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HomeMy WebLinkAboutKinder Care - 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; MILK & CREAM PERMIT 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:. KINDERCARE EDUCATION Whose place of business is: KINDER CARE 515 WEST STREET PERSON(S) IN CHARGE: KAITLYN CHUPINSKI, CENTER DIRECTOR Permit Expires: December 31, 2019 Food Fee: $10.00 License Number: RS -1 BOARD OF HEALTH MichaeCHealey, Chairman 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: `<I n dr -r W re, Establishment Address: q I r)- N GS. -i- St Establishment Mailing Address(if different): Establishment Telephone No.: 5 8 3 Applicant Name & Title: Kaltl nt ttpi nS h) wi-cr Di rector Applicant Address:.5l 5 vq eS Sf Man S h Ud , M h 0/h0q9 Applicant Telephone No.:509-5,31.80 00 24 Hour Emergency No.: S00-01gq Applicant E-mail: kAw p O nsk� @ Ki rdo (a re . co m Owner Name & Title (If different from applicant): K1nQ er Urej EQU_U0.17 oh Owner Address: U60 NG t-fOIIad1( S'r SU I-Ifj 1400 p0rtItna, ®P, 613 Owner Telephone No.: 50? -331-9000 Owner E-mail: �� I IU rid erCdXe (�m Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. @/A Corporation El An IndividualQI N me y� Title Address LJ �1 1 S(Gfi 1 ffl► EJAPart ,��n_I_c�— _�_�_I .... win}P___j^�(_�. �Q_oI1c�OCk�� 0.1 Dfas lerE EJ Other legal alEntity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: K( WI V) ChU P INKI, MW D l rerr r Address: 515 WeS -1 mushelcl MA oow Telephone No: S09-337-9006 24 Hour Emergency No: FAX: 560'a(Qj' 1395 E-mail: KChrtip)JnSA� e rii'1d&6ta� C©#7 Alt E -Mail: District Or Regional Supervisor (if applicable) applicable)) 1 -rQ U er Name & Title: Un(6 Omaro U D Y1 Address: Lqq WIntpYJ1.Wd0n(6 k /k1 aae95 Telephone No: I i i0l.03� - q l-71 24 Hour Emergency No: a/0-(3as _ jq' V l� 7 FAX: h E-mail: hImll t hm 6) kc -d ucAh//�� r), orn Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: 1-0 W n l� �V 1 ' DEP Public Water Supply No: (If applicable) VV No. of Food Employees: DAYS/HOURS: 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): f'! Location: 0 Permanent Location Establishment Type 0 Caterer $35.00 1❑, Moblie Mobile Start Date: Retail ( Sq. Ft) WAilk & Cream $10.00 Mobile End Date:t❑ Food Service up to 100 INCLUDING i1 Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: g [Annual -- — 0 Food Service up to 101 -200 $250.00 Food Service up to 201 + $300.00 t,_i Manufacture Frozen Desserts/Ice Cream $25.00/freezer €❑' Pushcart $50.00 # of Pushcarts: El Seasonal Seasonal Dates: Supermarkets $400 I ' Residential Kitchen $100.00 [F] Reta' Food $125.00 etail Snack Food $50.00 i❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which needno further processing) IQ Sale of Commercially Pre -Packaged Non-PHFst❑' PHFCooked To Orderf❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Q Sale of Commercially Pre -Packaged PHFs t❑'. Preparation of PHFs For Hot And Cold Holding For Single Meal Service Susceptible HF and RTE Foods Pron epared tyFor Highly R1, Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer t i Customer Self -Service ❑ I❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ' :. Customer Self -Service of Non PHF and Non- Vacuum Packaging I Cook Chill ha Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health control) it Ice Manufactured and Packaged for Retail Sale E] Preparation of Non-PHFs Other Food Operations I] Juice Manufactured and Packaged for Retail Sale t❑ Offers Raw Or Undercooked Food Of Animal Origin (i Prepares Food/Single Meals for Catered Events or Institutional Food Service i❑ Offers RTE PHF in Bulk Quantihes 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 copiesvf 105 CMR 590.000 and the federal Food Code. c�V\F Signature of Applicant: r n • !'�\= �� a y� Pursuant to MGL Ch.62C, sec. 49A, I certify under the p nalties of perjury that I, to my best knowledge and be iiS ave filediet'Sfate tax rf and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal 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. urLdyCare Educedof Signature of Individual or Corporate Name U3-0gg1 ILQLV , **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:\Useis\sleite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc Department of Industrial Accidents Office of Invewigations 606 Washington Street Boston, MA 02111 wwrt.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Let?ibly Business/Organization Name: K j' da- Carer Address: wt 6 fre City/State/Zip: ivlMSfield MM MPhoneM §DH3i-Vo D0 Are you an employer? Check the appropriate box: Business Type (required): L 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. g• E] 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. ❑ We are a non-profit organization, staffed by volunteers, V , 11%,Other I_.e"h with no employees. [No workers' comp. insurance req.] *My applicant that checks box # 1 must also 811 out the section below showing their workers' compensation policy inform5tion, **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 ant an employer that is providing workgrs' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: 17 City/State/Zip: _ � I VJllt-J TN512305 N 1 n Policy # or Self -ins. Lic. # PP Q 5 1 A 0 I0 Expiration Date: 1 a ! I b< 9 Attack 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 Investieatioils of the DIA for in ran_ coverage verification. I do hereby cer ' , unrjet:'theA ains ay4enaldes ofperjury that the information provided above is true and correct Official use on City or Town: Do not write in this area, to be completed by city or town official. 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.mass.gov/dia Phone Page 1 of 2 ACORD® CERTIFICATE OF ILIA6IL�ITY INSURANCE I DATE 11/05/201805/2018 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(fes) 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 Willie Insurance Services of California, Inc. C/o 26 Century Blvd P.O. Box 305191 CONTACT Willie Towers Watson Certificate Center NAME: PHONN Eu 1-877-945-7378 FAX No: 1-888-467-2378 EMAIL ADDRESS: certificatesWwillis.com INSURERS AFFORDING COVERAGE NAIC9 Nashville, IN 372305191 USA INSURER A: Arch Insurance Company 11150 INSURED RUEHG Corp.: INSURER B: Travelers Indemnity Company 25658 INSURER C: XL Insurance America Inc 24554 RinderCaze Education LLC: RC REE Holdings, Inc., INSURER D: Arch Indemnity Insurance Company 30830 And Their Wholly Owned Subsidiaries 650 HE Holladay Street, Suite 1400 Portland, OR 97232 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W8788671 REVISION NUMRFR- 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 ADOL SUER POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP M /DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ 3,000,000 DAMAGE TO RENTED 3,000,000 PREMISES Ea occurrence $ MED EXP (Anyone person) $ Excluded A PERSONAL& ADV INJURY $ 31000,000 71GPPOS12310 12/01/2018 12/01/2019 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEo LOC GENERALAGGREGATE $ 61000,000 PRODUCTS -COMP/OPAGG $ 3,000,000 $ OTHER: AUTOMOBILE LIABILITY ' COMBINED SINGLE LIMIT Ea accident $ 2,000,000 BODILY INJURY (Per person) $ X ANY AUTO B OWNED SCHEDULED AUTOS ONLY AUTOS HC2E-CAP-477M5687-TCT-18 12/01/2018 12/01/2019 BODILY INJURY ( )Peraec ident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERYDAMAGE $ Per accident C X UMBRELLA LIAR A OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 EXCESS LIAR CLAIMS -MADE US00011222LI18A 12/01/2018 12/01/2019 DED I I RETENTION$ RETENTION $__101 000 A WORKERS COMPENSATION AND EMPLOY RS'LIASILIITY YIN ANYPROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBERNo EXCLUDED7 NIA 71WCI4952010 12/01/2018 .: 12/01/2019 ' x STATUTE ERH � E.L. EACH ACCIDENT $ 11000,000 (Mandatory In NH) If yes, describe under E.L. DISEASE -EA EMPLOYEE $ 11000,000 E.L. DISEASE - POLICY LIMIT $ 1, 000, 000 DESCRIPTION OF OPERATIONS below A Workers Compensation 6 71WCX4953810 12/01/2018 12/01/2019 E.L. Each Accident $1,000,000 Employers Liability - E.L. Disease-Pol Lmt $1,000,000 Per Statute E.L. Disease -Each Eraf $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) This Voids and Replaces Previously Issued Certificate Dated 11/02/2018 WITH ID: W8768788. Legal Entities: XUEHG Corp. SEE ATTACHED GhRFIFICATE HOLDER CANCELLATION 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 Posting Posting Notice - XS"" C "- ©1988-2016 ACORD CORPORATION. All Hants reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD sa to, 17013269 BATCH, 940876 AGENCY CUSTOMER ID: LOC #: A` R ® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED KUBHG Corp., Willis Insurance Services of California, Inc. KinderCare Education LLC; KC SHE Holdings, Inc.; And Their Wholly Owned Subsidiaries POLICY NUMBER See Page 1 650 HE Holladay Street, Suite 1400 Portland, OR 97232 CARRIER NAIC CODE EFFECTIVE DATE: See Page 1 See Page 1 See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance KinderCare Education Holdings LLC Knowledge Schools LLC KinderCare Education LLC KU Education LLC KinderCare Learning Centers LLC KinderCare Education at Work LLC KCE Champions LLC KC REE Holdings, Inc. REE Investment LLC REE Holdco, Inc. REE Midwest, Inc. REE Southeast, Inc. D/B/A KinderCare Learning Center KinderCare Education at Work Knowledge Beginnings The Grove School Cambridge School Champions Rainbow Child Care Center T's Learning Center Alexander's Academy Coverage for abuse, neglect and molestation is included within the Commercial General Liability Insurance policy evidenced herein. Workers' Compensation for all states except Monopolistic states. Endorsement to policy HC2ECAP477M5687TCT18 applies as respects Kansas financial responsibility. Named Insured maintains a Student Accident Reimbursement Program, whereby parents are reimbursed for out-of-pocket medical expenses up to the limits of $5,000 per student injury to occur while within Named Insured's care. INSURER AFFORDING COVERAGE: Arch Indemnity Insurance Company POLICY NUMBER: 74WCI1000610 EFF DATE: 12/01/2018 EXP DATE: 12/01/2019 .TYPE OF INSURANCE: Workers Compensation & Employers Liability Per Statute 120081011 LIMIT DESCRIPTION: E.L. Each Accident E.L. Disease-Pol Lmt E.L. Disease -Each Emp LIMIT AMOUNT: $1,000,000 $1,000,000 $1,000,000 © 2008 ACORD The ACORD name and logo are registered marks of ACORD SR ID: 17013269 BATCH: 940876 CERT: W8788671 NAIC#: 30830 reserved. Shedt4 0 TOWN OF MANSFIELD -- SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURERS No. DEPT: BOARD OF HEALTH _ - Date. --- 12/5/2018 Type of Payment: CASH _. _ _ ACCOUNT NO: 01512 -445006 --- Page 1 Bank ft Pkt# TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: BOARD OF HEALTH - FOOD Date: 1-16-2019 Schedule: JHD 11619 From Whom Account Number Amount KINDER CARE LEARNING CENTER 01512-445006 $ 50.00 Cash $ 60.00 Checks $ Total $ Hao Online or Wire Receipt $ TOTAL: $ woo Mansfield, MA 1-16-2019 To The Officer Making the Payments: The above is a detailed list of moneys collected b me, amountingin thea regale to: $ 50.0o for the period ending 1-16-2019 which I have paid to the Town Treasurer whose receipt I hold therefor. -Em toe ead ..tP