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HomeMy WebLinkAboutB. good - 12/31/2019FOR 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: �,(00J Establishment Address: 1 ASO S6f'00¢ Establishment Mailing Address (if different): St /�UhsfeE�/J(� O,,04 S Establishment Telephone No: 14 0 1- ii oo- H g � S Applicant Name &Title: )GS0' swCP'YNPOU)he( Applicant Address: U I Le)n40r 1 m ✓ M itiGr" /�/q 0)4s-)- Applicant Telephone No.: �o I i % - 0 - -L- 24 Hour Emergency No.: j Applicant Email: G1sons ©D 500d ® Gory-, Owner Name & Title (If different from applicant): Owner Address: Owner telephone number: Owner email: - _-..--- Establishment Owned By: El An Association C1 A Corporation El An Individual K A Partnership El Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Person Directly Responsible For Daily dOperations (owner, person in charge, supervisor, manager etc.) Name & Title: � P_ � rnck V 1Q, V0,14 (\Ja e n Address: 1 3 �)n1on St Aht I t�Yigo��QlaTe( /�JiI cad aq Telephone No: �J i a 0 2d Hour Emergency No: FAX: 1 E-mail: Alt E -Mail: I District Or Regional Supervisor (if applicable) Name&Title: �ntQh DC f(AiV(� Address: a CC) �(is Telephone No: FAX: 1 I E-mail: 6& CQ Vrn� si �oo(h, �O hn 24 Hour Emergency No: I7 Food Establishment Information — — - -- -- - WATER SOURCE; SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food EmDlovees: I C DAYS/HOURS: �� Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. p t DeEm(nr;P (MACH[ ofes ) A r,t�vpt De Pa�vrj � 1; c;C1 (owed, I RolwJ Yew r� Person Trained in Anti -Choking Procedures (If 25 Seats or more): E Location: 'Permanent Location Establishment Type: Mobile Mobile Start Date: L) Retail ( Sq. Ft) $125 Mobile End Date: Food Service up to 100 INCLUDING Mobile Comments: FOOD TRUCKS $175.00 Length of Permit: — KAnnual Seasonal Seasonal Dates: UJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Q Food Service up to 101 -200 $250,00 Q Food Service up to 201 + $300.00 R Supermarkets $400 El Caterer $35.00 El Milk & Cream $10.00 Q Mobile Food Consesslon NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Q Pushcart $50.00 # of Pushcarts: 0 Residential Kitchen $100.00 Tobacco Products $150.00 Retail Snack Food $50.00 Food Operations: ,(Check all that apply): Definitions..PHF - Potentially hazardous food(dmeBemperature controls required) Non -PHIS - non -potentially hazardous rood(no tlmedemperature controls required) RTE - ready -lo -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Q 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 Q 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 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours Q Vacuum Packaging /Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) E] Customer Self -Service of Non PHF and Non- Perishable Foods Only Q Customer Self -Service 0 Ice Manufactured and Packaged for Retail Sale II❑ Preparation of Non-PHFs Other Food Operations O Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin E3 Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for _ Catered Events or Institutional Food Service El Retail Sale of Salvage, Out -Of -Date _ j or Reconditioned Food = FToe completed by the Board of Health ---- al Permit Fee:ment is due with application Ej 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: Pursuant to MGL Ch.62C, sec. 49A, I certify nder the penalties of pequry 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 to: i (' [ �q ' '^ Signature of Individual or Corporate Name: �1��nv- IfJ-e(i-----�,..�'1 (9 God l rl%il Mv� i e l A L C b Big- B. Gaon Jane Doucette From: Amy Donovan -Palmer Sent: Friday, August 16, 2019 8:34 AM To: Jane Doucette Subject: Updated contact information Attachments: B.GOOD Mansfield Health Form.pdf coef!!d ytnut upd'ete [yiiood ss can tact iiqfvflmat5wiim, Accces's? I CN*ih* tiN*ue had so ns- amgps, sc ik aakied t $em to) fi'10 mut a wfh'cs{�- new, fo: m tv Cord m l we [have 0'8 carnect i� ffQnr Can , Thartk1s}, A, [yr From: Jason Sweeney [mailto:jasons@bgood.com] Sent: Wednesday, August 14, 2019 10:59 PM To: Amy Donovan -Palmer Cc: Lars Mohlin Subject: RE: Fats Oil Grease (FOG) regulations The tracking sheet at the restaurant should be updated. Our grease trap pumping company was just out last week. I have attached the updated health form with contacts you requested. Tham'#ityyou" Dasonr: Su+se'e�n�� @x.�% � Fvtamct�=isty n�rc`//�Sgt�;nar. M4nsf iV„ MiA1„ Ccanst ao RA, amd l $aW Street P oW�temr From: Amy Donovan -Palmer <adpalmer@mansfieldma.com> Sent: Monday, August 12, 2019 5:06 PM To: Jason Sweeney <jasons@bgood.com> Cc: Lars Mohlin <larsm@bgood.com> Subject: RE: Fats Oil Grease (FOG) regulations Th,Eese reef W& a:re 040Y *6aWO) A4PrQ[' N) wanu I aw_ #hq m mtrez ¢wik rre&wd&v Alm From: Jason Sweeney fmaiito:jasons@bgood.com] Sent: Monday, July 29, 2019 5:23 PM To: Amy Donovan -Palmer Cc: Lars Mohlin Subject: RE: Fats Oil Grease (FOG) regulations Yes, Silas recently left our company to pursue his training to be a State Police Officer. Please add my e-mail and cell number 617-877-0252 as a main point of contact. I understand that my partner Lars Mohlin did e-mail you on May 281h the attached summary of our grease removal invoices from Wind River. Is this satisfactory or do you need additional back up from Wind River? I have printed the maintenance log to post in the restaurant this week. Ta9CS% SwcLL emey �..GOOD Fraiiehiiaeu ne /1Q} naCaK t fen feint A)3 Cra atom R11 aad 3%4119rrRges ftvvidealle 4Q?1-4�=4181315; rauvrtu�uj.�.Qorm From: Amy Donovan -Palmer <adlaalmerc@mansfieldma.com> Sent: Monday, July 29, 2019 5:02 PM To: Jason Sweeney gasons &bgood.com> Cc: Lars Mohlin Qarsmbgood.com> Subject: Re: Fats Oil Grease (FOG) regulations Hi Jason, On the FOG permit, the email address was for Silas. He's been receiving everything. It was a last minute thought today when I was resending everything to include others on the food permit. Should I include you moving forward? Amy Amy Donovan -Palmer, MPH, RS Health Agent 508-261-7366 Sent from my iPhone On Jul 29, 2019, at 4:52 PM, Jason Sweeney Jasons9bgood com<maiIto: asansCDbgood.corn>> wrote: Hi Amy, For some reason I cannot find any of your previous e-mails about the grease pumping. Can you please let me know if I was on the distribution list? We have a monthly maintenance contract through Wind River. I have reached out to Wind River to get their records and will send along. We will be sure to keep the Grease Removal Maintenance Log updated at the restaurant going forward. Sorry for the delayed follow up, this is the first time I have seen this issue raised. Thank you, Jason Sweeney B.GOOD Franchise Owner/Operator Mansfield, MA, Cranston RI, and Thayer Street Providence 401-400-483 5Qe l: (401 ).%20400-4835> www bgood.comQ•xttsr.//www.bgood.com(> From: Amy Donovan -Palmer <adpalmera@rnansfieldm,3 com<mailto adpalrnerEmansfietdma corm» Sent: Monday, July 29, 2019 12:52 PM To: Amy Donovan -Palmer <adpalmer(Omansfiekdma_com<mail e:adpalmer@marTsfFetdma.com>> Subject: F\W. Fats Oil Grease (FOG) regulations Hello, Grease trap pumping records are now past due. Please submit all necessary grease trap pumping records immediately. H reports are not received to the BOH by Monday, August 5th , your presence may be required at the September 5th BOH meeting to explain the delay. **According to the BOH FOG Regulations, internal grease trap pumping MUST occur monthly and external grease trap pumping MUST occur quarterly.** At this point in enforcement, I must see both the log noting the amount of combined solids and grease removed and the invoices from the pumpers. Because of inconsistencies in reporting practices of the pumpers, I am now asking that EVERYBODY use the attached cleaning log and require the pumpers to enter ALL the data into the form when they are pumping. Please contact the Health Department with any questions. Amy From: Amy Donovan -Palmer Sent: Monday, July 8, 2019 2:53 PM To: Amy Donovan -Palmer Subject: RE: Fats Oil Grease (FOG) regulations Hello all, Please be aware that monthly FOG pumping records for April -June are due to the BOH today. Please contact the Health Department with any questions. Amy From: Amy Donovan -Palmer To: Amy Donovan -Palmer Subject: Fats Oil Grease (FOG) regulations RE: Fats Oil Grease (FOG) regulations Please note the following requirements apply to all food establishments. Current regulations are attached for your reference. * Indoor traps must be inspected, serviced and cleaned at least monthly by a professional drain cleaner, licensed plumber or Permitted Offal/Septage Hauler. * Outdoor/Underground Grease Interceptor must be pumped, inspected and serviced by a Permitted Offal/Septage Hauler at least every three (3) months or at a frequency deemed necessary to prevent any potential blockage. * A copy of "The Grease Trap Maintenance Log" shall be kept onsite and properly maintained relative to the operation/maintenance of any FOG Pretreatment System. * Any waste grease and oil (i.e. yellow grease) must be stored in an appropriate container on an impervious surface, such as concrete or pavement, and in a sheltered area to prevent entry of precipitation and vermin. The container must be sealed and the surrounding area must be kept in sanitary conditions at all times. The container must be collected by an approved vendor. At this point, the BOH is requesting the following information be sent to the Health Department: * By April 8th, 2019, January, February and March pumping records and a copy of the grease trap maintenance log * By July 8th, 2019, April, May, and June pumping records and a copy of the grease trap maintenance log * By October 8th, 2019, July, August, and September pumping records and a, copy of the grease trap maintenance log * By January 8th, 2020, October, November, and December pumping records and a copy of the grease trap maintenance log A sample maintenance log is attached for your use. Please contact the Health Department if we can be of any additional assistance. Thank you, Amy Amy Donovan -Palmer, MPH, RS Health Agent Town of Mansfield 6 Park Row Mansfield, MA 02048 508-261-7366 Disclaimer 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. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here-lettp:ffwww.m€mecast.comfproducts, -. The information, including any attachments, contained in this electronic message is intended for the exclusive use of the addressee(s) and may contain confidential or privileged information. Any use of the material by any unintended recipient is strictly prohibited. If you are not the intended recipient, please notify the sender immediately and destroy all copies of this message and any attachments. Thank you. Disc1ainler P V *_ k'J sr _ 't7 ...`. i� <'`.4xp+.d-'f m"-1 e., cul ( .J rv. .t ;�`_ ce lr:,. xi r_. ei um%f<I_ "1 4�.n, z ' g "dS � I.Y A ., �., cr r., .. .. l:"_t,...d° r .. T' _ , t';@&-�x&3zEtt e�a£s!. i ., � u : a 4 ' Ci ��. 44w . fi1„ °_ .. s � 6� �xv: 'ax .....,. i -� v s3 „r✓1 � 1 , e; Se'au� .. i ", _*.".�.�.#� aY`1fi1 „ ::�., �r � ,, t"'.., ,. ,.. .an c ;`". y v�4 't � ,�;y�; C1 ick REie_ The information, including any attachments, contained in this electronic message is intended for the exclusive use of the addressee(s) and may contain confidential or privileged information. Any use of the material by any unintended recipient is strictly prohibited. If you are not the intended recipient, please notify the sender immediately and destroy all copies of this message and any attachments. Thank you. Tha x'B'i,'S` a-rb 3 cM to rus t. ry I zo bn for S`c L, vhS* -.'Y e _ .+m� ! us E&'�., �3 ... ,. P. . 1, .. j a— idH " w ....d ,, v...t� .. da nbutjco 61, taking r. rtl Batla v le w_... .5 .,f w .s c. ..._ .t„ Sofa 4.-e' ,_y t . _ Safety a"ia sS arg Useful —.. sea' _.. .. ..,. ._ _... 3'c.rp E61Ck The information, including any attachments, contained in this electronic message is intended for the exclusive use of the addressee(s) and may contain confidential or privileged information. Any use of the material by any unintended recipient is strictly prohibited. If you are not the intended recipient, please notify the sender immediately and destroy all copies of this message and any attachments. Thank you. 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) {� fh�aa�Si tG 6 m C - Establishment Name: � x Establishment Address: � } SCI @ $ i eEi 8 to F ` y v °' °Nov1 � 2018 � Establishment Mailing Address(if different): Establishment Telephone No.: Applicant Name & Title: GSo r SW e 6 n eta � I C �"el Applicant Address: � `a nr to ^ � J (i t /utn $ (I f -i A L} Applicant Telephone No.: (} - _ V I S D 24 Hour Emergency No.: Applicant E-mail: q asc y Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association P4 A Corporation O An Individual partner. Name Title Address �� w� Lln E El A Partnership JC.� fin` jdg� , 4�Ivt Garrey e t i6C JLl El Other legal Entity r09 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: j _ 7(h}�' Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: 7)4" So?' eP r' J Address: '�CpAGV-P_ Telephone No: 24 Hour Emergency No: FAX: E-mail: 0 Food Establishment Information WATER SOURCE: DEP Public Water Supply No: (If applicable) SEWAGE DISPOSAL: NO. Of F00, Employees: { DAYS/HOURS: - j� 14 a r" P _...- 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): Location: [ ( Permanent Location ❑Moblie Moblie Start Date: Moblie End Date: Moblie Comments: Establishment Type E] Retail ( Sq. Ft) Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 ❑Food Service up to 201 + $300.00 ❑ Supermarkets $400 E] Caterer $35.00 ❑ Milk & Cream $10.00 ❑ Mobile Food Consession NO PHF PREPARED ON SITE $100.00 o Manufacture Frozen Desserts/Ice Cream $25.00/freezer E] Pushcart $50.00 # of Pushcarts: ❑ Residential Kitchen $100.00 0 Retail Food $125.00 Retail Snack Food $50.00 -- Length of Permit: Annual Q Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Fooderations P (Check all that apply): Definitions. PHF Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperatum controls required) 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 Hol 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 F1 Sale of Raw Animal Foods Intended to be Prepared by Consumer Cj Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service E Ice Manufactured and Packaged—for Retail Sale Q Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail 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 ❑ 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: Pursuant to MGL Ch.62C, sec. 49A, I certify and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal ID: penalties of perjury that I, toYnny best knowledge and belief, have filed all state tax returns I e1J(L 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. i�G Cod /M ak j &i W (_LC msec, Signature of Individual or Corporate Name By: Corporate Officer (Mandator% if Applicable) 7)q -70Y "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:\Osem\sleite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 J www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information gg�� rr g Please Print Legibly Business/Organization Name: R ✓ Coed a,w t'ieW L Lt Address: �,SrjSf 16Li § A C4 ��i ° id Phone#: x(01 906"493�_ Are you an employer? Check the appropriate box: Business Type (required): 1. a I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. Restaurant/Bar/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. 8• ❑ Non-profit [No workers' comp. insurance required] 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. F1 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 am an employer that Is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy ff or Self -ins. Lic. M Expiration Date: j{ 1 I I E C _ 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, under the pains and penalties ofperjury drat the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: 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.mms.gov/dia A� hr CERTIFICATE OF LIABILITY INSURANCE DAT1/19/2018 YI 11!19/2018 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 McSweeney & Ricci Insurance Agency, Inc. 420 Washington Street Braintree MA 02185 CONTACT NAME: PRIA CN o Eat,, 781-848-8600 FAX No:781-843-8807 EMAIL ADDREss: mrirece tionamcsweene ricci.com INSURER S AFFORDING COVERAGE NAIC 9 1013112018 INSURER A: The Hanover InSUrenCe COm an 22292 EACH OCCURRENCE $1,000,000 _ INSURED RGF00-2 BG Food Mansfield LLC BG Food LLC INSURER a INSURER C: - PERSONAL &ADV INJURY $1,000,000 280 School Street #D115 INSURER D: INSURER E: Mansfield MA 02048 INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED _ AUTOS AUTOS NON -OWNED HIRED AUTOS HAUTOS COVERAGES CERTIFICATE NUMBER: 1196484508 REVISION NUMULK: 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 NTH 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 R OF INSURANCE ADDLTYPE INSD MID SUER POLICYNUMBER MMIDIDYrYYYY MMIDDNYYYY LIMITS A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I -X-1 OCCUR 2BN008450700 1013112018 102112018 EACH OCCURRENCE $1,000,000 OAMAGET RENTED PREMISES Ea occurrence $1,000,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY []PRI LOC JECT OTHER: GENERAL AGGREGATE $2,00,000 PRODUCTS-COMP/OP AGG $2,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED _ AUTOS AUTOS NON -OWNED HIRED AUTOS HAUTOS COMBINED SINGLE LIMIT Ea accitlenl $ BODILY INJURY (Per person) $ BODILY INJURY(Per acGtlent) $ PROPERTY DAMAGE $ Per acadenl A X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE UHND06554500 10/3112018 1"12019 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 DEO X RETENTION $j IIII0_ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) (Mandatory It yes, tlescribe under DESCRIPTION OF OPERATIONS below NIA MND05921300 10/12018 10/1!2019 STATUTE PEROERH - E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached if more space is required) ormir ATE u" neo CANCFI I. ATION ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) 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 WITH THE POLICY PROVISIONS. to whom is may concern AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD �' `- at. „�...� �� �� �: p-�} ❑ ® _ o® • i t k p� • G y`�'� ' —�.�� '3 • _ :� �?a �'6 t { f> e � • '� � P • � {�'� �. • _ _ .zt WI4 0 � � u � � � (M� z *--4 z z W4 (W� P4 � � � I � § t3 3 / \ /) y % 42 ) t3 ;t % \ » 4i \\}\ \ \\ t3 t ƒ / ( my\ : ƒ / ƒ / U \ 0 \d \ U § t3 3 / \ /) y % 42 ) t3 ;t % \ » 4i \\}\ \ \\ t3 / my\ ƒ / Jane Doucette From: Jason Sweeney <jasons@bgood.com> Sent: Tuesday, January 8, 2019 5:15 PM To: Jane Doucette Cc: Silas Centeio; Lars Mohlin Subject: B.good Mansfield Food Permit Hi Jane, Our new B.GOOD Mansfield Manager is Silas Centeio. His information is below. We have another certified Manager Elizabeth Colling who is also currently on staff. Please let me know anything else. Silas Centeio silas@bgood.com Cell- 617-291-6165 Thank you, Jason Sweeney B.GOOD Franchise Owner/Operator Mansfield, MA, Cranston RI, and Thayer Street Providence 401-400-4835 www.bgood.com The information, including any attachments, contained in this electronic message is intended for the exclusive use of the addressee(s) and may contain confidential or privileged information. Any use of the material by any unintended recipient is strictly prohibited. If you are not the intended recipient, please notify the sender immediately and destroy all copies of this message and any attachments. Thank you. `' z&i (,Ce% cmc% n �Gu�vetlae�ii`z.� u�umv ��fa: Delmarie Valladares /0cc iuucore feece J,1C, fr c/ CO -17" -17 fele,/ Y/0", .The Always FoodSafeCompany Allergen Awareness Employee Food Safety Online Course & Exam Date: 02/06/2019 (valid+ until 2/6/2022) Course reference: ALGN Learner reference: ALGN1001874592 INE This training is approved for 1 continuing education hour toward the initial or recertification application for ACF certification • !r I Nick Eastwood The Always Food Safe Company #7203 President - --t•aal Circle, St. Paul, MN 55702. The Always Food Safe Company Congratulations! Go ahead and traiiic Keep in your wallet for anytime, anywhere proof you passed! AIW S � Safe compony Delmarie Valladares The Nways food Safe Company Allergen Awareness Emplayee Food safety online Course 6 Exam mm: 02f0W019 (validt until2f6/2022) eoa..o.enree.e: ALGN ......erenMe: ALGN1001874592 czmPorn for I eared This lard! h approved for 1 continuirg education uc'ari Delmarie Valladares hour toward the initialed apPli ran ACF ceNIIca er, The Alrays Food Safe Company mo a.or••ooaz,reca.�p ay luras w non ssnam:ml c:.ao.sco:,n. rnxssoz m� .... w.nes�oo-+::w+i •.+r. �oaaomom Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! I 1P For your manager to keep and admire !r>r Aivvagrs Safe czmPorn Delmarie Valladares The Alrays Food Safe Company Allergen Awareness Ea loyee hod Safely enure Cou6e Is Exam aarr OW0612019(validt unlit VW2022) cea,:o,ere:aa�e: ALGN wmo, �eremre: ALGN1001874592 educatin o Tris training is approved for 1 mndion a hour toward the tnWal or recertificationppliglldn for ACF.M.11. wa E..n.. w �reaw.n woex.r.co..:e.m mioy wesem. easr..«.aeac.aa.see+m.rxnssloi mea. -.m rwa s:er�..p.::r .,.„..�»oyrotisloror ALUMNI REFERRAL CODE vc-alumref-31093-1161433 Managers: Get the best training for your staff at alwaysfoodsafe.com/manager and get 10% off $25 or more with this referral code! z O LLMa V W V c 0 0 •E � V c C n v WN O •� .= u t a � W �g ..Q OU Z I.i c f Lo K 0 0 0 LL `Y v rn < N o w Q p p Q X N N ® N r w Cl) J J �= N � O \ € N •O W-2 Z �o w E w f Q v m f v .n a V WV p V N u N � 3 M n v WN