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HomeMy WebLinkAboutWendy's - 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:. WENDY'S PROPERTIES LLC Whose place of business is: WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE PERSON(S) IN CHARGE. JASON DAGRACA, GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -82 BOARD OF HEALTH MichaeCHeatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION'S (Application must be submitted at least 30 days before the planned opera te) Establishment Name: Establishment Address: WLf CDpPt"d Dy 1 V Establishment Mailing Address (if different): ' Dowel 1 t O VnCLS61 V -00. . DljJ1 r H6 H Establishment Telephone No: So 3�DI T)44 Applicant Name & Title: WMIJIS Fy_0 3CW j-eS LL -C-- Applicant Address: Bowe, �yyvks LjIVO , Du'bk i n , Dt{ 42_ -)Orr - Applicant -i2_ -)O rr Applicant Telephone No.:Lip I(t-_JtpLf.-31L)0 24 Hour Emergency No.: Applicant Email: rL�,�S I ` Cd AS M _ Owner Name & Title (If different from applicant): J Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 13 An Association partner. A Corporation Na�mm.e�� Title I Address An Individual rWXY-W_- El A Partnership _ El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: J1 WY) D VtgyW ` UkA Address: Ute( CD IG2MIJ t) �I'Vb Telephone No: S� J J� - �y 24 Hour Emergency No: 4 `-t' FAX: E-mail: sj-'U , ())L LP eW MGLgSStDV Pi- C 0 ""1 Alt E -Mail: District Or Regional Supervisor (if applicable) Pfv Sc� W3, 1 - L i ) '� j S�YI t 1 YZGUYIG. Name & Title: , r �A 1 c p �J a n t� r� pc Address: i Ca v, i S W RGL • 'A (��16D WOkud i't/t�l l V I D 0 LO Telephone No: U Ii- ,157u - LH4 p, 24 Hour Emergency No: IS 14- q4,v i' - a100 FAX: /� E-mail: � I SSG I Lo e W Onct S• UM Food Establishment Information WATER SOURCE: rj ► i r SEWA7DISPOSAL D�b l 1^' DEP Public Water Supply No: (If applicable) V No. of yees: DAYS/HOURS: Mho- Sun team- _ .tarn Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seals or more): L21 Location: = i Permanent Location Establishment Type: Caterer $35.00 Mobile Mobile Start Dale: E Retail ( Sq. Ft) $125 Milk & Cream $10.00 Mobile End Date: 0ood Service up to 100 INCLUDING EJ Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Mobile Comments: FOOD TRUCKS $175.00 ref Manufacture Frozen Desserts/Ice Cream )($25.00/freezer - Length of Permit: od Service up to 101 -200 $250.00 `Fl Annual E Food Service up to 201 + $300.00 E Pushcart $50.00 # of Pushcarts: — E Seasonal 0 Residential Kitchen $100.00 Seasonal Dates: Supermarkets $400 Tobacco Products $150.00 E Retail Snack Food $50.00 E Temporary Temporary Start Date: Temporary End Date: _ Temporary Time: Rain Dale: Ford Operations: Definitions; :PHF - Potentially hazardous food(time/lemperature controls required) Non-PHFs - non -potentially hazardous food(no fime/lemperature controls required) (Check all that apply): RTE -ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) —L--. E Sale of Commercially Pm -Packaged Non-PHFs i [N� PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service E Sale of Commercially Pre -Packaged PHF s - Preparation of PHFs For Hot And Ei PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service E Delivery of Packaged PHFsSusceptible ❑+ Sale of Raw Animal Foods Intended Population Facility _. E Vacuum Packaging / Cook Chill E Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours - E Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- E Customer Self -Service Perishable Foods Only E e Manufactured and Packaged for contact alternative, time as a public health _ Preparation of Non-PHFs --1 Retail Sale control) ❑' Juice Manufactured and Packaged for E Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal Origin E Prepares Food/Single Meals for E Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service E Retail Sale of Salvage, Out -Of -Date or Reconditioned Food -- _ To be completed bythe �Board of Health Total Permit FeeA Payment is due with application E waived 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: LLCM & I V Uy " V_V v v 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 stale tax returns and paid stale taxes required under law. Social Security Number or Federal ID: Tr_ ,� vv Signature of Individual or Corporate Name: I �' � 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. 1 i a VUf/hG m,s comp" Signature of Individual or Corporate Name 41 — �)Lqe I 1 gg **Social Security No. (Voluntanj) 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 Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 17te Con,aroruvealth of 111assaclutsettc Deparnaeill Of Industrial Accidents Office Ofinvestigations 600 Washington S'trect �\ Boston, HA 02111 nn v rv. mass. go h/dia `,Yorkers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: l4 X WI('ib-1 (.11'S C_C7MMl LSI Address: Oil- D"Z T,-om-�s bwa_ City/State/Zi p.pubtlVI, L�1 Lt,:�u�� Phone 9: Are you an employer? Check the �appropriate box: LV I am a employer with 3(D employees (full and/ or part -tune). - 2 ❑ 1 am a sole proprietor or pan ierslup and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. VRestaurantBar/Earing Establislunent 7. ❑ Office and/or Sales (incl. real estate, ante, etc.) & ❑ Non-profit 9. ❑ Entertairunent 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other -wry applicant Ihat checks box #1 must also Fill out the section below showing their workers' compensation policy information. -`"If the corporate onicers have exempted themselves, but the corporation has other employees, a workers' compensation policy is requited and such an organization should check box a 1. I (on an emptoyer (hat is providing workers' compensation insurance for my employees. Below is the policy informrdion. Insurance Company Name: W 4,y;uLVGw C,9- CZY V 1 CLS bC'om� (I Insurer's Address:, clo �, P C.Q VA�{'liyq ( wd • 1P,0. X City/State/Zip: 1V�S�J�1/I��Q,TJ(P +�� C Policy # or Self -ins. Lie. # W V U GU "I W �eI 1 J Expiration Date: 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 critrutral penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn 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 herehy certify, under the pains anti pentrlties ofperjury that the information provided above is true and correct l� Phone #: ^t�' Offceia(use on1e% no not write in this area, to be coveyileterl by city or town offtciai Cite or Tolrn: _ Permit/L.icense /t Essuin��Auth orifi (ci rcic our I- Board of health 2. €luildio<,r Department 3. Cit%/Totrn Clerk 1, Licensing Board 5. Selectmen's Oificc 6. Otho Contact Person: Phone R: � z�® CERTIFICATE OF LIABILITY INSURANCE Page 1 of 2 DATE IMWOOIYYYY) 12/28/2017 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 andorsement(s). PRODUCER CONTACT .Willis Insurance ServicesNAME: of Georgia, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd C No E#: A/C No: E-MAIL cezti.ficates@willis.com Box 305191 ADDRESS: @willis. com Nashville, TN 372305191 USA INSUREWSI AFFORDING COVERAGE Nara INSURERA: ACE American Insurance Company 22667 INSURED INSURERB: ACE Fire Underwriters Insurance Company 20702 The Wendy's Company ne ODave Thames Blvd INSURER C: Dublin, OR OSA ivaiovo 1. COVERAGES CERTIFICATE NIIMRFR- W4902238 - nctrrclnnl nN IaAmcn. C 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' Company s AUTHORIZED REPRESENTATIVE One Dave Thomas Blvd " Dublin, OR 430175452 © 1988.2035 ACORD ACORD 25 (2096103) The ACORD name and logo are registered marks of ACORD sR ID: 15458435 eaxce: 553163 reserved. 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. INBR I ADOLSUBR LTR TYPE OF INSURANCE POLICYNUMBER POLICY EFFPOLICY MM/DO EXP MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MAGE OCCUR DAMAGERENT PREMISESS(Ea accunence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMITAPPLIES PER: PRO- POLICY❑ ECT OC PRODUCTS - COMPIOP AGO $ $ OTHER: AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY (Par Person) $ OWNED SCHEDULED BODILY INJURY (Per accident) S AUTOS ONLY AUTOS H I HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY PERTnt $ Per ($ I LiUMBRELLA UA8 EACHOCCURRENCE $ EXCESS LIAB C AGGREGATE $ $ OED RETENTION $ WORKERS COMPENSATION PER DTH-- 4LAIM&MADE ANDEMPLOYERS'LIABILITYA ANYPROPRIErORIPARTNER/EXECU OFFICER/MEMBERFXCLUOEO? WLR 064625263 01/01/018(Mandatory in NH)Ifyes, describe under DESCRIPTION OF OPERATIONS bB Workers' Compensation - SCF 064625287 Ol/01f2018 01/01/2019 E.L Each Accident $1,000,000 Per Statute E.L Cisease - Ea map $1,000,000 E.L Disease - Pal L $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AdditaW Remarks Schedule, may be attached if more space is required) SEE ATTACHED C 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' Company s AUTHORIZED REPRESENTATIVE One Dave Thomas Blvd " Dublin, OR 430175452 © 1988.2035 ACORD ACORD 25 (2096103) The ACORD name and logo are registered marks of ACORD sR ID: 15458435 eaxce: 553163 reserved. AGENCY CUSTOMER ID: LOC #: AGENCY NAM EO INSURED The Wendy's Company Willis Insurance Services of Georgia, :no One Dave Thomas Blvd POLICY NUMBER Dablin, OR USA See Page 1 CARRIER NAIC CODE See Page 1 Be' Page 1 EFFECTIVEOATE: Be. Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUM13ER: 25 FORM TITLE: Certificate of Liability Insurance INSURER AFFORDING COVERAGE: ACE American Insurance Company POLICY NDbMER: WCU C64623275 EFF DATE: 01/01/2018 EXP DATE: 01/01/20.19 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 Page 2 of 2 NAIC#: 22667 © 2008 ACORD CORPORATION. Ail rights The ACORD name and logo are registered marks of ACORD >R ID: 15458435 same-: 553163 =RT: W4902238 Wendy's Officer Listing Name Title Todd A. Penegor President and Chief Executive Officer Robert D. "Bob" Wright Executive Vice President, Chief Operations Officer and International Kurt Kane Executive Vice President, Chief Concept & Marketing Officer Dana Klein Sr. Vice President — Corporate Securities Counsel & Assistant Secretary Gunther "GP" Plosch Chief Financial Officer Abigail E. Pringle Chief Development Officer Matthew C. "Coley" O'Brien Chief People Officer Liliana Esposito Chief Communications Officer Eric J."EJ"Wunsch Chief Legal Officer&Secretary David Trimm Chief Information Officer Leigh Burnside Chief Accounting Officer Kris A. Kaffenbarger Vice President—System Optimization Kyndall1, Potts Vice President—Tax Gavin P. Waugh Vice President—Treasury & Enterprise Risk Management 09/19/18 n