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HomeMy WebLinkAboutChipotle Mexican Grill #1113 - 12/31/2020I� FOR BOARD OF HEALTH USE ONLY Permit # Issued rUUU EJ I /At5LI0r1IV1EIV I FERMI I /ArrLIUM I IUIV (Application must be submitted at least 30 days before the planned opening date) 1Q Establishment Name G(,,am (cc mr'x Corn ✓ (� # � 2J Establishment Address Z$ 7 s 6,,,m Establishment Mailing Address (if differ nt) eo (3oX ��25�o6/�luvh�/u4� Establishment Telephone No SO$ -C?9 " Z-50b1k) Applicant Name & Title: 42�A k's�Ckto' Applicant Address ro 6ax tsV�?66I WUVVtbttisl" Applicant Telephone No.:Gtq-31z-?K13 24 Hour Emergency No.: Applicant Email �� �) ���ip { I o , GOM Owner Name & Title (If different from applicant) �( irY( (J ' D er1 Fec v�. '12- f a Owner Address Gi (O t►O6vi(�cr'`b �✓ti�' Or, PFnr'� 1 Cam' Owner telephone number Owneremail Qco'�V,,¢)reew 0. co"-\ OM Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or L11 An Association partner. LJ A Corporation Name , Title Address An Individual UIC 1�O1A!"GIC—�— L7 A Partnership motet ! a f� Other legal Entity Cr 1 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: r?vw,ndo'V\ ,mc,,14Q Address: 5 (6 Jos cnwl S d rocr b j �e �o �� I ✓� ei 2 7(p� Telephone No: 774-- 9a S —57,15 24 Hour Emergency No: FAX: I t r (c ov".r c,(c3c�w lIt,• cx) W E-mail: ✓ `" Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: �5 �vs�OSi'�r�us�pv�u�nf Telephone No: /) t7 (_ 3 M 379�6`6 24 Hour Emergency No: FAX: E-mail:'t Gcyy�jt aJ�y, Y t C'0VVj Food Establishment Information WATERSOURCE: �> r'L SEWAGE DISPOSAL: No. of Food Employees: 13 DEP Public Water Supply No: (If applicable) DAYS/HOURS: (dew 5„ r� IOi�d$g �n•Iop✓"� Name of Person(s) In Charge Certified in Food Protection Management: V r~,80'^ Wk1f,✓OC* o Name of Person(s) In Charge Certified in Allergen Awareness Training w-C>'-C_C'W0 Name of pest control company routinely inspecting the premises for evidence of pests-lccs G 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. XYes Does this establishment require a FOG permit? Y'S% If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual 0 Retail Food $125.00 [] Mobile Food Consession Temporary -J Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 - Manufacture Frozen Desserts/Ice Cream Temporary Start Dale: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: I, ;] Food Service up to 201 + $300.00 Li 'I] Pushcart $50.00 # of Pushcarts: Temporary Time: (j Supermarkets $400 ❑t Residential Kitchen $100.00 Rain Date: XMilk & Cream $10.00 Ed Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(time4emperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no limellemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs l _l PHFCooked To Order ( ) Hot PHF Cooked and Cooled or Hot Held U Sale of Commercially Pre -Packaged PHFs tom' Preparation of PHFs For Hot And for More Than a Single Meal Service 0 Delivery of Packaged PHFs Cold Holding For Single Meal Service �] PHF and RTE Foods Prepared For Highly Fl Sale of Raw Animal Foods Intended Susceptible Population Facility n Reheating of Commercially to be Prepared by Consumer U Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours I] Customer Self -Service and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Nan - contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) E] Preparation of Non-PHFs Retail Sale I -:] Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale j Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities r] 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 establishment operation will cor board of health on how to obtaii Signature of Applicant: y of the information provided in this application and affirm that the food 1 105 CMR 590.000 and all other applicable law. I have been instructed by the of 105 CMR 590.000 and the federal Food Code. Pursuant to MGL Ch.62 s�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 r ired under law. Social Security Number or Federal ID: j l � t f/ P Co/e j 8 / / /+ Signature of Individual or Corporate Name: ��.Y� 7 �v �� l� / O"C l ✓YXJ't (-,—(-,ilJ 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 Ca (o✓rrncj0 (,u, , `*Social Security No. (Voluntary) or Federal Identification Number By: iWorate 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 Daouments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/Food Establishment Name: f 'W,,64[e, rVE61CCu✓y (7�t'� J4 Ill 7 N. Mailing Phone/Fax Number: G(N - 5(8-7413 k5 , d Email: UC- r--,4 <i 'A rcd.OW d441 G - C�V M Contact Person/Title for Grease Traps � 5(' F�f tC' Ito ✓A S6e4w"'& i�rJ+'k 6uj Wrn� 4v vV1 S Name of Company scheduled to pump internal grease trap(s) monthly: Wiwj P"Iyw Name of Company scheduled to pump external grease trap quarterly: W i ✓G° 9i ✓ (i✓ 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,4t the information submitted in these documents is true, accurate and complete. Date II 2J lq Print NarYfe )LFi") hPet&(P,, 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. Seating Capacity (per Fire Department Regulation): ( t)o Seating Capacity (Actual Count): 6 Z Normal Hours of Food Preparation/Service: Monday iG:WsuL41—IaPCAI Tuesday Thursday Friday Sunday \\, \l Wednesday Saturday N f (. 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 I Handwashing sink Commercial Dishwasher Bar sink ( Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods Z Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): art ✓k"(4,e(f, cps i,., C w I <irk_S Sc1411✓1 Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? nLuv�� �r�E 1'alOv) <11"I - 'e&' SGVgsOlf/`c(, Wr"SY`I1� 01 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 51A 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)? XYes No Size ( 5cl0 gallons ,/ Where is the existing outdoor GRU located? (091A )S icoc oek) r � Ig 41-6 iL 71J— u! ` ljly` 9 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 Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: The Commonwealth of Massachusetts m Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 m Boston, MA 02114-2017 t www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Chipotle Mexican Grill of Colorado, LLC 10 Newport Center Drive City/State/Zip: Newport Beach, CA 92660 Phone 9:6143187413 Are you an employer? Check the appropriate box: Business Type (required): 1. 0 I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑✓ Restaurant/Bar/Eating Establishment 2. ❑ 1 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.] 12.0 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 an; an employer that is providing workers' compensation insurance for my employees. Below is the policy infornation. Insurance Company Name:Safety National Casualty Corporation Insurer's Address:1832 Schuetz Road City/State/Zip: St. Louis, MO 63146 Policy # or Self -ins. Lie. OLDS4047264 Expiration Date:10/1/2020 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 cerd ider the pans and penalties of perjury that the information provided) above `is true and correct. Sinnafiire� Official rise 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 #: 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 a joint 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 bum 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 7/2010 U 5W I Customer Service Report Schedule Now for Service Nov 2019 Call (800) 499-1682 Workorder# 0210164364 Customer Since: 2012 System Owner System Location river i waste oc, - ch'pot IledI I 11 HALE t IQ R,,,,i "' 111i 2H7 School Street Suite JO1 MA 020,48 P"A F3ank, Ili 0 1 7f I pl,e' Road (-, 1 5 - 14 '-',; Service Date: THU 08/08/2019 07:00 AM Frequency: 14.w-h I i 75ny; Household Occupancy Service Type: Trz.,, Previous Service: r-7, I I 1 6 Approx. Gals: i5oo CCLS; A lb i I Depth Below: Custom Clean: !q " 18 1 1 Cust Home: 11 Fitter: 0 20 lA iF I J I Township: Inspection/T5: I 'R 1,3 1 County: B I Build Up: Description Qty Unit Price Ext Price Score From Table 15DO.00 Garbage Disposal? 1,"el Energy System Age , 10 Years? Seasonal Occupancy? Bacteria Additive Used? Total Adjustments Net Score Score Service Every: 8 I v")n 0 System Normal Keep Your system healthy by following these 3 steps: Schedule Now for Service • Regular Service Nov 2019 • Use CCLS Bacteria Additive Cal( 499-1682 • UseaFiltel (800) El Excessive Solids Use CCLS Bacteria Additive Payment Detail: rr", Customer not on site 0 Heavy Sludge Use CCLS Bacteria Additive [I Tee Missing/Broken Repair/Replace Tee 0 High Liquid Level Possible system failure. Call for evaluation or custom Clearing. 0 Distribution Box Issue See notes below for details, [3 Missing Fitter Use a filter [] Other See notes below for details. To schedule repairs, custom cleaning, or system evaluation. call (800) 499-1682 x Technician :W1 r, li,, o Ai lived at: AN Left at:,�-; i ',ii Tech Notes I', I '-Selllv" ',r"; i t I, T Customer Signature WIND RIVER ENVIRONMENTAL AC<> Jb® CERTIFICATE OF LIABILITY INSURANCE DAT/YYYY) 11/2512/25/2019 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 Ileu of such endomement s . PRODUCER MCGRIFF, SEIBELS 8 WILLIAMS OF TEXAS, INC. 5080 Spectrum Dr., Suite 900E CONTACT NAME: ac° No Sid): 469-232-2100 ac No): Addison, TX 75001 El4AIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Safety Nafional Casualty Corporation 15105 INSURED Chipotie Mexican Grill, Inc. INSURER B:James River Insurance Company 12203 INSURER C 610 Newport Center Drive Newport Beach, CA 92660 INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:W2PV2E3 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, ITR TYPE OFINSURANCE O D S BR =0 POLICYNUMBER POLICY EFF MM/OD POLICY EXP MWOO LIMITS A GL4047266 10/01/2019 10/01/2020 EACHOCCURRENCE $ 5,000,000 tCOMMERCIALO5NERALLIASTLITY CLAIMS -MADE OCCUR PREMISES(EE. aaunenca $ 1,000,000 NED EXP(Anyone person) $ uor Uab$5M Each Occ/Aggregale PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE It 5,000,000 POLICY PRO- LOC ECT PRODUCTS - COMP/OPAGG $ 10,000,000 Policy Max General Agg: It 25,000,000 OTHER: A AUTOMOBILE LIABILITY CAS4047262 10/01/2019 10/01/2020 COMBINED LIMIT 1,000,000 X BODILY INJURY (Par person) $ MY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident) § HIRED NON -OWNED AUTOS ONLY ApUTOS ONLY Dad00 ONLY X y1,000 Coll Dad PROPERTY DAMAGE Per accident § X $ B UMBRELLA LIAB X OCCUR 000793742 10/01/2019 10/01/2020 EACH OCCURRENCE $ 10,000,000 X AGGREGATE $ 10,000,000 EXCESS LIAR CLAIMS -MADE DED RETENTION§ $ A WORKERS COMPENSATION ANDEMPLWERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDE09 � (Mandatory in NH) NIA LDS4047264 ((ADS) PS4047265 PADS) SP4061405 (Excess OH) 10/01/2019 10/01/2020 PER OTH- X STATUTE E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 S $ 8 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Store #: 1113 Location Address: 287 School Street, Mansfield, MA 02048 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. Town of Mansfield AUTHORIZED REPRESENTATIVE 6 Park Row-�r Mansfield, MA 02048 Page 1 of 1 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 0 0 a U K W � N o O M Q N N ' � r 0 d U i-{ O b U Q p Ul