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HomeMy WebLinkAboutTGI Friday'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:. GC FRIDAY'S BOSTON LLC Whose place of business is: TGI FRIDAY'S 280 SCHOOL STREET, SUITE A 100 PERSON(S) IN CHARGE: MATTHEW BOLER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: FS -76 BOARD OF HEALTH MlchaeCHeatey, Chairman x Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued \� FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: TGI FRIDAYS Establishment Address: 280 SCHOOL STREET, SUITE A100, MANSFIELD, MA Establishment Mailing Address (if different): PO BOX 781898 WICHITA, KS 67278 Establishment Telephone No: 508/261-4021 Applicant Name & Title: GC FRIDAYS BOSTON, LLC Applicant Address: 133 SEVILLA AVE, CORAL GABLES, FL 33134 Applicant Telephone No.: 305/567-3852 24 Hour Emergency No.: Applicant Email: 2750@FRIDAYS.COM Owner Name & Title (If different from applicant): SAME Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. O A Corporation Name Title Address O An Individual ALFONSO FERNANDEZ, COO 133 SEVILLA AVE, CORAL GABLES, FL 33134 11 A Partnership FERNANDO ANON, CFO 133 SEVILLA AVE, CORAL GABLES, FL 33134 6 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MATTHEW BOLER Address: Telephone No: 508-261-4021 24 Hour Emergency No: 774/504-4371 FAX: E-mail: 2750@fridays.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: ANNE BIRON Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: 603/553-1832 Town of Man field 6 Pak Ron, Alan fell, iWassacbusetts 02048 Health Department .4n0y Donovan -Palmer, N113H, R.S, Healtb Agent Massachusetts state law requires food establishments to obtain a permit from the local board of health. A food establishment is defined as an operation that: "...stores, prepares, packages, serves, vends food directly to the consumer, or otherwise provides food for human consumption such as a restaurant; satellite or catered feeding location; catering operation if the operation provides food directly to a consumer or to a conveyance used to transport people; market; vending location; conveyance used to transport people not including farm trucks; institution; food bank; residential kitchens in a bed -and -breakfast operations; residential kitchens for a cottage foods operations and ....... relinquishes possession of food to a consumer directly, or indirectly through a delivery service such as home delivery of grocery orders or restaurant takeout orders, or delivery service that is provided by common carriers." Please use the following checklist to ensure you have all the necessary documentation for a complete food establishment application: I Food Establishment Permit Application. I All Food Service establishments must attach copies of Serve Safe and allergen training certificates. I If there is seating capacity for 25 or more, include anti -choking training certificates. Tax Certification Form. Worker's Compensation Insurance Affidavit: General Business is required. It must be filled out by the organization that is actually vending the product. I Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). For new Food Establishments, please contact the Health Department to determine if a Facility and Operating Plan is required. In order to obtain a permit, all documents must be filled out, signed and returned to the Health Department, 6 Park Row, Mansfield, MA 02048. If your establishment is cooking food and has indoor seating, you must obtain a common victualler license from the Selectmen's Office. Any filing for that does not meet these requirements will be returned and no permit will be issued. Sincerely, Amy Donovan -Palmer, MPH, RS Health Agent Pbone (50b)261-7366 Vav (508)261-7425 • - I;rnailoAralincr( rine/irlrlura.ron 1C)D Food Establishment Information WATER SOURCE: TOWN SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) No. of Food Employees: 65 DAYS/HOURS: 7 DAYS/WEEK 11AM-1 AM Name of Person In Charge Certified In Food Protection Management: If more than 3 individuals are certified, complete list is on file. MATTHEW BOILER Person Trained in Anti -Choking Procedures (If 25 Seats or more): IN Location: ® Permanent Location Establishment Type: yp [j Caterer $35.00_.___\ Moblie Moblie Start Date: Retail -NO FOOD PREP ( Sq. Ft) $125 [)j Milk & Crum $10.00 Moblie End Dale: Q Food Service up to 100 seats Mobile Food Consession Moblie Comments: INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: 11 Manufacture Frozen Desserts/Ice Cream Food Service for 101 -200 seats $250.00 $25.00/freezer ® Annual [ Food Service for 201+ seag] 300.010 ❑ Pushcart $50.00 # of Pushcarts: Seasonal -� Seasonal Dates: ❑ Supermarkets $400 E Residential Kitchen $100.00 ❑ Tobacco Products $150.00 Temporary E] Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food(limeiumireralure conlrols required) Non-PHFs - non-polenllally hazardous leonine lime/temperature controls required) (Check all that apply): RTE -ready-to-eal foods (Ex. sandwiches, salads, muffins which needed further processing) Pq Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hol 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 Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly [ Reheating of Commercially Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours of Process Requiring A Variance Q Customer Self -Service of Non PHF and Non -Use and/or HACCP Plan (including bare hand Perishable Foods Only E Ice Manufactured and Packaged for contact alternative, time as a public health [� Preparation of Non-PHFs Retail Sale control) Other Food Operations ( Juice Manufactured and Packaged for EJ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service E Retail Sale of Salvage, Out -Or -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $310.00 Payment is due with application lj 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 PMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 10b CMR 590.000 and RW fed e 1 Food Code. Signature of Applicant: VYI\ Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of kerj,ry that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: L� O 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. GC FRIDAYS BOSTON, LLC Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number J z( &41�11Ct..e- By: Corporate 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. CAUvers`sleile` )CSL toll' Scott's UucunteNs`Pood IisebliAlloCols- Iemli'IAN CP.R'IIFICA I']ON FORNI.doc The Commonwealth of Massachusetts up, Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: GC FRIDAYS BOSTON, LLC 280 SCHOOL STREET, SUITE A100 City/State/ZipMANSFIELD, MA 02048 phone #: 508/261-4021 Are you an employer? Check the appropriate box: 1. [ I am a employer with 40 employees (full and/ or part-time).* 2. I am a sole proprietor or partnership 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' with no employees. [No workers' comp. insurance Business Type (required): 5. ❑ Retail t. 6.[NRestaurantBar/3atingEstabbshment 7. [] Office and/or Sales (incl. real estate, auto, etc.) 8. n Non-profit 9. ❑ Entertainment 10.0 Manufacturing I LF] Health Care *Any applicant that checks box 81 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 N1. I ant an employer that is providing workers' compensation insurance for my employees. Below Ie the policy Information. Insurance Company Name: SAFETY NATIONAL CASUALTY CORPORATION Insurer's City/State/Zip: 1832 SCHUETZ ROAD ST LOUIS, MO 63146 Policy flor Self -ins. Lic, it LDS4053852 Expiration Date: 4/01/2019 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 tip to $250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify, url'der the pains and penalties ofperjury that the Information provided above Is true and correc4 12/12/2018 316/685-1622 X3155 Official use only. Do not write In this area, to be completed by city or town offlclat 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 one n: cnvuomnenun ncann 1 rorms a r•uv s Updated 10/3/2013 Pa3e 6 of 7 BRAND] M W I M M ER 90 PLEASANT VALLEY STREET METHUEN, MA 01844 Tgi Fridays Mas ichesetls- Savage ._ .....�... _..._ .. _.. _..._ _... _. ... .,•ems C'ul IL:rc 6 Prometric Score Report Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Score Status Exam Date 80 PASS 03/27/2017 qW BRANDI M WIMMER t? Exam 4201 Recognl>,ed By Conforonco For Food Protection iun _ e......'13/27/17 rnnu r.unnu on 1944418 03127122 '12/1,2/2018 09:20AM 508401360 ,NSN PAGE 02/02 a� vYi� c- Sy O C7 O o a ai c O;' V E m a 0. m o U- 0 Q LL v u C a c Q U W N o U 52 C PAGE 02/02 12/12/2018 09:20AM 5084681860 PAGE 01/02 '12/1,1/2018 05:38PM 5084631360 PAGE 01/01 CL 40 rz lu I X 'XI W U V z z v J W z W z rW P4 W f/1 0 Q O w d d 0 N ry m 0 N N s a ®II' N Q � A � 1 � o z 8 u u U o U 4 Q k, wo Q rz e° U °Wo s, 0 Ca�Q�so s a ®II' N Q � A � 1 v� a I I 0 N Q � a Q v� a 90 "e tl v ^O � a I I 4 INFOSYNC Compelrrmfcv RjumeU Proem Sdraio ri Attn: Licenses and Permits I am enclosing the license renewal applications along with the appropriate fees for TGI Fridays Restaurants. Once the licenses have been issued, please mail them to the address listed below. Copies will be made for our files and the new licenses will be mailed directly to the restaurants. GC Friday's Boston, LLC Attn: Terri Carman PO Box 781898 Wichita, KS 67278 If you need further information or have any questions, please contact me at 316/685-1622, X3155 or by email terri.carmanL(i!issvc.com Sincerely, Terri M. Carman Terri M. Carman License Supervisor /enclosures InfiSyne Service 1938 N. WooPubmn, Suite 110, Wichita, KS 67208 11:316-689-1622 AICCA?a mss, CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDOIYYYY) z/oa/zo18 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, ANDTHE 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 endorsement(s). PRODUCER MCGRIFF, SEIBELS & WILLIAMS, INC. 3400 Overton Park Drive BE CONTACT Cary CDWal1 AIC NNo Ext : 404 497-7500 ac No ADDRESS: AE SS: CCowa0@mc9n r Coup Suite 300 Atlanta, GA 30339 INSURERS AFFORDING COVERAGE NAICp INSURER A:Safely National Casualty Corporation 15105 INSURED RMET Holdings, Inc. INSURER B: CLAIMS -MADE � OCCUR DBA Gold Coast Holdings INSURER C: 133 Sevilla Avenue Coral Gables, FL 33134 INSURER D: D R PREMISES Ea occurrence $ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:AE7Z4EPS 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. INSR LTR TYPE OF INSURANCE DD iNSD S D POLICY NUMBER POLICY EFF MWDD/YYYY POLICY EXP MWDD/YYYY LIMITS sem' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE � OCCUR D R PREMISES Ea occurrence $ MED EXP (Any one parson) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ POLICY❑PRO LOC ECT $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE IT Ea m,ddanl $ BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident - UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICEMMEMBER EXCLUDED? a iMandatery In NH) N I A LDS4053852 04/01/2018 04/01/2019 OTH- X IM 5 E E.L.ACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 lives, describe under DESCRIPTION OF OPERATIONS below A Liquor Liability UL4053854 04/01/2018 04/01/2019 Aggregate 2,000,000 Each Common cause $ 1,000,000 $ $ S DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Store #2750 GC Fridays Boston LLC -280 School Street Suite At 00, Mansfield, MA 02048 CERTIFICATE HOLDER CANCELLATION Page 1 of 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE W ITH THE POLICY PROVISIONS. Town of Mansfield AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield, MA 020 sem' Page 1 of 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Jane Doucette From: Terri Carman <Terri.Carman@issvc.com> Sent: Wednesday, December 5, 2018 3:49 PM To: Jane Doucette Subject: RE: Food Service Establishment Inspection changes Hi Jane, I am just following up on the Health Permit application and fee amount for TGI Fridays. Thanks, retrr(I M. Ca rrvna w 0 INF() YN C%Mpwf"a ira Iiuiin , hoar olwions- 1938 N. Woodlawn #110 Wichita, KS 67208 P 316/685-1622 x3155 F316/681-4666 From: Terri Carman Sent: Tuesday, December 04, 2018 12:46 PM To: 'Jane Doucette' <Jdoucette@mansfieldma.com> Subject: FW: Food Service Establishment Inspection changes Jane, I just received this email from Amy however there is no application. I then looked back to see if I had other emails from her which I did only it was for the FOG regulations. And again no application. Thanks, re r& M. Caarwuxw LGr�SupervW) r INF 4005Y f:smprolx :+rk ftazsM6r Nfty rf .W mrionx- 1938 N. Woodlawn #110 Wichita, KS 67208 P 316/685-1622 x3155 F 316/681-4666 1 From: Amy Donovan -Palmer [mailto:adpalmer@mansfieldma.com] Sent: Tuesday, December 04, 2018 12:37 PM To: Amy Donovan -Palmer <adpalmer@mansfieldma.com> Subject: Food Service Establishment Inspection changes Please see the attached memo about changes in Food Service Establishment inspections. Thank you, Amy Amy Donovan -Palmer, MPH, RS Health Agent Town of Mansfield 6 Park Row Mansfield, MA 02048 508-261-7366 The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. 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