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Home My WebLink AboutVillage at Willow Crossing - 12/31/2019 (2)Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type; FOOD 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:. KRE HUSKY WILLOW CROSSINGS LICENSEE LLC Whose place of business is: THE VILLAGE AT WILLOW CROSSING 25 COBB STREET PERSON(S) IN CHARGE: FLORENCE BOTTI Permit Expires: December31, 2019 Food Fee: $260.00 License Number: FS -88 BOARD OF HEALTH MichaeCWeaCey, Chairman Milk & Cream W 0 FOR BOARD OF HEALTH USE ONLY Permit # Issued I"S'� FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: The Village at Willow Crossings7 77,h z Establishment Address: 25 Cobb Street i Establishment Mailing Address (if different): (same) I' 1, JUL 0 3 2019 Establishment Telephone No: 508-261-1333 - '-----.—---- Applicant Name & Title: Andrea M. Teichman Applicant Address: 201 Jones Road, Suite 300 West, Waltham, MA 02451 Applicant Telephone No.: (781) 489-2825 24 Hour Emergency No.: Applicant Email: Owner Name & Title (If different from applicant): KRE Husky Willow Crossings Licensee LLC Owner Address: 201 Jones Road, Suite 300 West, Waltham, MA 02451 Owner telephone number: (781) 489-2825 Owner email: compliance@benchmarkquality.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. A Corporation Name Title Address O An Individual N/A O A Partnership 7 Other legal Entity IIC Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Florence Botti Address: 25 Cobb Street, Mansfield, MA 02048-4505 Telephone No: 508-261-1333 24 Hour Emergency No: FAX: E-mail: fbotti@benchmarkquality.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: James Hourihan Director of Dining Services Address: 201 Jones Road, 3rd Floor West, Waltham, MA 02451 Telephone No: 978-944-4902 24 Hour Emergency No: FAX: 781-235-01368 E-mail: jhourihan@benchmarkquality.com ,5� Q n a_ai e t-, a—+I-\Q n 5G r1 i no ZJo L-� JOct \-fh6?na_+ ar150nrrznv0,6 ' Food Establishment Information WATER SOURCE: No change. SEWAGE DISPOSAL: No change. DEP Public Water Supply No: (If applicable) No, of Food Employees: 5 DAYS/HOURS: No change. 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 Seats or more): L f oca ion. ni Permanent Location Establishment Type: Moblie Moblie Start Date: Moblie End Date Moblie Comments: Length of Permit: Annual Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: LJ Retail -NO FOOD PREP ( Sq. Ft) zii1 IwFood Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 [/ood Service for 101 -200 seats $250. Food Service for 201+ seats $300.00 Supermarkets $400 ❑] Caterer $35.00 D Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer E] Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 ❑ Tobacco Products $150.00 ❑ Retail Snack Food $50.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercials Pre -Packs ed PHFs for More Than a Single Meal Service Y g ❑Preparation of PHFs For Hot And _ EJ Cold Holding For Single Meal Service ❑X PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs P 9 Y ale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Perishable Foods Only -- Customer Self -Service of Non PHF and NoJRetail tomer Self -Service U Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) _ Manufactured and Packaged for ail Sale __ Preparation of Non-PHFs Other Food O erations p e Manufactured and Packaged for Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin rs RTEPHF in BulkQuantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service eail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ,naivad the, I, the undersigned, attest to the accuracy of the information provided in this application and affirm that 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 ofACMR 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 state taxes required under law. Social Security Number or Federal ID: 84_1955974 Signature of Individual or Corporate Name: 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. HIRE Husky Willow Crossings Licensee LLC Signature of Individual or Corporate Name By; Corporate Officer (Mandatory, if Applicable) 84-1955974 "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'•U5crsVlei10Tcsktap'Scoll1s Dammemsffood Usiablishmenis• TanpIxAX CERTIFICATION FORMdoc The Coninionwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 tvtvtatnassgov/dia Workers' Compensation Insurance Affidavit: General Businesses .Applicant Information Please Print Leeibly Business/Organization Name: The Village at Willow Crossings Address: 25 Cobb Street City/State/Zip: Mansfield, MA 02048-4505 Phone #: 508-261-1333 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time)." 2.2 1 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]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.1 Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing I Lx❑ Idealth Care 12.❑ Other "Any applicant that checks box #1 must also fill out thesemion below showing their workers' compensation policy information '"If the cogwmte officers have exempted themselves, but the cotpomtion has other employees, a workers' compensation policy is required and such on organization should check box #I. I any an employer that is providing workers' contpensadon insurance for aty employees. Below is the policy information Insurance Company Name:___ Insurer's Cily'State.rZip: Policy # or Self -ins. Lic. 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 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 certify,to er the pains ®and penahies of perjury that the information provided above is true and correct. Signature, ZY . nut,. Julv 2, 2019 Phone #: (781) 489-2825 OfTchd use only. Do not write in this area, to be completed by city or town oJrcial. 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.muss.goroia Phone WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 01 A INFORMATION PAGE Insurer: POLICY NO. ARCH INSURANCE COMPANY 91WC14987906 2345 Grand Blvd Suite 900, Kansas City, MO 64108 NCCI Code N 28355 I. The Insured: BENCHMARK SENIOR LIVING LLC Individual Partnership Mailing address: (SEE NAMED INSURED ENDT) 201 JONES ROAD Corporation or SUITE 300 WEST LLC WALTHAM MA 02451 Other workplaces not shown above: See Workers Compensation Classification Schedule 2, The policy period is from. 04-01-2019 to 04-01-2020 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: CT MA ME NH RI VT B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policylimit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AL AK AZ AR CA CO DE DC FL GA HI ID IL IN IA KS KY LA MD MI MN MS MO MT NE NV NJ NM NC OK OR SC SO TN TX UT VA WV WI D. This policy includes these endorsements and schedules: See Schedule of Forms and Endorsements 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of Annual Annual Remuneration Remuneration Premium See Workers Compensation Classification Schedule Total Estimated Annual Premium $ 1,136, 764 Minimum Premium$ 750 Expense Constant$ 338 Countersigned by 0 1'/119,N lI mul Cvmxll mr Cumpemminn Imurvvry Policy Number 41WC14987906 SCHEDULE OF FORMS AND ENDORSEMENTS ARCH INSURANCE COMPANY Named Insured BENCHMARK SENIOR LIVING LLC Effective Date: 04-01-2019 12:01 A.M., Standard Time Agent Name WILLIS OF ILLINOIS, INC. Agent No. 208 WORKERS COMPENSATION FORMS AND ENDORSEMENTS 00 ML0065 00 06-07 US TREASURY DEPT'S OFAC ADVISORY NOTICE 05 ML0043 20 05-08 PH NOTICE - ME ACC PREVENT/LOSS CONTROL 05 ML0002 22 06-13 MASSACHUSETTS SIGNATURE PAGE WC 00 00 01 A 07-97 WC INFORMATION PAGE LOCATION2 11-99 SCHEDULE OF NAMES & LOCATIONS WC 89 06 01 01-98 SCHEDULE OF NAMED INSURED(S) WC 89 04 15 07-97 WC CLASSIFICATION SCHEDULE WC 00 00 00 C 01-15 INSURANCE POLICY 00 WC0001 00 12-02 WORKERS COMP & EMP LIAB INS POL DED ENDT 00 WC0001 30 04-03 WORKERS COMP & EMP LIAB INS POL DED ENDT 00 WC0031 00 08-11 LARGE RISK ALTERNATIVE RATING OPTION 00 WC0031 46 01-12 VT L RISK ALT RTG OPT DEDUC PREM COM END 00 WC004 00 11-03 EARLIER NOTICE OF CANCELLATION BY US WC 00 03 01 A 02-89 ALTERNATE EMPLOYER ENDT WC 00 03 03 C 10-04 EMPLOYERS LIABILITY COVERAGE ENDT WC 00 03 10 04-84 SOLE PROP, PARTNERS, OFFICERS, OTHER COV WC 00 03 11 A 08-91 VOLUNTARY COMP AND EMPLOYERS LIAB COVG WC 00 03 13 04-84 WAIVER OF OUR RIGHT TO RECOVER WC 00 04 14 07-90 NOTIFICATION OF CHANGE IN OWNERSHIP ENDT WC 00 04 14 A 01-19 90DAY REPORT-NOTIF CHANGE IN OWNERSHIP WC 00 04 19 01-01 PREMIUM DUE DATE ENDORSEMENT WC 00 04 21 D 01-15 CATASTROPHE (OTHER THAN CERT ACTS) ENDT WC 00 04 22 B 01-15 TERRORISM RISK PGM REAUTH ACT DISCL ENDT WC 00 04 25 05-17 EXPERIENCE RATING MODIFICATION FCTR REV WC 06 03 01 04-84 CT APPLICATION OF WORKERS COMPENSATION WC 06 03 03 C 07-11 CT WC FUNDS COVERAGE ENDT WC 06 06 01 A 10-17 CT NONRENEWAL & RENEWAL ENDT WC 18 06 01 04-84 ME INSPECTION IMMUNITY ENDT WC 18 06 03 A 06-95 ME CANCELATION AND NONRENEWAL ENDT WC 18 06 04 05-88 ME FINAL PREM AUDIT ENDT WC 18 06 06 08-99 ME NOTICE WC 18 06 07 A 07-11 MAINE SUPPLEMENTAL BENEFITS FUND ENDT WC 20 03 01 04-84 MA LIMITS OF LIABILITY ENDT WC 20 03 02 A 09-08 MA ASSESSMENT CHARGE WC 20 03 03 D 08-10 MA NOTICE TO POLICYHOLDER ENDT WC 20 04 05 06-01 MA PREMIUM DUE DATE ENDT WC 20 06 01 A 07-08 MA CANCELLATION ENDT WC 28 04 04 01-08 NH PENDING RATE CHANGE ENDT WC 28 06 01 04-84 NH SOLE REPRESENTATIVE ENDT WC 28 06 04 04-92 NH AMENDATORY ENDT WC 34 03 01 C 03-10 OH EMPLOYERS LIABILITY COVERAGE ENDT WC 38 04 01 B 01-15 RI SHORT RATE CANCELLATION ENDORSEMENT WC 89 0614 Policy Number 41WCI4987906 SCHEDULE OF FORMS AND ENDORSEMENTS ARCH INSURANCE COMPANY Named Insured BENCHMARK SENIOR LIVING LLC Effective Dale: 04-01-2019 12:01 A.M., Standard Time Agent Name WILLIS OF ILLINOIS, INC. Aoent No. 208 WC 38 06 01 04-84 RI DIRECT LIABILITY STATUTE ENDT WC 38 06 02 06-93 RI SAFETY INSPECTION ENDT WC 44 06 01 04-84 VT LAW ENDORSEMENT WC 44 06 02 B 07-14 VT CANCELLATION AND NONRENEWAL ENDT WC 99 06 03 05-04 WC & EMP LIAB INS FOREIGN COV ENDT WC 99 06 03 MA 05-04 FOREIGN COVERAGE ENDT-MASSACHUSETTS WC 99 06 03 VT 05-04 FOREIGN COVERAGE ENDORSEMENT -VERMONT WC 89 0614 NCCI Carrier Code 28355 ARCH INSURANCE COMPANY NAME AND LOCATION SCHEDULE Named Insured BENCHMARK SENIOR LIVING LLC Agent Name WILLIS OF ILLINOIS, INC. State MASSACHUSETTS B -XII HAVERHILL LLC 254 AMESBURY ROAD HAVERHILL MA 01830 Legal Entity: LLC FEIN: 47-2560198 SIC Cade: 8059 NAIC Code: 623311 If EMP : 86 B -XII LEOMINSTER LLC 1160 MAIN STREET LEOMINSTER MA 01453 Legal Entity: LLC FEIN: 47-2570446 SIC Code: 8059 NAIC Code: 623311 If EMP : 73 B -X MANSFIELD LLC 25 COBB STREET MANSFIELD MA 02048 Legal Entity: LLC FEIN: 27-4452440 SIC Code: 8059 NAIC Code: 623311 N EMP : 136 B -X NORTH CHELMSFORD LLC 2 TECHNOLOGY DRIVE NORTH CHELMSFORD MA 01863 Legal Entity: LLC FEIN: 27-4396657 SIC Code: 8059 NAIC Code: 623311 If EMP : 80 Effective Date: 04-01-2019 12:01 A.M., Standard Time Agent No, 208 Page 8 f Ix 3 1 W o 44Z f O � t, y Z W f a # a O h �1-4 LL. x L. V a m , X W W U f Ix 3 1 W o of W � t, y T � F S a f 1i m I 9 Ix W o of W � W a m I 9 V ij I a a a ❑ a A 3 L•J W- R M 6 T v �e \\ \) \\ , / } .( ƒ/ + � \} \ rr ui $ƒ - �- » \ƒ d< ;± »; 0/j n 0 04 N v o 0 Q Z V U V O A t4l N co Q ,-- T H E '-"'- NATHANSON GROUP July 2, 2019 SEND VIA FEDERAL EXPRESS Town of Mansfield Health Department 6 Park Row Mansfield, MA 02048 Re: Food Establishment Permit Application for Change of Ownership To Whom It May Concern: '_3 JUL 03 2019 pl ' [ 1 Y This letter is to inform you of the upcoming change of ownership scheduled to occur on or about July 11. 2019 at the assisted living residence known as The Village at Willow Crossings and located at 25 Cobb Street, Mansfield, MA 02048-4505 (the "Facility"). The current licensed operator is B -X Mansfield, LLC and the new licensed operator will be KRE Husky Willow Crossings Licensee LLC (the "New Operator"). We understand that as part of the change in ownership, we must obtain a new food establishment permit in the New Operator's name. Accordingly, we are submitting the New Operator's application with this letter. Please note that there will be no change to the menu, the staff, or any other aspect of the food establishment as part of the change of ownership. While we will diligently work to complete any requirements for your Department, in the instance we are not able to finalize the New Operator's food permit by July 11, 2019, we assume that our filings allow us to continue to conduct food service operations at the Facility until the New Owner's license is issued. If this is incorrect, please call or email me at aishiad@nathansongroup.com or (206) 623-6239. Thank you. Sincerely, Aishia Dueno Regulatory Compliance Coordinator Enclosures w/ filing fee One Union Square 600 University Street, Suite 2000 Seattle, WA 98101-1192 206.623.6239 www.NathansonGrouptom THE �NATHANSON -, GROUP July 11, 2019 SEND VIA FEDERAL EXPRESS Town of Mansfield Health Department 6 Park Row Mansfield, MA 02048 Attn:Jane Doucette Re: Food Establishment Permit Application Adjusted Fee To Ms. Jane Doucette: Attached please find the check with the corrected fee of $260.00 for the food establishment permit application for the assisted living residence known as The Village at Willow Crossings and located at 25 Cobb Street, Mansfield, MA 02048-4505. If there are any problems or questions, please call or email Jody Hanson at jodyh@nathansongroup.com or(206)623-6239. Thank you. Sincere) , Ann -btsuka Regulatory Compliance Coordinator Filing Fee Enclosed One Union Square 600 University Street, Suite 2000 Seattle, WA 98101-1192 206.623.6239 www,NathansonGroup.com