HomeMy WebLinkAboutCosi #209 - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit# lssued'q'
FOOD ESTABLISHMENT PERMIT APPLICATION e�
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name COST #209
Establishment Address 280 School Street, Mansfield, MA 02048
Establishment Mailing Address (if different) Cosi #209
500 Rutherford Avenue, Ste. 130
Charlestown, MA 02129
Establishment Telephone No 508-261-8740 Attn: Legal / Licenses
Applicant Name & Title: Vicki Baue, Vice President
Applicant Address Cosi, 500 Rutherford Avenue, Ste. 130, Mansfield, MA 02129
Applicant Telephone No.: 312-310-1336 24 Hour Emergency No.:
etcosi.com David Plocharczyk, Area Director, M: 856-770-4922
CosiL!censes@getcosi.com Email @g Paul Tobin, M: Dir. of Ops Services, M: 781-389-6960
vbaue@getcosi.com
Owner Name & Title (If different from applicant) Cosi, Inc.
Owner Address 500 Rutherford Avenue, Ste. 130, Charlestown, MA 02129
Owner telephone number 857-415-5000
Owner email: CosiLicenses@getcosi.com
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
El An Association
partner.
IA Corporation
Name Title Address
11 An Individual
Vicki Baue, VP, 500 Rutherford Ave., Ste. 130, Charlestown, MA 02129
David Polonitza, EVP, 500 Rutherford Ave., Ste. 130, Charlestown, MA 02129
El A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: David Plocharczyk, Area Director
Address: Cosi, 500 Rutherford Avenue, Ste. 130, Charlestown, MA 02129
Telephone No: 856-770-4922 24 Hour Emergency No: 856-770-4922 -David Plocharczyk
FAX: 847-580-4964 401.450-7718 - Jessica Savage
Onsite - Jessica Savage, General Manager
David. Plocharczyk@getcosi.com Coal #209 (Mansfield), ) , 280 School Street,
Mansfield, MA 021048; restaurant phone #
Alt E-Mail: Paul.Tobin@getocosi.com or 508-261-8740; restaurant email: xcb00209@getcosi.com
vbaue@getcGsi-.com
District Or Regional Supervisor (if applicable)
Name & Title: David Plocharczyk, Area Director
Address: Cosi, 500 Rutherford Ave., Ste. 130, Charlestown, MA 02129
Telephone No: 856-770-4922 24 Hour Emergency No: 856-770-4922
FAX: 847-580-4964 Alternate: Paul Tobin, Dir. of Ops Services
E-mail:osi, 500 Rutherford Avenue, Ste. 130,
-mail: David. Charlestown, MA 02129
M: 161-:RW-bVbU
Paul.Tobin@getcosi.com
Food Establishment Information
WATER SOURCE: TOWN
SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable)
No. of Food Employees: 9
DAYS/HOURS: Mon -Fri 7:30a - 9:00p, Sat. 7:30a - 8:00p, Sun. 8:30a - 8:00p
Name of Person(s) In Charge Certified in Food Protection Management:
Jessica Savage
David Plocharczyk
Name of Person(s) In Charge Certified in Allergen Awareness Training
David Plocharczyk
Name of pest control company routinely inspecting the premises for evidence of pests ECO LAB
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. Xl Yes
Does this establishment require a FOG permit? yes If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
FA Annual
❑ Retail Food $125.00 Mobile Food Concession
Temporary
Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00 o Manufacture Frozen Dessertslice Cream
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00 El Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 E] Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 D Caterer $35.00
Food Operations: Definitions. PHF Potentially hazardous food (timeRemperature controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous food(no tlme/tempereture controls required)
RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
Sale of Commercial) Pre -Packaged PHFs for More Than a Single Meal Service
y g � Preparation of PHFs For Hot And
Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
(� Reheating of Commercially 0 Sale of Raw Animal Foods Intended
Processed Foods for Service Within 4 Hours to be Prepared by Consumer El Use of Process Requiring A Variance
Customer Self -Service and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non- contact alternative, time as a public health
Perishable Foods Only i Ice Manufactured and Packaged for control)
i)q Preparation of Non-PHFs Retail Sale
El Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Pq Vacuum Packaging / Cook Chill
Cosi reheats food; oesn't
cook food onsite. ❑ Offers RTE PHF in Bulk Quantities i] Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Dale 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 1105 CMR 590.000 and the federal Food Code.
Signature of Applicant: ).-A Qic IICIA _, Vicki Baue, Vice President, Cosi, Inc.
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have riled all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID: 06-1393745
Signature of Individual or Corporate Name: COST, Inc.
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.
Cosi, Inc
Signature of Individual or Corporate Name
06-1393745
**Social Security No. (Voluntanj) or Federal
Identification Number
, Vicki Baue, VP, Cosi, Inc.
By: Corporate 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\Scott'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
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Cosi, Inc.
500 Rutherford Avenue, Ste. 130
City/State/Zip: Charlestown, MA 02129 Phone #:
857-415-5000
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑X I am a employer with 685 employees (full and/ 5. ❑ Retail
or part-time).* approx. 6. 0 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] $• ❑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,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: The Hartford
Insurer's Address: c/o Hays Companies, 133 Federal Street, 4th Floor
City/State/Zip:
Boston, MA 02110
Policy # or Self -ins. Lie. # 08WE ADOSE3 Expiration Date: 5/10/2020
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, wader the pains and penalties ofperjury that the information provided above is true and correct.
VP. Cosi. Inc. Date- 12/04/19
312-310-1336
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Fom Revised 5-26-05 www.mass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: Cosi #209
Address: 280 School Street,Mansfield, MA 02048
Mailing Address: 280 School Street, Mansfield, MA 02048, Attn: Legal / Licenses
Phone/Fax Number: Tel: 508-261-8740 Fax: 847-580.4964
Email: Restaurant: CosiLicenses@getcosi.com [Legal /Licenses: vbaue@getcosi.com]
Contact Person/Title for Grease Traps: Area Director: David Plocharczyk Licenses: Vicki Baue, VP
Name of Company scheduled to pump internal grease trap(s) monthly: _Raggs
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments
Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection
$50
container
Each grease interceptor/trap over 3
$50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the information submitted in these documents is true, accurate and complete.
Signed �� 'UC c &AA^ '� Vicki Baue VP Cosi Inc. Date 12/04/19
Print Name Vicki Baue
Facility Onerational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation): 85
Seating Capacity (Actual Count):
Z
Normal Hours of Food Preparation/Service:
Monday 7:30a - 9:00p Tuesday 7:30a - 9:00p Wednesday 7:30a - 9:00p
Thursday 7:30a - 9:00p Friday 7:30a - 9:00p Saturday 7:30a - 8:00p
Sunday 8:30a - 8:00p
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
1
Y
3 compartment sink
4
N
Handwashingsink
-0-
N/A
Commercial Dishwasher
1
N/A
Bar sink
1
N
Mop Sink
-0-
N
Garbage Disposal
1
N
Ice Making Machines
-0-
N/A
Fryolators
1
N
Grills or Ovens
2
N
Exhaust Hoods
4
N
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Cleaned every 6 months by a hood cleaning service.
Is dinnerware pre -rinsed before being washed? X Yes No
If yes, at what station/sink? First Sink
2
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site? 1 Internal
Please list fixtures attached to each grease trap
Grease Trap 1
under 3-bay sink (passive)
Grease Trap 2
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
X Yes No Size gallons
Where is the existing outdoor GRU located? outdoor trap
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owner's Name:_
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
N/A
Where is the grease storage unit located?
N/A
How often is this grease storage unit emptied?
N/A
Please list the vendor who removes the waste:
N/A
3
(Policy Provisions: WCOOOOOOC)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: SEE ATTACHED ENDORSEMENT
NCCI Company Number: 10448
Company Code: 9
e
�.m
is
1'1
Suffix
LARS RENEWAL
POLICY NUMBER: 08 WE ADOS_E_ 3
Previous Policy Number: New
1. Named Insured and Mailing Address: COSI INC
(No., Street, Town, State, Zip Code) 500 RUTHERFORD AVE STE 130
CHARLESTOWN MA 02129
FEIN Number: 06-1393745
State Identification Number(s): TIN: NJ 061393745000
Refer to the EXTENSION OF THE INFORMATION PAGE — WC990365.
The Named Insured is: Corporation
Business of Named Insured: Limited -Service Restaurants
Other workplaces not shown above: See Endorsement - WC990366
2. Policy Period: From 05/10/19 To 05/10/20 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: THE HAYS GROUP INC
133 FEDERAL STREET 3RD FLOOR
BOSTON MA 02110
Producer's Code: 08087820
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877) 853-2582
Total Estimated Annual Premium: $271,555
Deposit Premium:
Policy Minimum Premium: $985 CT (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by I�Fae�l If 05/28/19
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 05/28/19 Policy Expiration Date: 05/10/20
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