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HomeMy WebLinkAboutOmaha Steaks - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit #Issued t 6 2010 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) rN EstablishmentName r re24'� Establishment Address � 4 C' a.t .C" ,t iy e, A <<< idt. _b tiI/\ o L =tom Establishment Mailing Address (if different)f r e_e k t c7 T r_ �4 Establishment Telephone No Applicant Name & Title: Applicant Address ttc 3-- Applicant Telephone No.: (402-) 53'i_' f° `T z -t 24 Hour Emergency No.: Applicant Email F t ti �� l Viz, c �r tf z,k<, CL'„ Owner Name & Title (If different from applicant) CS { tr._sC�• t i:. . Owner Address \tD 3„ G Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. A Corporation Name Title Address 17 An Individual L ` `. kF �)� «l 't 4- y st � � �s>� >rr.� (irr, s lkc,�c OCA (A"A -" kAC, Ls El A Partnership D Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title Address: Telephone No: 24 Hour Emergency No: (yci) q _> - FAX: E-mail: Alt E -Mail:, District Or Regional Supervisor (if applicable) Name & Title. or �z` r;l ,rr , k Address: 2f,c� cni .Sf< •+ r- I>tsc, �F��:�=�<<a�i C E C1c`t Telephone No ( ct;) y.c 24 Hour Emergency No: (rice}) ..'KIL'( FAX: E-mail: Food Establishment Information WATER SOURCE: t r SEWAGE DISPOSAL No. of Food Employees: L(. DEP Public Water Supply No: (If applicable) DAYS/HOURS: 1—tc , - ;>,% D zv� - g S't- tuft/'_ L i�... Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. 0 Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [X�, Annual [9 Retail Food $125.00 Mobile Food Consession Temporary i❑', Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: (6i Food Service up to 101 -200 $250.00 ']$25.00/freezer Temporary End Date: [[] Food Service up to 201 + $300.00 '] Pushcart $50.00 # of Pushcarts: Temporary Time: Li€ Supermarkets $400 Residential Kitchen $100.00 Rain Date: I`t Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(timertemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous/ood(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) EX] Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ] Hot PHF Cooked and Cooled or Hot Held [] Sale of Commercially Pre -Packaged PHFs [ij] Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service 7]PHF and RTE Foods Prepared For Highly (] Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer ] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self and/or HACCP Plan (including bare hand -Service � J Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Preparation Retail Sale p of Non-PHFs Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 'l�- Vacuum Packaging / Cook Chill h] Offers RTE PHF in Bulk Quantities _1 Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal to: Signature of Individual or Corporate Name:' TAX CERTIFICATION FORM 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 47-0805669 **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. CAUsers\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commomvealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street U11 Boston, MA 02111 rvivw.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: OS SALESCO, INC. Address: 11030 O STREET City/State/Zip: OMAHA, NE 68137 Phone #: (402) 597-3000 Are you an employer? Check the appropriate box: Business Type (required): 12 I am a employer with 14 employees (full and/ 5. ❑ Retail or part-time).* wr tMrt 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-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]** 110 Health Care 4.❑ We are a non-profit organization, staffed by volunteers, 12.Q Other 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 # I. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: LIBERTY MUTUAL INSURANCE Insurer's Address: 175 BERKELEY STREET City/state/zip: BOSTON, MA 02116 Policy # or Self -ins. Lie. # WA2-64D-444507-079 Expiration 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 ofperjury that the information provided above is trite and correct. Signature: `1`1 rlsi--,b',,C,,* Date: Ioit lnh, o, ,�. (402) 597-8221 Official use only. Do not write in this area, to be completed by city or town official City or Town: Perinit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY thePty Mutual. INSURANCE INFORMATION PAGE 175 Berkeley Street Boston, MA 02116 Issued by Liberty Mutual Fire Insurance Company (a stock company) 16586 Policy Number WA2-64D444507-079 Issuing Office Lewiston, ME Renewal Of WA2-64D-444507-078 Issue Date 07/03/2019 Account Number 4-444507 1. Insured and Mailing Address Omaha Steaks International, Inc. 11030 O Street OMAHA NE 68137 Sub Account 0000 FEIN 44-0652560 NJ TIN 440652560000 Risk ID 917128308 MI Risk ID 0701300A Status Corporation Other workplaces not shown above: See Item 4. Premium - Extension of Information Page 2. Policy Period: The policy period is from 07/01/2019 to 07/01/2020 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: AZ CA CO CT FL GA IL KS KY MD MA MI MN MS MO NE NV NJ NY NC OK PA RI TN TX VA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A and the States of: ND OH WA WY D. This policy includes these endorsements and schedules: See Item 3. Coverage D - Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rales and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Total Rate per $100 Estimated Annual Premium will be billed Annual Producer 0002 007662 ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC 10050 REGENCY CIR STE 300 OMAHA NE 681143721 Total Estimated Annual Premium $ 3r/,/d/ Deposit Premium $ 327,787 Deposit Tax/Surcharge/Assessment $ 5,289 Countersigned by Authorized Rep. (FL) - 9;4 �— WC 00 00 01 A ©1987 National Council on Compensation Insurance, Inc. WC 00 00 01 6 (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1