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HomeMy WebLinkAboutQdoba Mexican Eats - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. QDOBA RESTAURANT CORPORATION Whose place of business is: QDOBA MEXICAN EATS #2365 280 SCHOOL STREET PERSON(S) IN CHARGE: AUSTIN SCHLAK, MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-64 BOARD OF HEALTH AichaeCHeaCey, Chairman Milk & Cream t� :p .I FOR BOARD OF HEALTH USE ONLY Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned openinw,i ?'r Establishment Name: o U` NOV01 Establishment Address: P9 % .S'C,hVo Establishment Mailing Address(if different): 933a t� Establishment Telephone No.:C7�� Applicant Name & Title: i` 6V-Z°yt Vag Applicant Address: 9330 Talho0. �' /�",t • �Q� �%+t�t' M q',03 Applicant Telephone No.: t�5 c� 57l 3 3 h 3 24 Hour Emergency No.: L4-d-(')- &Ya j Applicant E-mail: U U t �aC (S II LL 1LtS �f u u(C t CU1G l CNvt Owner Name & Title (If different from applicant): Qr d ol)6t 'j ieua'U7 (2v P7/ce (/✓1 Owner Address: g330 I'/60rn Owner Telephone No.: e $e 'S -7 OwnerE-mail:S cn.f,lS�cCE/1f�� la' ]6r-G���`�Jo'�L�✓1 - J Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. UA Corporation Name Title An Individual Kt�f m — tfu r Address % �j�fl li-���G�L s'tip�GC El A Partnership3 t 0 a [ocC,a,s /Jl El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ��n[A/iGL/�� •ill ante �n/ Address: hirr buff �GQ l7 l� t fiiA o ,)-,-)U 3 Telephone No:24 Hour Emergency No: FAX: A OY-L- `/ E-mail: 1 00&3&Sid rVZ 7a,fUv✓t Alt E-Mail: District Or Regional Supervisor (if applicable) (� Name & Title: p I1 t i�NG �r� tv 1 Address: -7a Ica tiU( S-4- ILI,I,G���( !� r 141PI Telephone No: �JU'�a1 3((i(2 24 Hour Emergency No: FAX: OoYL,�, E-mail: My� , ari/ J (C �� <n eJ Le f-cJvvL Food Establishment Information WATER SOURCE: • SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Suppplly� No: (If applicable) DAYS/HOURS: VrtOn Sa �avvl-1(� j f l✓1 /� 30 �t,n — 7 3D�, Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. A LA SL�L Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ Location: Permanent Location Establishment Type ❑ Caterer $35.00 ❑Moblie Mobile Start Dale: ❑•Retail ( Sq. Ft) 4iilk & Cream $10.00 Mobile End Date: Food Service up to 100 INCLUDING ❑ Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 ❑ Food Service up to 101 -200 $250.00 ❑ Food Service up to 201 + $300.00 ❑ Supermarkets $400 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $50.00 # of Pushcarts: ❑ Residential Kitchen $100.00 ❑ Retail Food $125.00 ❑Retail Snack Food $50.00 Length of Permit: .R.,./, @y,Annual - ------ -- Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ---- — Food Operations (Check all that apply): De(niflons:PHF- Potentially hazardous food thmellemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, mums which needno Nrtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs -- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging I Cook Chill ..._.___—_-- ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Offers Raw Or Undercooked Food Of Animal Origin Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Ej Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Oul-Of-Date or Reconditioned Food ( To be completed by the Board of Health L Total Permit Fee: Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply 11�pith 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 590.00Q 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 fled all state tax returns and paid stale taxes required under law. nn (� (1 n � �) Signature of Individual or Corporate Name: Social Security Number or Federal ID: Q/! / N b 0'1 �S 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. y 1 Signature of Individual or Corporate Name By: Corporate Officer (Man atory, if Applicable) 8,q- /y30�a,5 `*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\ScotCs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Departntent'of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: 0MA AYI L4 Z L Y-C-4,230 - Address: ,_'�?PO SC 001 04 b100 City/State/Zip: :?I` r� G� �r}ti�l Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. a I am a employer with 7,2� employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/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, with no employees. [No workers' comp. insurance 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 #l. I out an employer that is Insurance Company Nair. Insurer's City/State/Zip: compensation insurance for my employees. Below is the policy information. v . ,� g / /� Policy # or Self -ins. Lic. # /✓L /�_c J3 3� 1 A Expiration 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 tine 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 ceer-tiifft,�under the pains and pe altiesgoft ierjeny that the information provided /above /is trite and correct CionarrrP- Date.- Phone #: 0 5V' S ? / — 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 www,mass.gov/dia Phone Client#- 43217R JACKIN1 ACORDT., CERTIFICATE 'OF LIABILITY INSURANCE DATE(M 9/26/2018YYY) 018 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lety Martinez Marsh & McLennan Agency LLC PHONE g58.242-5785 858.452.7530 A/C No E,d: AIC, No Marsh &McLennan Ins. Agency LLC _ E-MAIL Let Martinez@MarshMMA.com ADDRESS: Lety.Martinez@MarshMMA.com PO Box 85638 INSURER(S) AFFORDING COVERAGE NAIC If San Diego, CA 92122 ACE INSURER A: ns^y 22667 INSURED INSURER S : Indemnity Ins. Co. or North Am. Qdoba Restaurant Corporation Attn: Eva Gala INSURER C: 9330 Balboa Ave INSURER D: San Diego, CA 92123.1524 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. MSRR TYPE OF INSURANCE ADDLSUSR NSR WVD POLICY NUMBER MMIDDY EFF MM/DDYIYEYYV LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACHOCCURRENCE $ PREMISES Ea oocunence $ _ MED EXP (Any one person) $ PERSONAL &AOV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY r JECT LOG OTHER: GENERALAGGREGATE $ PRODUCTS - COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANYAUTO OWNED F SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per acodenl) $ PROPERTY DAMAGE PeracCident $ _ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ A B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? N (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WLR C6543331A WLR C65433394 9/01/2018 9/01/2018 09101/2019 09/0112019 X PER OTH- E.L. EACH ACCIDENT $1 DOD 000 E.L. DISEASEEAEMPLOYEE $1 DOD, 000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) FOR REFERENCE ONLY. FOR REFERENCE ONLY I 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S36927681M3647717 V1/SHLM �� ae CERTIFICATE OF LIABILITY INSURANCEa2.,18THIS IDDJYYYY) CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDEDOLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREHORIZEDREPRESENTATIVE 7HOLDER. OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must ave ADDITIONAL INSURED provisionorsed. IfSUBROGATION IS WAIVED, subject to the forms and conditions of the policy, certain policies may require an endorsement.nt on thiscertificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER AOn Risk Services Northeast, Inc. NEW York NY Office CONTACT NPHONE AME. AIC.W.EM): (866) 283-7122 .Nu,: (SOW-.,__,_... EMAIL AUDRESB: One Liberty Plaza 165 Broadway, Suite 3201 , INBURER(Si AFFORDING COVERAGE RAID New York NY 10006 USA INSURED INSURER A: QBE Insurance Corporation 39217 Odoba Restaurant Corporation 9330 Balboa Ave San Diego CA 92123-IS16 USA INSURER B: American Guarantee & Liability xns Co 26247 IN6URER C: INSURER D: INSURER E: INSURER F: ;am3ilyLN_II�a11d1.14: re 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 WfTH 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. Limits shown are as requested INSR TYPE OF INSURANCE INg VIVO POLICY NUMBER MAVOIT MWD LIMITS X GOMMERCW.GENERALLUSIR-ITY GLA- - EACHOCCURRENCE $1,000.000 CLAIMS,MADE ❑% OCCUR E PREMISES Ee oumnenm $1,000,000 MEDEXP(Anyonepeteon) $10,000 PERSONAL 6 ADV INJURY S1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER GENERA -AGGREGATE $2,000,000 POLICY ❑�Ea �tOC PRODUCTS-COMPIOPAGG S2,000,000 OTHER B AUTOMOBILE LIABILITY GLA-0781182-00 03/21 201 03/21/2019 COMBINED SINGLE LIMIT (So aworl)..,.-_. $1,000,000 BODILY INJURY ( Per p,R en) X ANYAUT4 BODILY INJURY (Per atddsel) OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUIOS NON-0WNED ONLY AUTOS ONLY PROPERTY DAMAGE Parettident A X UMBRELLALPB EXCESS LUIB % OCCUR CLAIMS MADE CCU1333423 SIR applies per policy ter 03 21 2 118 is & Condl 03 2 2019 ions EACHOCCURRENCE $2,000,000 AGGREGATE $2,000,000 DED X RETENTIoN WORKERS COMPENSATION AND EMPLOYERS' UABILON YIN AWN PROPRIETOR I PARTNER I EXE(UTNE PER OTH• STATUTEER EL EACHACLIDENT OFFICEMSMSER EXCLUDE% (MendsWry In NH) NIA El DISEASE£AEMPLOYEE H Yyes, Poc,R , WMer 0 5CRIPTION OF OPERATIONS "I"E.L DISEASE+v?LICY L.Mn DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, ABdPoonal RemurW Schedule, mey ha saached It more space Is required) Proof of Insurance I G O Z u U A. .. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Qdoba Restaurant Corporation AUTHORIZED REPRESENTATIVE Attn: Leslie Whittaker, Risk Mgmt. 9330 Balboa Avenue r� eJitA �r A/!M San Diego CA venue 1516 USA ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD ONN CERTIFICATE OF PROPERTY INSURANCE D08/30%DO 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. PRODUCER AOn Risk Services Northeast, Inc. New York NY Office One Liberty Plaza 165 Broadway, Suite 3201 New York NY 10D06 USA INSURED Qdoba Restaurant Corporation 9330 Balboa Ave San Diego CA 92123 1516 USA INSURER F: (866) 283-7122 ) /eMr w., (800) 363-0105 S70000075088 Zurich American Ins Co LOCAnON OF PHEMIBERV DESCH(MON OF PROPERTY IARW, ACORD 101, MdXIMPI Ranedu Schedule, N R mWay It nx,ulr ) 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 TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE(MM/DONYYY) POLICY EXPIRATION DATE (MWDD/YYYY) COVERED PROPERTY LIMBS A X PROPERTY CAUSES OF LOSS DEDUCTIBLES ER P NCPco. Prop cvg 1 3 3 1 BUILDING PERSONALPROPERTY BUSINES9IVCOME EXTMEXPENSE RENTAL VAt UE BIANKETBU LOING BLANKET PENS PROP BLANKET BLDGa PP Flood AOBIeBale BASK; BUILOINO BROAD SPECIA CONTENTS EANTIIOUME WIND X $76,000.000 X FLOOD end BAPP Dad % T2$,000.R00 CAUSES INLAND MARINE OF LOSS NAMED PERILS TYPE OF POLICY POWCYHUMBER CRIME TYPE OF POLICY Qrnl, f$ R ?"PIIPI@RY EQUIPMENT BREAKDOWN SPECIAL CONDRIONS'OTHER r.OVERAGES(ACORO 101. Mdlllonel Romerke enhedU4, meVM nnnnhetl Kmore RPRM is r .Iu ) Proof of Insurance SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. id D3 z Q O IC W U Qdoba Restaurant Corporation t4j' Attn: Leslie Whittaker, Risk Mgmt. CA S330 Balboa Avenue A':"HOflIZEr flEPPESEMATiVE N �5�� — 9San33 Diego 1516 USA El///Ly/,il•/Pq 01995.2016 ACORD CORPORATION. All rights reserved. ACORD 24 (2016103) The ACORD name and logo are registered marks of ACORD r h i i IN V Kol � Kol � is 1 4z