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HomeMy WebLinkAboutLonghorn Steakhouse #5296 - 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:. RARE HOSPITALITY INTERNATIONAL, INC. Whose place of business is: LONGHORN STEAKHOUSE #5296 390 WEST STREET PERSON(S) IN CHARGE: ANGEL MADERA Permit Expires: December 31, 2019 Food Fee: $250.00 License Number: FS -41 BOARD OF HEALTH MichaeCHeatey, Chairman Milk & Cream (' FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICAI IUN (Application must be submitted at least 30 days before the planned opening date) Establishment Name: Longhorn Steakhouse #5296 Establishment Address: 390 West Street, Mansfield CL Establishment Mailing Address(if different): P.O. Box 695016 Orlando FLGNOV 32869-5016 Establishment Telephone No.: Applicant Name & Title: RARE Hospitality International, Inc. Applicant Address: 1000 Darden Center Drive, Orlando FL 32837 Applicant Telephone No.: 407-245-6787 24 Hour Emergency No.: 800-248-4918 Applicant E-mail: rhayward@darden.com 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 0 An Association partner. Title Address 'LI A Corporation Name O An Individual See attache�LisL__ O A Partnership - O Other legal Entity Person Directly Responsible For Dally Operations (owner, person in charge, supervisor, manager etc.) Angel Madera Name &Title: 54 Desoto Rd Apt 2 West Address: Roxbury, MA 02132 24 Hour Emergency No: 253-820-0989 Telephone No: 253-820-0989 FAX: E-mail: AMadera@loho.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Stephen Scott Address: 1000 Darden Center Drive, Orlando FL 32837 Telephone No:407-245-4000 24 Hour Emergency No: 253-820-0989 FAX: E-mail: Q(�j) <'. ) (It o ` c 1 0 1 Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 4 q DAYSMOURS: Sun-Thurs 11AM-10PM Fri -Sat- 11AM-11PM Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Angel Madera Person Trained in Anti -Choking Procedures (If 2b Seals or more); -� Location: Permanent Location PMoblle Mobile Start Date: Establishment Type Retail ( Sq. Ft) ,t❑�1�. Caterer $35.00 u Mlik & Cream $10.00 Mobile End Date: Mobile Comments: 0 Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 •200 $250.00 El Mobile Food Consession NO PHF PREPARED ON SITE $100.00 0 Manufacture Frozen Dessertslice Cream $25.00Rreezer Length of Permit: 9 Annual 90 Food Service up l0 201 + $300.00 Pushcart $50.00 # of Pushcarts: Q Seasonal Seasonal Dates: cl Supermarkets $400 Residential Kitchen $100.00 0 Retail Food $125,00 Retail Snack Food $50.00 0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food OperationsDefirillions:PHF•Polentlalyhaiamous load( &nehempemrum conhds rmuhe� Non PHPs -non-porenNellyhazemous food(no BmeRempenuum mnhois raquiroo (Check all that apply): I R7E-modylo-eel roods (Er. sandwiches, salads, muffins which need no Nnherpmoessing) 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 or Commercially Pre -Packaged PHFs -- Preparation or Si For Hof And Cold Holding For Single Meal Service O PHF and RTE Foods Prepared Far Highty Susceptible Population Facility ❑cQ Delivery of Packaged PHFs QG Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commerolaliy Processed Foods for Service Within 4 Hours Q Vacuum Packaging I Cook Chill Q Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Q Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑Q Customer Self -Service Ice Manufactured and Packaged for Retell Sale Preparation of Non-PHFs ,,--,,(( Lug 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 sl Offers RTE PHF in Bulk Quantities 0 Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ---- ---- To be completed by the Boal of Health Total Permit Fee: I Payment is due with application w ilvetl I. the undersigned, attest to the accuracy of the information provided In this application and affirm that the food establishment 0 lion will ce ty with 105 CMR 590.000 and all other applicable law. I have been Instructed by the board of heallh on how to ob n cepie of 105 CMR 590.00 and the federal Food Code. Signature of Applicant co �.>'® /.rz Rita Ha ayw rd Agent Pursuant to MGL Ch.02C, 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. Signature of Individual or Corporate Name: RARE HOsPitalit�: International Inc. Social Security Number or Federal to: 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. RARE Hospitality Tnt'l Tom— ijL,14 6 A Colleen Hunter Lyons, Asst Sec Signature of Individual or Corporate Name B orporate Offic (Mandatory, if Applicable) 58-1498312 **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:\UsemWeite\Desktop\Scott's Dmuments\Food Establishments- Temp\TAX CERTIFICATION FORMAoc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 3 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: RARE Hospitality International Inc. dba LongHorn Steakhouse #5296 Address: 390 West Street City/State/Zip: Mansfield, MA 02048 Phone #: 508-261-8810 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 47 employees (full and/ 5. ❑ Retail or pat•t-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. [No workers' comp. insurance required] $• ❑ 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care 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 for my employees. Below is the policy information. Insurance Company Name: XL Insurance America, Inc Insurer's Address: City/State/Zip: Stamford CT 06902 Policy # or Self -ins. Lic. # RGE3001137 Expiration Date: 6/1/2019 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited 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 certif under the pains and enalties o(pergp y that the information provided above is true and correct. ARE HOSPITALII INTERNATIONAL, INC. d Signature: By 11 4u)r" Gt Date: 16131119' Phone #• 800-248-4918 x6787 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia Al^� ®`r—f • — 6 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 05/2912019 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh USA, Inc. 3031 N. Rocky Point Drive West, Suite 700 Tampa, FL 33607 Attn: Tampa.cedrequesl@mamh.com CONTACT NAME: PHONE FAX C o E AIC No Aoorsess: INSURERS AFFORDING COVERAGE NAICN INSURER A: ACE Property & Casualty Insurance Company 20699 CN101737850--GAWU-19-20 5296 LONG INSURED - Darden Restaurants, Inc. GMRI, Inc. - INSURER B: Greenvrich Insurance Com any 22322 INSURER c: XL Insurance America Inc. 24554 INSURER D: XLSpecialty Insurance Company 37885 1000 Darden Center Or Orlando, FL 32837 INSURER E: GENERALAGGREGATE $ 51000,000 INSURER F SIR $ 1,000,000 B rnvconr_cc CERTIFICATE NUMBER' ATL -004378780-11 REVISION NUMtltK: Z v 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. ILTR TYPE OF INSURANCE won won SUER POLICY NUMBER MMODIMYY MMIDO/YYVY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X❑ LIQUOR LIABILITY of Marsh USA Inc. RGE3001137-03 06/01/2019 0610112020 EACH OCCURRENCE $ 1,000,000 PREM SES Ea cccDAMAGE Ture nce $ 1,000,000 X MED EXP (Any one person) $ PERSONAL B ADV INJURY $ 1.000,000 GEML AGGREGATE LIMIT APPLIES PER: X POLICY ❑ PHO ❑LOC ECT OTHER: GENERALAGGREGATE $ 51000,000 PRODUCTS - COMP/OP AGG $ 5,000,000 SIR $ 1,000,000 B AUTOMOBILE UAeam X ANY AUTO SCHEDULED AUTOS X NON -OWNED AUTOS ONLYIAB RAD943779603 0610112019 0610112020 Ea aoc deDISINGLE LIMIT $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Per accidenDAMAGE $ 0HIREDx X OCCURXOO CLAIMS -MADE G28123383004 06/0112019 06/0112020 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 ETENTION$ 25000$ C D D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE Y/N OFFICERIMEMBER EXCLUDED? (Mandatory In Nin Ir yes, describe wMer DESCRIPTION OF OPERATIONS below NIA RWD3001138-03(ADS) RWR3001139-03 (W, AK) RWE9435480-03OH, WA ( ) SIR: $1,000,000 (OH, WA) 06101/2019 06/0112019 I- 1/2020 -' 06/0112020 0610112020 X 8ERTUTE ETH E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE -EA EMPLOYEE $ 2,000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) RE: LongHorn #5296-.390 West Street, Mansfield MA 02048 - This cenifcate cancels and supersedes all previously issued certificates. c unr nco CANCFI I ATION V TBtta-Z06 AGOKU GORFORAI IVIV. All rrgNr3 re5elveu. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Board of Health THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjeeu- V TBtta-Z06 AGOKU GORFORAI IVIV. All rrgNr3 re5elveu. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD .�%O® CERTIFICATE OF LIABILITY INSURANCE OATE VYY) o51z1120181zo16 IY 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh USA, Inc 3031 N. Rocky Point Drive West, Suite 700 Tampa, FL 33607 Attn: Tampa.certrequest@marsh.com- CONTACT NAME: CN JAICNa EeIP FA C No— _ ABDRIESS: INSURER(SIAFFORDINGCOVERAGE NAICN _ INSURER A: ACE Progeny & Casually Insurance Coamany 20699 CNIO1737850--GA_WU-18-19 VARIO DA RDE INSURED Darden Restaurants, Inc. GMRI, Inc. INSURER B : Greenwich Insurance Company 22322 _ — --'- INSURER C: XL Insurance America Inc. 24554 INSURER D: XL Specially Insurance Company 3788_5_ 1000 Darden Center Dr Orlando,FL 32837 -- INSURER E: INSURER F: GENERALAGGREGATE $ 5,000,000 nnvcRArcq CFRTIPICATF NUMRFR: ATL -004375533-07 REVISION NUMBER: I 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. INSRADDL LTR TYPE OF INSURANCE INSD SUBR WVD - POLICY NUMBER POLICYEFF MMID011'YYY POLICYEXP MMIDDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS MADE1XI OCCUR UQUORLIABILITY RGE3001137-02 06/01/2018 0610112019 EACH OCCURRENCE__ $ 1,000,000 DA AGET RRENTED 1,000,000 PREMISES(Eoccunence)a$ X MED EXP (Any one person) $ PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: JECT LOC X POLICY PRO1:1 OTHER: GENERALAGGREGATE $ 5,000,000 - 5,000,000 SIR $ 1,000,000 B AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY RAD943779602 06/0112018 06101/2019 COMBINED SINGLE LIMIT g 2,000,000 Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Peraccident) $ PeOra cRtlTY enDAMAGE $ g X UMBRELLA LIAR E%CESS LIAB X I OCCUR CLAIMS - MADE XOD 628123383003 06/0112018 0610112019 EACH OCCURRENCE g 1,000,000 AGGREGATE g 1,000,000 DED X I RETENTION525,000 $ C D D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYICERIM MBERPARTNER/E%ECUTIVE InH RExcLUDED? N (Mandatory in NH) (Mandatory If yes, describe under DESCRIPTION OF OPERATIONS below NIA RWD3001138-02(AO8) RWR3001139-02 (WI, AK) RWE9435480-02 OH, WA ( ) SIR: $1,000,000 (OH, WA) 06/0112018 06/01/2018 -06/0712019 06101/2018 06/0112019 0610112019 X I S_T_6 UTE ER PER oTH- _ E.L. EACH ACCIDENT b 2,000,000 E.L. DISEASE -EA EMPLOYEE 8 2,000,000 _ EL DISEASE -POLICY LIMIT s 2,000,000 I I — I — 1 7 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: See attached locations This certificate cancels and supersedes all previously issued certificates. The Commonwealth of Massachusetts Office Investigations 600 Washington Street, 7th Street Boston, MA 02111 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 of Marsh USA Inc. Manashi Mukherjee _Dlau,w r,.: IN411teKAA4� ree loom-9n1F Ar:opri cnRPORATIGN. AIf riahis reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER` ID! CN101737560- LOC #: Atlanta ACCN76s ADDITIONAL REMARKS SCHEDULE Page 2 of z ADDITIONAL REMARKS. THIS ADDITIONAL REMARKS FORM. IS A:SCHEDULE+TQ ACORD FORM, .FORM NUMBER: 2S FORM TITLE: 'Certificate of Liability Insurance #1419 Olive Garden, 80 North Dartmouth Mall, North Dartmouth MA 02747. 914360140 Garden, NevryodAve, SouthAlgaboro, MA 02703.' #1460OWe Garden, 1300 Boston Road::Sp.An911e14, MAOtt 19 #1511 Owe Garden; IWorchestar Road Framingham MA DIM #152A Onve Garden, 10951yannough", Hyannis, MA 02601 01626 Odiv0 Gordon, 728 Donald LynodON., Manhorough, MA 01752. 01639Olive Golden, 422 Middlesex Road. Tyrigsboro. MA 01879. #1644 Olive Borden. 1013 County S1601, Taunton, MA 02780 #1659 Clive Gordon, 401 TodmabgyCenter Drive, Stoughton, MA 02072 01674 or" Garden, l l S Matek Road, Oomhester, MA 02125: #d6880gm Gordon, 3Omherd HN Park Drive, Leominster, MA 01453 #1730002 Garden, 102 Odkmy PlacoRoad, PNmaulh, MA 02360: #1804Olive Cordon, 919 RiverdaleS0e4k West Springfield, ;MA.01009 dill 608Olive Garden, 392 Patmal Place South, TSSugditg, Foxboro, MA 006 91025 Or" Garden, go Present Valley.Avenue, Methuen, MA 01844 #INSOWe Garden, 7.Tobin Saloon Way, Womceste(, MA 01844. #1874 Ogm Gordon, 153 Andover Sbeel, Danvers; MA 01923 WS Mama Breeze, 413 Middlesex Road, Tyn05hom, MA 01870 #8328 Yazd Hous, 200 Legacy Place, Dedham, MA 02026 4335 Yard Rated, 8396,126 Brookline Avenue, BOS100MA 02215 #8348 Yazd Revs; 340 Market Shot, Building 320), LynnneM, MA 01940 #5140 Long Ham, 250 FmOdin Village 06", Ranklin, MA 02038 #5145 Long Ham, 227 N Main SI2el, Lemminster, MA 01453 05148 Long Ham, 401 Parti Drive, Basion; MA 02215 45156 Long Ham, 191 Gordan Post Road W. Medbordugh MA 01152 95158 Long Ham, 1260 S Washington Street Fashion Classing Mat, NorthAlthbaro, MA 02760:. #5181 Lang Ham, 59 Plaistev, Read, Haverhi#,MA 01830 #5195 Long Rom,1105 Riverdale, Steel.. West Springfield, MA 010,89 #5226 Lang Rom, 70 WoRCeeler P2vddmr Drive. Suile GM Millbury, MA 01527 95M Long Hem. SM Rout044, Raynbaln. MA 02767 95284 Long Ham. 11910 Andover Sued, Tewksbury, MA 01816 -. 05296 Long Hem, 390 Well Street Mansfield, MA 02048 45310 Long Ham,125 Chu arStreet. Pembroke; Me 02359. 05323 Lang Mom, 2421 Cranberry Hwy, Suter 480, Wareham, MA 02571 05325 Log Mom, 39 Walkers amok Olive. Reading, MA 01067 #5518 Lang Ham, $0Higidem! Avenue, Seekonk, MA 02771 #8004 Capital Grike, 250 8aydsmn Sh et CbostautHdl, MA 02487 0028Capilal Grille, l0 Wayside Road, Burlington, MA 01803 907 Coolal Grille, 900 Boylston steel. Hynes Convention M, Boston, MA 02t 16 #4538 Caj inial Gn11e, 220 Boylston Stmet:. Chasten Hl.!, MA 02467 #4530 Seasn's 52, 6 Wayside Road, 8udington, MA 01803 �. ACORD 161 (2006!01) LU 2008ACORD CORPORATION. All rights reserve The ACORD name and logo are registered marks of ACORD AGENCY Marsh DSA, Inc. NAME4INSUPE4 Darden Restaurants Ina. GMRI, Ina 1W60arden Cdate(Or Orlando, FL 32837 POLICY NUMER CARRIER NAIC.CODE . EFFEC7WE GATE:. ADDITIONAL REMARKS. THIS ADDITIONAL REMARKS FORM. IS A:SCHEDULE+TQ ACORD FORM, .FORM NUMBER: 2S FORM TITLE: 'Certificate of Liability Insurance #1419 Olive Garden, 80 North Dartmouth Mall, North Dartmouth MA 02747. 914360140 Garden, NevryodAve, SouthAlgaboro, MA 02703.' #1460OWe Garden, 1300 Boston Road::Sp.An911e14, MAOtt 19 #1511 Owe Garden; IWorchestar Road Framingham MA DIM #152A Onve Garden, 10951yannough", Hyannis, MA 02601 01626 Odiv0 Gordon, 728 Donald LynodON., Manhorough, MA 01752. 01639Olive Golden, 422 Middlesex Road. Tyrigsboro. MA 01879. #1644 Olive Borden. 1013 County S1601, Taunton, MA 02780 #1659 Clive Gordon, 401 TodmabgyCenter Drive, Stoughton, MA 02072 01674 or" Garden, l l S Matek Road, Oomhester, MA 02125: #d6880gm Gordon, 3Omherd HN Park Drive, Leominster, MA 01453 #1730002 Garden, 102 Odkmy PlacoRoad, PNmaulh, MA 02360: #1804Olive Cordon, 919 RiverdaleS0e4k West Springfield, ;MA.01009 dill 608Olive Garden, 392 Patmal Place South, TSSugditg, Foxboro, MA 006 91025 Or" Garden, go Present Valley.Avenue, Methuen, MA 01844 #INSOWe Garden, 7.Tobin Saloon Way, Womceste(, MA 01844. #1874 Ogm Gordon, 153 Andover Sbeel, Danvers; MA 01923 WS Mama Breeze, 413 Middlesex Road, Tyn05hom, MA 01870 #8328 Yazd Hous, 200 Legacy Place, Dedham, MA 02026 4335 Yard Rated, 8396,126 Brookline Avenue, BOS100MA 02215 #8348 Yazd Revs; 340 Market Shot, Building 320), LynnneM, MA 01940 #5140 Long Ham, 250 FmOdin Village 06", Ranklin, MA 02038 #5145 Long Ham, 227 N Main SI2el, Lemminster, MA 01453 05148 Long Ham, 401 Parti Drive, Basion; MA 02215 45156 Long Ham, 191 Gordan Post Road W. Medbordugh MA 01152 95158 Long Ham, 1260 S Washington Street Fashion Classing Mat, NorthAlthbaro, MA 02760:. #5181 Lang Ham, 59 Plaistev, Read, Haverhi#,MA 01830 #5195 Long Rom,1105 Riverdale, Steel.. West Springfield, MA 010,89 #5226 Lang Rom, 70 WoRCeeler P2vddmr Drive. Suile GM Millbury, MA 01527 95M Long Hem. SM Rout044, Raynbaln. MA 02767 95284 Long Ham. 11910 Andover Sued, Tewksbury, MA 01816 -. 05296 Long Hem, 390 Well Street Mansfield, MA 02048 45310 Long Ham,125 Chu arStreet. Pembroke; Me 02359. 05323 Lang Mom, 2421 Cranberry Hwy, Suter 480, Wareham, MA 02571 05325 Log Mom, 39 Walkers amok Olive. Reading, MA 01067 #5518 Lang Ham, $0Higidem! Avenue, Seekonk, MA 02771 #8004 Capital Grike, 250 8aydsmn Sh et CbostautHdl, MA 02487 0028Capilal Grille, l0 Wayside Road, Burlington, MA 01803 907 Coolal Grille, 900 Boylston steel. Hynes Convention M, Boston, MA 02t 16 #4538 Caj inial Gn11e, 220 Boylston Stmet:. Chasten Hl.!, MA 02467 #4530 Seasn's 52, 6 Wayside Road, 8udington, MA 01803 �. ACORD 161 (2006!01) LU 2008ACORD CORPORATION. All rights reserve The ACORD name and logo are registered marks of ACORD all M a In Ir M a d O x � w Z a P! v O H LL LL a a % w LU :1 c „{ 4 Lb u' V r' O O � o ® -` w a y l0 Va G c U 7U T G O a` � r1 N y 'm 9 N W a v , LL LU wa w 9 c N 9 z ii uj �= a 3 E J � a uapjeQ « zLggLgzgpS PJQL�GueW uJOy6uOj -` 6A Va 7U T a wy� V � r1 N y 'm m y N N V uapjeQ « zLggLgzgpS PJQL�GueW uJOy6uOj � r1 I L W4 � u � woo � ul� � Q� z O -M4 z � I 2� W4 0 P4 LT. � � � 7 \ Q = 2 e 2 7 } ƒ * \ - § \ \ \ \ E2z d ©@m « eaL£K§@@;sm u046U g 65§L24p9L2 4"q 'ca* I w. 4"q RARE HOSPITALITY INTERNATIONAL, INC. OFFICERS AND DIRECTORS Address all official correspondence to any of the Corporate Officers below to: P.O. Box 695016, Orlando, FL 32869-5016 Name Title Residence William R. White, III President, Treasurer 4035 Gilder Rose Place and Director Winter Park, FL 32792 Joseph G. Kern VP/Secretary 112 Kennison Drive Orlando, FL 32801 Colleen Hunter Lyons Assistant Secretary 11762 Aurelio Lane Orlando, FL 32827 (RARE Hospitality International, Inc. is a wholly owned subsidiary of GMRI, Inc., whic is wholly owned by Darden Restaurants, Inc., a publicly traded company) National Registry of Food Safety Professionals Food Safety Manager Certification Examination Pass List Order: 9566287 Order Expires: 3/10/2019 Batch: 1 I. BARBOSA , MICHAEL M 2. DMOUR A, ANDERSON R 3, MADERA , ANGEL 4. MANCINI . CIARA A Certificate: 21533395, Date: 12/16/2018 Admin: Jeffrey Isidorio Company: Darden, Jeffrey Isidorio Certificate: 21533396, Date: 12/16/2018 Admin: Jeffrey Isidorio Company: Darden, Jeffrey Isidorio Certificate: 21533397, Date: 12/16/2018 Admin: Jeffrey Isidorio Company: Darden, Jeffrey Isidorio Certificate: 21533398, Date: 12/16/2018 Admin: Jeffrey Isidorio Company: Darden, Jeffrey Isidorio 2018-12-31 14:56 o�400b4 a y ucnronm momux Lon9h,arn Mansfield 5082618812r»'Darden P 1/1 NATIONAL REGISTRY OF FOOD SAFETY RRQFESSIONALSO ANGEL MAb,114RA. HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER! UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS I' PRESI'DENT:- LAWRENIICE 54.. LYNCH, CAE ISSUE DATE: DECEMBER 16, 2018 EXPIRATION DATE: DECEMBER 16,2023 CERTIFICATE NO 2153x997 TEST FORM: EXE79 Thi, crnifaalr I, not "Ild (ar marc • flan Ara yme hone 1W ofinna. Notification of Test Results ID#:XXX-XX- Scaled Test Score: 92 Candidate Status: Pass Test Date: December 16, 2018 Congratulations! Attached is your certificate and wouct card. Picase notify, tho National Registry ornamo or address changes at U+e address below, . Preventing Contamination and Croce Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Campatent) Acllvaly Managing Controls In a Food Establishment (Mastered) Monitoring the Flow of Foods (Mastered) Ensuring Product Time and Temperature (Mastered) Conducting Cleaning and Sanitizing (Mastered) Managing:Physlcal Facility Design & Malntenance:Preventing & Controlling Pests (Competent) National Registry of Food 5ufuly Professionals CERTIFIED FOOD SAFETY MANAGER ANGEL MADERA 54 DESOTO RD APT 2 W ROXBURY, MA 02132 Nationpl Itdgisoy of Food safety PrpfeyNionulNW I G751 Fomm Drive sta 220 I Orlando, p!. 72521 I Phono: 407.=.3830 I Fax: 407352.3603 ANGEL MADERA � ;�M1Il1 N,gm'OrIW''ki -, ienv�rteooeueaiJ%.h Ccnlnanip No; 21377741 .qh mtmibrlanw�,, brae Date: Decenlbcr l0, 3018 .,y,Pu (rMl?]]•ww,l�,: Lxplratbn Data: Decnmhnr143027 wjmNN4nmVn i ANGEL MADERA 54 DESOTO RD APT 2 W ROXBURY, MA 02132 Nationpl Itdgisoy of Food safety PrpfeyNionulNW I G751 Fomm Drive sta 220 I Orlando, p!. 72521 I Phono: 407.=.3830 I Fax: 407352.3603