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HomeMy WebLinkAboutKindercare Mansfield - 12/31/2020IQQ�g1 �0, FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) b Establishment Name (GI I"1 C�X" �o v e, � hm fi e izo Establishment Address 515 Wst Sf i V t nS h d& Nt A V 2 0t 6 Establishment Mailing Address (if different) Establishment Telephone No - -- ApplicantName&Title: Applicant Address S Q YY1 Q ab 0 V >vi - 6 Lj 10 24 Hour Emergency No.: 1509 • � 6 � ) A Q t k Applicant Telephone No.: 5o gtt. 331 Applicant Email b(4i Ltr1 ('�,J V-1 Ki r)j rrCjq . Lcm 3 0 0. 3P, - Q I q q Owner Name & Title (If different from applicant) �) n d e rUrc E AW 61 # � O n �( Owner Address U" N6 �ib(� Aa ay si' Shct6 Itj-O[_N (''brtLmljj OR Q1 R3 Owner telephone number 50 9' 331 -�O 0 Q Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. KACorporation El An Individual Niaim�e, y� n Title 1t y Address # { �Lr-`-�_�_ r 6Q-I r Gt-�� I e�-4 ___ _ ���I I n t t,� S -I. El A Partnership qi �S�) NutA lit° F I} 0 j) ( 0 % fit° f K I �V UPI 5 El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: K1AIV L, )`LWW�in06) �` nt(r b)(611W Address: 515 tq tst M U 1STRJ J� MA n - 0+3 Telephone No: S o 5. 331- Q ( 24 Hour Emergency No: � a 8., 3 ti ' Q i j q FAX: 5 it 9 --oW l -13 01 5 E-mail: KCkVlhSi lY KAVIA er(l e 'COM Alt E-Mail: F r District Or Regional Supervisor (if applicable) Name & Title: Tw t'6�{ t tU�iiJ� KQ�1 y Address:uq Ytl�'{.�i�.5� �'V&j Telephone No: 4 01 - tY 3 LO- q 111 24 Hour Emergency No: g ^33 a - [ C� FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) ...t-n (r4� n No. of Food Employees: DAYS/HOURS: 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: Annual ❑ Retail Food $125.00 El Mobile Food Consession Temporary (❑ 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: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 ❑Pushcart $50.00 If of Pushcarts: Temporary Time: 0 Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Dentitions: PHF- Potentially hazardous food (11meltempemtum controls required) a Nan-PHF's -non-potentially hazardous lood(no lime/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-PHFs ❑ 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 ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand Customer Self -Service Customer Self -Service of Non PHF and Non - contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) n Preparation of Non-PHFs Retail Sale ❑Offers Raw Or Undercooked Food Of r ❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities ❑ 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: 1\ X4 I t A 42 l..}' IJ<! 14 /1 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 ID: ''nn Air ��� �! ,( ,, �., Signature of Individual or Corporate Name: y o,1_ Ai -T I a_ tf> t' CAM /(_-tJ� I (1ie� 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 "*Social Security No. (Voluntary) or Federal Identification Number Officer (Mandatory, if Applicable) *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. C:\Users\sleite\Desktop\Scou's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IN www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: n d t r ra ry,. Address: City/State/Zip: wi0,RS4 i C1d kjA 0n+5 Phone Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ S. ❑Retail rrrr� or part-time).* 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. [No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ 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 , l with no employees. [No workers' comp. insurance req.] 12.5Q Other LeQ n i n a r c n I[ r *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 #1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: M i ]s sa V I %'r j o f U11 (n i a r Inc c_ Insurer's Address: r4 n � fi mif! ],Y tj B ` U ( _ P. 0, B o X City/State/Zip: NL13} V1 i f i M A`; 2� 0 5 141 Policy # or Self -ins. Lic. # 1 4- N i. f� C {? �� Expiration Date: C q 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 certi , under the paints and penalties ofpeijury that the information provided above ist. sttrue and correct. Signature: Date: C 0 j{ 1 I 1 9 cnt—cr 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 Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: Phone www.mass.gov/dia Page 1 of 2 1 $d ACORO CERTIFICATE OF LIABILITY INSURANCE t6o_ �_ DATE IMMIDDNYYY) 11/02/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ONTACT Willis Towers Watson Certificate Center NAME: PHONE FAX ' 1-877-945-7378 AIC No; 1-888-467-2378 Willis Insurance Services of California, Inc. c/o 26 Century Blvd P.O. Box 305191 EMAIL ADDRESS: certificates@willia.com INSURERS AFFORDING COVERAGE NAICp Nashville, IN 372305191 USA INSURERA: Arch Insurance Company 11150 INSURED INSURERB: Travelers Indemnity Company 25658 INSURERC: XL Insurance America Inc 24554 KUEHG Corp.; KinderCare Education LLC; KC ME Holdings, Inc.; INSURER D: Arch Indemnity Insurance Company 30830 And Their Wholly Owned Subsidiaries INSURER E: 650 HE Holladay Street, Suite 140D Portland, OR 97232 INSURER F: COVERAGES CERTIFICATE NUMBER: W8768785 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR OF INSURANCE ADDLTYPE Man Wvn SUBR POLICY NUMBER EFF MMIUDTYYYY MMIDDIYYY LIMITS X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED3,000,000 PREMISES Ea occunance $ MED EXP (Anyone person) $ Excluded A 71GPPOS12310 12/01/2018 12/01/2019 PERSONAL& ADV INJURY $ 3,000,000 AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 6,000,000 GENT, POLICY ❑ PECROT- � LOC J PRODUCTS - COMP/OP AGO $ 3,000,000 $ OTHER: 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Es accident $ 2,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ B OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY HC2E-CAP-477M5687-TCT-18 12/01/2018 12/01/2019 PROPERTYDAMAGE Per accident $ h C X UMBRELLALIAB E%CESSU B X OCCUR CLAIMS -MADE US00011222LI18A 12/01/2018 12/01/2019 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DEG RETENTION$ RETENTION $ 10,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBEREXCLUDED7 No (Mandatory in NH) NIA 71WCI4952010 12/01/2018 12/01/2019 X PER I ERH E.L. EACH ACCIDENT $ 1, 000, 000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Workers Compensation s 71WCX4953810 12/01/2018 12/01/2019 E.L. Each Accident $1,000,000 Employers Liability - E.L. Disease-Pol Lmt $1,000,000 Per Statute E.L. Disease -Each Rail $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Legal Entities: KUEHG Corp. KinderCare Education Holdings LLC Knowledge Schools LLC SEE ATTACHED rPDTIFIr:ATF Wnl nrR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Posting Notice - ADS 91988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR In: 16982243 M=H: 939106 AGENCY CUSTOMER ID: LOC #: A4C rzo a® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Corp.; Willis Insurance Services of California, Inc.UEHG KinderCare Education LLC; KC ME Holdings, Inc.; And Their Wholly OHned Subsidiaries POLICY NUMBER See Page 1 650 WE Holladay Street, Suite 1400 Portland, OR 97232 CARRIER NAIC CODE EFFECTIVE DATE: See Page 1 See Page 1 See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance KinderCare Education LLC KU Education LLC KinderCare Learning Centers LLC KinderCare Education at Work LLC KCE Champions LLC KC HER Holdings, Inc. REE Investment LLC BEE Holdco, Inc. REE Midwest, Inc. BEE Southeast, Inc. D/B/A KinderCare Learning Center KinderCare Education at Work Knowledge Beginnings',, The Grove School Cambridge School . Champions Rainbow Child Care Center TIE Learning Center Alexander's Academy Coverage for abuse, neglect and molestation is included within the Commercial General Liability Insurance policy evidenced herein. Workers' Compensation for all states except Monopolistic states. INSURER AFFORDING COVERAGE: Arch Indemnity Insurance Company POLICY NUMBER: 74WCII000610 EFF DATE: 12/01/2018 EXP DATE: 12/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation & E.L. Each Accident $1,000,000 Employers Liability - E.L. Disease-Pol Lmt $1,000,000 Per Statute E.L. Disease -Each Emp $1,000,000 NAICII: 30830 The ACORD name and logo are registered marks of ACORD SR ID: 16982243 BATCH: 939106 CERT: W8768785 CORPORATION. All rights reserved.