HomeMy WebLinkAboutLonghorn Steakhouse #5296 - 12/31/2020119
®310.
FOR BOARD OF HEALTH USE ONLY Permit # Issf�ed Mop
' '� '
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)'`-.
Establishment Name: Longhorn Steakhouse #5296
Establishment Address: 390 West Street, Mansfield
Establishment Mailing Address(if different): P.O. Box 695016
Orlando FL
Establishment Telephone No.: 32869-5016 _ ? > r
Applicant Name & Title: RARE Hospitality International , Inc.
Applicant Address: 1000 Darden Center Drive, Orlando FL 32837
Applicant Telephone No.: 407-245-6787 24 Hour Emergency No.: 800-248-4918
Applicant E-mail: rhayward@darden.com
Owner Name & Title (If different from applicant):
Owner Address:
Owner Telephone No.:
Owner E-mail:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
An Association partner.
0 A corporation Name Title Address
O An Individual See attached List___--
O A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Joellen Sasville
Name &Title: 14 Crapo Street Apt#1
Address: Taunton, MA 02780
Telephone No: 24 Hour Emergency No: 580-261-8810
FAX:
E-mail: JSasvflle@loho.com
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title: Stephen Scott
Address: 1000 Darden Center Drive, Orlando FL 32837
Telephone No:407-245-4000 24 Hour Emergency No: 253-820-0989
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: Town
SEWAGE DISPOSAL:
Town
DEP Public Water Supply No: (If applicable)
No. of Food Employees: 47
DAYS/HOURS: Sun-Thurs 11AM-IOPM Fri -Sat 11AM-11PM
Name of Person(s) In Charge Certified in Food Protection Management:
See attached certificates
Name of Fier�on�s�n t�orpge Certified in Allergen Awareness Training
ee a tac e er r 1c tes
Name of pest control company routinely inspecting the premises for evidence of pests_ Ecopest-1-800-325-1671
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. IN Yes
Does this establishment require a FOG permit? Yes If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
[Annual
Retail Food $125.00
I] Mobile Food Consesslon
[] Temporary
li] Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
r_ Manufacture Frozen Desserts/Ice Cream
[Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
f�.. Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400
t�-. Residential Kitchen $100.00
Rain Date:
Lr-,�3T Milk 8 Cream $10.00
ID Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food himeRampemfure controls required)
(Check all that apply): Non-PHFs- nonpolenfially hazardous food(no fimeRempendure conhls required)
RTE- mady-toeaf foods (Ex. sandwiches, salads, mums which need no funherpmressing)
IN Sale of Commercially Pre -Packaged Non-PHFs [5PHFCooked To Order
Hot PHF Cooked and Cooled or Hat Held
Sale of Commercial PHFs ❑ ty Pre -Packaged g [.Preparation of PHFs For Hot And
for More Than a Single Meat Service
Cold Holding For Single Meal Service
Delivery of Packaged PHFs
PHF and SITE Foods Prepared For Highly
UK Reheating of Commercially � Sale of Raw Animal Foods Intended
Susceptible Population Facility
Processed Foods for Service Within 4 Hours to be Prepared by Consumer
I] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Customer Self -Service
El Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only 0 ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
[ Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
0 Prepares Food/Single Meals for
Q Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
1, 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. 1 have been Instructed by the
board of health on how to ptltein 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 slate taxes required under law.
Social Security Number or Federal ID: 58-1498312
Signature of Individual or Corporate Name: RARE lloshitafi!X International, Inc.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
UlfBoston, MA 02111
www.mass.gov/din
!Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: RARE Hospitality International, Inc. dba LongHorn Steakhouse #5296
Address:
City/State/Zip: Mansfield, MA 02048 Phone #: 508-261-8810
Are you an employer? Check the appropriate box: Business Type (required):
1. ® I am a employer with 55 employees (full and/ 5. ❑ Retail
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]**
4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care
with no employees. [No workers' comp. insurance req.] 12.0 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: XL Insurance America, Inc
Insurer's Address
City/State/Zip: Stamford CT 06902
Policy # or Self -ins. Lic. # RWD3001138-03 Expiration Date: 6/1/2020
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 certif�y,�{nder the pains and penalties ofperlury tlmt the information provided above is true and correct.
FdAh�E HOSPITALITY INTERNATIONAL. INC.
Phone #: 800-248-4918 x6787
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 Person: Phone #:
wwv .mass.gov/dia
A`6R�® CERTIFICATE OF LIABILITY INSURANCE
DOSM2019Dmm
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(les) 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 endorsements).
PRODUCER
Marsh USA, Inc.
3031 N. Roc Point Drive Weal, Suite 700
99
Tampa, FL 33607
Attn: Ti mpa.cerlrequesl@manh.00m
CONTACT
NAME:
-_
PHONE FAX
AN: Not,
E-MAIL
Aaoaess:
INSURERS AFFORDING COVERAGE
NAICd
INSURER A; ACE Property & Casualty Insurance Company
20699
C1,1101737850-GAWU-19.20 MULTIP MULTIP
INSURED arden Restaurants Inc.
INSURER a: Greenwldl Insurance Company
22322
INSURER C: XL Insurance America In.
24554
GAIN, Inc.
INSURER D: XL Spedfuly Insurance Company
37885
1000 Darden Center Or
OrlandGFL 32837
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-004376596.14 REVISION NUMBER: 6
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 NSR
ADOLTYPEOFINSUNANCE man
un
POUCYNUMBER
MPMLDDVYYv
MPOLIOYEXP
LIMITS
B
X
COMMERWALGENERALLIABIIJTY
CLAIMS -MADE rx-1 OCCUR
LIQUOR LIABILITY
RGE3001137-03
06101019
0610112020
EACHOCCURRENCE
$ 1,000.000
PREMISES Eeocommrrce
S 1.000,000
X
MEDEXP Anyone
$
PERSONAL&ADVINJURY
$ 11000,000
GENY AGGREGATE LIMIT APPLIES PER:
X POLICY ❑JEr° LOC
OTHER:
GENERALAGGREGATE
S 5,000,000
PRODUCTS-COMP/OPAGG
$ 5.000,000
SIR
$ 1,000,000
B
AUTOMOBILE LIABILITY
PANYAUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED X NON -OWNED
AUTOSONLY AUTOS ONLY
HAD 377 03
06I01n019
O61D1020
COMBINED SINGLE LIMIT
Ea accidenli
$ 2000ggg
BODILY INJURY(Per Pare.)
S
BODILY INJURY(For ecadenl)
$
PROPERTYOAMAGE
ParrucIrf 1
$
X
UMBRELLALIAB
EXCESSLIAB
N
OCCUR
CLAIMS -MADE
XOO G281233B3004
06101/2019
08ro1020
EACHOCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
090 1 X I RETENTION52501)5
$
C
0
D
WORKERS COMPENSATION
MIDANDEMPLOYERS'LIABILITY
EM ILOYE S-LIABLITY acunvE YIN
O WROPUEMBERARTNE IEX
(Mandatory In NH)
It deeoteonder
DESCRIPTION OP OPERATIONS below
NIA
RWD300113B-03(ADS)
RWR3001139 03 (M. AK)
RWE943548003 (OH, WA)
SIR: $1.000.000(OH, WA)
06101n019
O6ro1n019
06/012 0
O6ro1n020
O6roin020
X PER TH-
STATUTE R
E.I. EACH ACCIDENT
$ 21000,000
E.L.OISEASE-EAEMPLOYEE
$ 2,000,000
E.L. DISEASE -POLICY LIMIT
S 2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD d(If, Addi lonal Remarks Schodule, maybe attached If more apace is mqulnd)
Sao A9shed.
This cedificale cancels and supersedes all previously issued ceNficades.
CERTIFICATE HOLDER CANCELLATION
The Commonwealth of Massachusetts
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Office Investigations
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
600 Washington Street, 7th Street
ACCORDANCE MTN THE POLICY PROVISIONS.
Boston, MA 02111
AUTHORMD REPRESENTATIVE
of Momh USA Inc.
Manashi Mukhedee
m 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
AC4OROe
L�
AGENCY CUSTOMER ID: CN101737850
LOC#: Atlanta
ADDITIONAL REMARKS SCHEDULE
Page 2 of 2
AGENCY
NAMEDINSURED
Marsh USA, Inc.
Darden Restaurants Inc.
GMRI, Inc.
1000 Darden Center Or
POLICY NUMBER
Orlando, R 32837
CARRIER
NAIC CODE
EFFECTIVE DAM:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
0141901Me Garden. 60 North Dadmauth Mall, North Damwuth, MA 02747
#1436 Give Garden, Newpod Ave, SOOAtee6ao. MA 02703
0460 Give Gerdes, 1380 Boston Road Springfield, MA 01119
W51I Me Gordon, i Worchester Road, FiaMngham, MA 01701
4152301Me Gordon, 10951yennough Road, Hyannis, MA D2601
#16260fwa Gordon, 728 Donald Lynch Blvd., Marlborough, MA 01752
#163901Me Garden, 422 Middlesex Road, Tyngstioro, MA 01879
in644 Olin Garden, 1013 County Street, Taunton, MA 02780
0165901hre Garden, 401 Techrrobgy Center Drive, Stoughton, MA D2072
in674 Oliva Gorden, 110 Agree Road. Dorchester, MA 02125
01686 Chas Garden, 30mhard Hill Park Drive, Leominster, MA01453
#173DChun Garden, 102Colony Place Road, Plymouth, MA 02360
0180401Me Garden, 919 Riverdale Street West Springfield, MA 01089
#180001iva Gordon, 392Palrot Place South, TS Building, Foxboro, MA 02035
#1825DINO Garden, 90 Pleasant Valley Avenue. Methuen, MA 01844
19606Olive Gordon. 7Toblas Boland Way, Womwster, MA01844
4187401Me Garden, 153 Andover Street, Danvers, MA 01923
43048 Bahama Susan, 413Middlesex Road, Tyn9sboro, MA 01879
#8326Yard Haute, 2410Legaq Place, Dedham, MA 02026
#8336Yard House, 8336.126 Brookline Avenue, Boston, MA 02216
ME Yard Rom, 340MMket Sheer Building 3200, Lynnfed, MA 01940
#5140 Long Hon, 250 Franklin Village Drive, Franklin, MA 02038
#5145 Long Hom, 227 N Main Sheet Leominster, MA01453
#5148 Lang Hom, 401 Park Drive, Boston, MA 02215
#5156 Long Horn, 191 Boston Post Road W, Marlborough, MA 01752
95168 Long Hour, 1250 S Washington Steel Fashion Crossing Mall, North Attleboro, MA 02760
#5181 Long Horn, 69Plaistow Food. Haverh1u, MA 01830
#5196 Lon Horn, 1105 PMerdale$Vast West6pringfald, MA01D89
#5226 Long Horn, 70 Warsonster Providence Ddve, Sinte635 Millbury, AN01527
#5233 Long Hom, 800 Route 44, Raynham, MA 02767
45284 Long None, 11910Andover Sheaf Tewksbury, MA 01876
95296 Long Horn, 390 West Street Mansfield, MA 02048
#5310 Lang Horn, 125Church Street Pembroke, Me 02359
95323 Long Hom, 2421 Cranberry Hwy. Suite460, Wareham, MA 02571
#5325 Long Hour, 39 Walkers Brook Drive, Readhg, MA01667
#5518 Long Hour, 80 Highland Avenue, Seekonk, MA 02771
#8004 Copse GOD, 250 Boylston SaeeL Chestnut HID, MA 02467
#8028 Capital Grille, ID Wayside Road, Burlington, MA 01803
08047Cat Grille, 100 Boylston street, Hynes Convention Ch., Boston, MA 02115
#4538CapiW Gods, 220 Boylston Street Chestnut Hilt MA02467
04530Seasons 52, 6Wayside Road, Burlington, MA 01803
f3dal3irtil
02008 ACORO CORPORATION. All
The ACORD name and logo are registered marks of ACORD
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.
Colleen Hunter Lyons, Asst Sec
RARE Hospital' Int'1 Inc v� Y
Signature of Individual or Corporate Name . Corporde Officer (Mandatory, if Applicable)
58-1498312
"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\sleite\Desktop\Scott's DocumentsUood Esmblisbmenm-Temp\TAX CERTIFICATION FORMAd
RARE HOSPITALITY INTERNATIONAL, INC.
OFFICERS AND DIRECTORS
Address all official correspondence to any of the Corporate Officers below to:
P.O. Box 695016, Orlando, FL 32869-5016
Name Title Residence
William R. While, III President, Treasurer 4035 Gilder Rose Place
and Director Winter Park, FL 32792
Joseph G. Kern VP/Secretary 112 Kennison Drive
Orlando, FL 32801
Colleen Hunter Lyons Assistant Secretary 11762 Aurelio Lane
Orlando, FL 32827
(RARE Hospitality International, Inc. is a wholly owned subsidiary of GMRI, Inc., whic
is wholly owned by Darden Restaurants, Inc., a publicly traded company)
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: RARE Hospitality International Inc. dba LongHorn Steakhouse #5296
Address: 390 W. Street Mansfield MA 02048
Mailing Address: Attn: Licensing #5296, PO Box 695016 Orlando FL 32869-5016
Phone/Fax Number: 407-245-6787 fax 407-872-3768
Email: rhayward@darden.com
Contact Person/Title for Grease Traps: SLM Michael Cooper 267-429-7431
Name of Company scheduled to pump internal grease trap(s) monthly: Windriver Environmental
Name of Company scheduled to pump external grease trap quarterly: Windriver Environmental
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 11/8/2019
Print Name Rita Hurd, Agent
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): 235
Seating Capacity (Actual Count): Same as above
Normal Hours of Food Preparation/Service:
Monday 11AM-10PM
Thursday 11AM-10PM
Sunday 11AM-IOPM
Tuesday 11AM-IOPM
Friday 11AM-11PM
Wednesday 11AM-10PM
Saturday 11AM-11PM
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
2
one
3 compartment sink
6
no
Handwashing sink
0
yes
Commercial Dishwasher
1
n/a
Bar sink
1
no
Mop Sink
0
no
Garbage Disposal
1
no
Ice Making Machines
1
yes
Fryolators
1
Grills or Ovens
2
yes
Exhaust Hoods
22
es
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
They are soaked at least 8 hours then ran through the dish machine
Is dinnerware pre -rinsed before being washed? X Yes
If yes, at what station/sink? Dish area in bus bucket
No
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to each grease trap
Grease Trap 1
Back of House 50 gal passive
Grease Trap 2
Back of House 50 gal passive
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
g Yes No Size gallons
Where is the existing outdoor GRU located? Dumpster Corral
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: Clemco, LLC
Property Owner's Address•390 West St PO Box 75 Mansfield MA 02048
Property Owner's Telephone Number: 508-339-6316
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located? Dumpster Corral
How often is this grease storage unit emptied? Monthly
Please list the vendor who removes the waste: Windriver Environmental
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