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HomeMy WebLinkAboutWendy's - 12/31/2020FOOD ESTABLISHMENT PERMIT APPLICATION (Applicati-S on must be submitted at least 30 days before the planned opening date) W � o Establishment Name r) - ! � � \Q U Establishment Address UL. yjCACWA 001're/ p Establishment Mailing Address (if d'iifferent) 01N,�, DU16 _ hOMOL S yvct -D 0 Establishment Telephone No ` S�f j - �r�(! Applicant Name & Title: jt 1xx (Vikt.l SmiY "-p4�� s� v��l"" - AICC OUN-ii n-'I Applicant Address t mo. Il v%�tk Applicant Telephone No.: (QI+- 1-ULV-3 Lbv 24 Hour Emergency No.: 5 ��-� I �_ � �r j Applicant Email bu'sihaS� Lp�Y) Z VV i Owner Name & Title (If different from applicant) Wt'/i 6JA tiS PY-Dee -h C gj L.L."G Owner Address v 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. .- ACorporation Name p�pi Title Address An Individuals a A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, "person in charge, supervisor, manager etc) _ �) Namme & Title: En U& I ty 1v1 1 V1 a-?� Address: (-u4 U)PeI YJ liY1I1� Telephone No; 1 24 Hour Emergency No: FAX: (,l E-mail: S} Qv °L 4 ���Q l; W iX1C AILS . LOYI) Alt E-Mail: CJ District Or Regional Supervisor (if applicable) Name & Title: j�-J�LA BA*I -LU Address:3 cowhSUL. RA 4960 (J Telephone No: 1 �,�� 4' 24 Hour Emergency No: FAX: V I l -ISIO' `t - E-mail: NSW- boa Lim S,%01-Yl Food Establishment Information WATER SOURCE �lt L SEWAGE DISPOSAL: 1 l\ DEP Public Water Supply No: (If applicable) No of Food Employees; DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Persons) In Charge Certified in Allergen Awareness Training I Name of pest control company routinely inspecting the premises for evidence of pests C3 If there is seating for 25 ppple or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. Yes I Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: V Annual '-� �Retail Food $125,00 Mobile Food Consession P Tem orary ✓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 I Temporary End Dale: I Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: I Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 Caterer$3500 Food Operations: Definitions.. PHF Potentially hazardous food (fimeltemperafum controls required) (Check all that apply)' Non PHFs - non -potentially hazardous rood(no lino himperalure controls required) RTE -mady-to-eat foods (Ex. sandwiches, salads, muffins which need no turtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs aHFCooked 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 of Nan PHF and Non - Customer Self -Service contact alternative, time as a public health >. �Perishable Foods Only Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of I 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: R,I LY� Mi/Cz•` Pursuant to MGL Ch,62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have tiled all state tax returns and paid state taxes required under law. 4'L- '] 1 nW I I �� Social Security Number or Federal ID: �1 ,7^�"�O�l,r�'ppr��{��;( /`f,�M �,.,/�fN�/,� Signature of Individual or Corporate Name: I'ht YVl/hlyl>~`1J l-�Vltvli.n.vfy"a--.. Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix In Conjunction with Food Estahliahment Permit To the Board of Health at the Town ofAlansfeld: /n accordance with the provisions ofsection 65H of Chapter 94 of the General Lmvs, as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license for a WHOLESALF✓RETAIL manufacture offrozen desserts and ice cream mix and submits the following information: t 1. Food Establishment Name 00n, �Q"f _ 2. Establishment Address: �{�-"1 -'C__ DYtvv 3. Location of Plants/ dessert machines: 4. Names of brands and trade or corporation name, if any, under which the products are to b 5. Number and capacity of freezers and f S ____ Fee: ($25.00 perfeezei) $ r�#Type) 6 Is the mix purchasA If so, from whom purchase 1 Or\ W � 7. Is the mix pasteurized? 8 Number of gallons of frozen desserts and/or ice cream mix sold in Massachusetts during the previous licensing period 9. Is the plant/ dessert mcachine constructed and equipped as provided in the regulations 10. Certified laboratory used for monthly testing 11. Regulations can be found at https://www.mass.gov/regulations/105-CMR-50000-good-manufacturing-practices- for-food. Please indicate if you would like a copy of the regulations emailed to you I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conditions. I attest that the information stated in this application is true and accurate under the pains and penalties of perjury. 01 (Cofnpan' owner/officePs signature) (DATE) (Title) (City or Town) 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. 1AV WM s Comm� Signature of Individual or Corporate By:/Corp4;rate Officer (Mandatory, if Applicable) 11 — U W I I v V "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. C:\Users\sleae\Desktop\Scotts Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name:-2Y�`�/ C �n Address: I4q- " - �)C\SJ4 ((t ` 1c� YEN Mailing Phone/Fax Number:_ (56� 33q- -7A Email: G 5Sc%cc I - lic-A tacv4gq Coyne Contact Person/Title for Grease Traps; A ma, "t t - �0 ( 11p1 Name of Company scheduled to pump internal grease trap(s) monthly: 4pqsySe +J icd Name of Company scheduled to pump external grease trap quarterly: L�C- l 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 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018, In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date l 0? U I `1)19 Print Nameb L h 1V lril DI W' , I\oAto wn Facility Operational Information Please answer all questions in this section. If an Item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. 1 1 Seating Capacity (per Fire Department Regulation): (7 O 6-)� d Seating Capacity (Actual Count): 70 \y�iCAso �P i Or rc S.ea&s Normal Hours of Food Preparation/Service: Monday QAI_�_1_4A Thursday I r� Av Sunday A_ Tuesday k?A1_sl_A "\ Friday _j kA Wednesday -\fyl`1- A M Saturday _I PA \" 1 (l' Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU _ 3 compartment sink _ Handwashing sink a Commercial Dishwasher 1 Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators 3 Grills or Ovens _ oL Exhaust Hoods Floor drains Other: How are hood vents cleaned? 1(i.e., inthree(3) bay sink, off site, by private company): �v� C���LYC ffF t✓�eyW_t�L` �T` a� �%t,�$SL1 . l�.s_ �1w�S Ut^� C`�c�__.—_ Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes No _ �/A Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 6A e- Please list fixtures attached to each grease trap Grease Trap 1 `j> Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does thisestablishmenthave an outdoor Grease Removal Unit (GRU/Interceptor)? Yes _ No Size (�Q _ gallons Where is the existing outdoor GRU located?�q��p {gyp j cF, hig 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? Where is the grease storage unit located?�Rw How often is this grease storage unit emptied? G Please list the vendor who removes the waste: 3 The Commonwealth of Massach usetts Department of IndustrialAccidents u,p Office of Investigations 1 Congress Street, Suite 100 Boston, AM 02114-2017 www mass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: The Wendy's Company Address: One Dave Thomas Blvd City/State/Zip: Dublin, OH 43017 Phone #: 614-764-3100 Are you an employer? Check the appropriate box: Business Type (required): 1.9 I am a employer with -30 employees (full and/ 5. ❑ Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7. El Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]** We by 11.❑ Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box 91 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 k 1. I am an employer that is providing workers' cornpensation insurance for my employees. Below is the policy information. Insurance Company Name: Willis Insurance Services of Georgia, Inc. Insurer's Address: c/o 26 Century Blvd P.O. Box 305191 City/State/Zip: Nashville, TN 37230 Policy # or Self -ins. Lie. # WCU C65438082 Expiration Date: 1/01/2020 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, under the pains and penalties of perjury that the information provided above is true and correct. 1/3/2019 Phone #:614-764-3100 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www.masa.gowam Page 1 of 2 A� " CERTIFICATE OF LIABILITY INSURANCE oA E(M/2018 12/26/2018 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 endomement(s). PRODUCER Willis Insurance Services of Georgia, Inc. c/o 26 Century Blvd CONTACT NAME: _ A/CNNr, Es, 1IE -877-945-7378 FAX No: 1-888-467-2378 P.O. Box 305191 E-MAIL ADDRESS: certificates@willis.com Nashville, TN 372305191 USA INSURERS AFFORDING COVERAGE NAICW INSURERA: ACE American Insurance Company 22667 INSURED The Wendy's Company One Dave Thomas Blvd INSURERS: North American Elite Insurance Company 29700 INSURERC: ACE Fire Underwriters Insurance Company 20702 INSURERD: Dublin, OR _ INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: W9645018 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. ILTR TYPE OF INSURANCE ADOL INSD SUBR D POLICY NUMBER PMIDDITFF MM/DDIYYYY POLICYEXP MMIDDfTfV( LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE � OCCUR DAMAGE TORENTED PREMISES Ea occurrence $ 2,000,000 _ X MED EXP(Any one person) $ 0 A $2,000,000 Per Location Aggregate - PERSONAL E ADV INJURY $ 2,000,000 —XI XSL G71231367 01/01/2019 01/01/2020 AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 20,000,000 GENT %< POLICY [] JECT LOC PRODUCTS -COMNOR AGG $ 5,000,000 SIR S 500,006 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident)_ $ 2,000,000 X BODILY I NJURY(Per person) $ ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS ISA H2528015 01/01/2019 01/01/2020 BODILY INJURY Per accident ( ) $ PROPERTY DAMAGE Per accident S HIRED NON -OWNED AUTOS ONLY AUTOS ONLY _ E X UMBRELLALIAB X OCCUR EACHOCCURRENCE $ 5,000,000 AGGREGATE 5 5,000,000 E%CESS LIAB CIAIMS4ADE UNB 2000696 01 01/01/2019 01/01/2020 DED I X I RETENTION$ 25,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBEREXCLUDEO? N/A MR C65938124 Ol/01/2019 Ol/01/2020 X SEATUTE EORH EL. EACH ACCIDENT_ $ 1,000,000 E.L. DISEASE - EA EMPLOYEE 5 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OFOPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1, 000 , 00 - C Workers' Compensation - WI SCF C65438161 01/01/2019 01/01/2020 E.L Each Accident $1,000,000 Per Statute E.L Disease - He Ear,J $1,000,000 E.L Oieease - Pol Li $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SEE ATTACHED CERTIFICATE HOLDER 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. The Wendy's Company AUTHORIZED REPRESENTATIVE One Dave Thomas Blvd �JIFpyj-. Dublin, OH 43017 ^`S.VI ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD -- To1 17301293 eATce: 1000978 AGENCY CUSTOMER ID: LOC #: A oRo® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis Insurance Services of Georgia, Inc. The Wendy's Company One Dave Thomas Blvd Dublin, OR POLICY NUMBER See Page 1 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance The following entities are included as additional Named Insureds under the above referenced policies of insurance: Wendy's BEV Guarantor, LLC, Wendy's Funding, LLC , Quality Is Our Recipe, LLC and Wendy's Properties, LLC. INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WCU C65438082 EFF DATE: 01/01/2019 EXP DATE: 01/01/2020 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Workers Compensation EL Ea. Accident: $1,000,000 Per Statute EL Disease-Pol. Lim.: $1,000,000 EL Disease -Ea. Empl.: $1,000,000 ADDITIONAL REMARKS: Workers Compensation Policy #WCU C64625275 applies to the following states: CO/FL/GL/IL/LA/MA/NC/NY/OH/VA/WV $500,000 SIR ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3R ID: 17301293 BATCH: 1000978 CERT: W9645018 Wendy's Officer Listing Full Name Title Deepak Ajmani SVP - US Company Operations James A. (Jim) Kelly VP - Restaurant Services Edward J. (Ed) Rafter DVP Operations Gavin Waugh VP - Treasurer & Enterprise Risk Management Elizabeth Geraghty VP - International Brand Marketing & Operations Stephanie L. Shaw VP - Enterprise Solutions & Analytics Kurt A. Kane EVP, Chief Concept & Marketing Officer Robert D. (Bob) Wright EVP, Chief Operations Officer Juanita Diane (Diane) Weed DVP Operations Carlos R. Ribas VP - International, Managing Director, LAC Robert (Bob) Hegedus VP - Restaurant Technology Operations Luke F. Sweeney DVP Operations Rajeev Sabharwal VP - International, Managing Director, AP/EMEA Juan Carlos (Carl) Loredo VP - Brand & Advertising Kris A. Kaffenbarger VP - Global Systems Optimization, Franchise & Portfolio Mgmt Matthew C. (Coley) O'Brien Chief People Officer Liliana Maria Esposito Chief Communications Officer Michael G. Gist DVP Operations Mary S. Winters Chief Public Affairs Officer Tammy Branham DVP Operations Todd A. (Todd) Penegor President & Chief Executive Officer Abigail E. Pringle Chief Global Development Officer & International Jeffrey Roberts DVP Operations Helena Josue VP - Human Resources Gunther (GP) Plosch Chief Financial Officer Lindsay J. Radkoski VP - Brand Stephen Piacentini VP - Restaurant Development Eric J. (EJ) Wunsch Chief Legal Officer and Secretary Leigh A. Burnside SVP - Chief Accounting Officer Frank J. Leary VP - Customer Experience Zacharias Athanasios (Zack) Kollias SVP - US Franchise Operations Aaron Kale VP - Tax Richard W. Hopkins DVP Operations Laura D. Titas Chief Digital Experience Officer John yh Li VP - Culinary Innovation Jorge Antonio Hernandez VP - CA Paul Hider SVP - Operations 5/13/2019 m W �' f W -�` N n `2 Z � � W .2 rV JJ V J W z 1 4 C CD N CD CDd N r d m 75 W _ L E d > Z C N L G d Z 0 (� CL •' Lj Q lL 4� o y". a — z