location: ❑Q Permanent Location 22) Establishment Type ❑ Bakery$25 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Caterer $25 Mobile End Date: ❑ Food Service up to 100 or ❑ Food Delivery $25 Moblie Comments: up to 10' PHF display $75 ❑� Food Service up to 101 -200 U Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: Annual or up to 25' PHF display $100 ❑ Mobile Food Temporary $25 ❑ Food Service up to 201 + or 254 PHF display $125 ❑� Food Service - Institution ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: 4(00 Meals/Day) ❑ Retail Food $50 Temporary End Date: ❑ Retail Snack Food $10 Temporary Time: ❑ Tobacco Products No Fee Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHF's - 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 furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PFHs �ij PHFCooked To Order Q 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 ❑ Customer Self -Service of Non PHF and Non- ❑d Customer Self -Service ❑� Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for contact alternative, time as a public health DV 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: $100.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuragy-of'th2-i formation provu i�thisa lication and affirmthat the food establishment operation will comp -Filth 105 C 590.000 a all otable law. I have been instructed by the board of health on how to ob/jncopies of 10� MR 590.00 and tod Code 24) Signature of Applicant" Pursuant to MGL Ch.620,�s _4 _A I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required 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 @ COVIDIEN-TYCO ADDRESS: 9 HAMPSHIRE STREET TELEPHONE AT LOCATION: (508) 261-8000 FAX NUMBER: (978) 897-3719 OWNER OF BUSINESS: LPM HOLDING CO., INC. TELEPHONE OF OWNER: (978) 897-0660 FEDERAL ID/SS NUMBER: 04 2273500 FEE: $2.00 PERMIT NUMBER: FS-17 2 ( U. LU � � .CL J � W (f) U) :D w \ |