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Home My WebLink AboutBuffalo Wild Wings - 12/31/20191D 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 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:. BLAZIN WINGS, INC. Whose place of business is: BUFFALO WILD WINGS 321 SCHOOL STREET, SUITE 110 PERSON(S) IN CHARGE: ENRIQUE DIAZ Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: FS-3 BOARD OF HEALTH NichaeCHeatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit tfIssued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date), , r� 1) Establishment Name /) 2) Establishment Addresshoo 3 Establishment Mailing Address if different A I 4) Establishment Te hone No 5) Applicant Name & Title:1 6) Applicant Address 7) Applicant Telepho No.: Ir 24 Hour Emergency No.' �L \ . .� ry�l /f VD 8) Owners Name & Title'tip'i 9) Owner Address (If different from applicant) Owner's telephone number �•.,��+ --. 10) Establishment Owned Ely. 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. Address ZA Corporation Name O An Individual I r — EJ A Partnership Q Other legal Entity- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:-f- r-ttom}��i-- Address: ;' C (y��, i�1 (�. Telephone No: ` a G i [ 7-• 24 Hour Emergency No: FAX: ` ��1///'''��, E-m ail (` i t 60�,�,�A`k� - -G # Alt E Mail, L ) i, + _( f 13) District Or Regional Supervisor (if applicable) Name & Title' . Address:"� - i I l lYi�l } k� tSF '1 -t h/O �l Yh✓t �L�) 1� r V j Telephone No. v 1 •i1 'J r � � " 4 Hour Emergency No: uV � � FAX E-mail�l�r��f�V Food Establishment Information WATER SOURCE: -row► SEWAGE DISPOSAL: nW 0 DEP Public Water Supply No: (If applicable) "d Employees: DAYSIHOURS:ah— myi-s � IC � /✓� �y i l cJ(��• � `�s y r t ^ 1 CJ�VYi 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 Establishment Type Caterer $35.00 E]Moblie Mobile Start Date: 0 Retail ( Sq. Ft) Milk & Cream $10.00 Moblie End Dale: Food Service up to 100 INCLUDING 0 Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: 0 Manufacture Frozen Dessertslice Cream 0 Food Service up to 101 -200 $250.00 $25.00/freezer D< Annual -------- ------ INFood Service up to 201 + $300.00 (J Pushcart $50.00 # of Pushcarts: Q Seasonal Residential Kitchen $100.00 Seasonal Dales: Supermarkets $400 Retail Food $125.00 0 Temporary 0 Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: j Food Operations Definitions: PHF- Potentially hazardous food (timertemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) (Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muXins which need no fudherprocessing) F] Sale of Commercially Pre -Packaged Non-PHFs XPHFCooked To Order E] 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 EJ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service - Delivery of Packaged PHFs ❑] Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ❑� Use of Process Requiring di Variance Customer Self -Service of Non PHF and Non- 0 Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health control) 0 Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin �' Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities, -_ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service ------ ------ To he completed by the Board of Health or Reconditioned Food Total Permit Fee: --------_. Payment is due with application waived I, the undersigned, attest to the accuracy of th information provided in this application and affirm that the food establishment operation'wiQ comply with 105 R 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies ofA CMR 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 slate tax returns and paid state taxes required under law. _ Signature of Individual or Corporate Name: Social Security Number or Federal ID: 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�a_ZAv) \W)QSt7QV Signature of Indivl ual or Corporate Name VP, Corporate Counsel `-�l— lit rz� ( c)---1 "*Social Security No. (Voluntanj) 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:\Users\sleite\Desktop\Scoffs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massaclutsetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 tvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: 3�1 � c._,t X City/State/Zip: N \Oms-�1QAd, M P 02M Wiv Are you an employer? Check the appropriate box: Business Type (required): 1. X I am a employer with kcf� 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. [No workers' comp, insurance required] 8. ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ 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 41 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 Insurer's Address: City/State/Zip: CCam�__ V Policy # or Self -ins. Lic. # Wk JP, C 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 $;50.00.a, day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the-bdA for insurance coverage verification. I do hereby, certiify, under the pains and penalties of perjury that the information provided above is hue and correct. 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 Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mass.gov/dia 1 ® f► CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYM) 1112812018 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(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 MARSH USA, INC. TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 CONTACT NAME: PNON No Y FAX - PHO Ex[ (A/C No): EMAIL ADDRESS: _,- INSURER(S)AFFORDING NAIC# _COVERAGE INSURER A: Americaninsuranw Company 22667 040876-BWW-GAWU-18-19 482 INSB ED Wild Wings, Inc. alo 5500 Wayzata Blvd, Suite 1600 -ACE INSURER B: NIA NIA INSURER C: N/A NIA INSURERD:N/A NIA Minneapolis, MN 55416 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: ATL-004823928-05 REVISION NUMBER: 4 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 ADDL SUBR POLICYNUMBER POLICY ppYEFF POLICY MMIDD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 1XI OCCUR SIR$750,000 XSL G71211605 Liquor Liability: $2,250,000 each common cause $4,000,000 aggregate $750,000 SIR 0612912018 0612912019 EACH OCCURRENCE _ -DAMAGE -RENTED $ 2,260,E TO PREM SES Ea ae $ 1,000,000 X X GEN'L X MED EXP(My one person) $ EXCLUDED Liquor Liability PERSONAL B AOV INJURY $ 2,250,000 AGGREGATE LIMIT APPLIES PER: PRG- ❑ LOC POLICY ❑ ECT OTHER: GENERALAGGREGATE $ 2.250.000 PRODUCTS - COMP/OP AGG $ 2,250,000 $ A AUTOMOBILE LIABILITY ANY AUTO X OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY CAL H2515969A 06129I2018 06129/2019 COMBINED SINGLE LIMIT Eaaccident $ 2,000,000 BODILY INJURY (Par person) _ $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Par accident -- $ _ 5 UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS $ A A A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMeERExcluDE09 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WLR C65228361 (AOS)SIR:$500K SCF C65228403 (WI) WOU C65228324 GA ( ) WCU C65228440(OH) I 1 : 06/2912018 06129/2018 06129/2018 06129/2019` 06129/2019 060912019 06129/2019 X PER OTH- STATUTE ER_ E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Localion: Buffalo Wild Wings #482, 321 School Street, Suite A110, Mansfield, MA 02048 Liquor Liability policy is continuous until canceled. Patio is included. CERTIRICATE Hint r1ER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ,l(� 91988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ISSUING COMPANY Workers' Compensation ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE and Employers Liability 12165 Insurance Policy Information Page POLICY NUMBER ❑ New Px] Renewal ❑ Rewrite Symbol: WLR Number: C6 52 28 36 1 PREVIOUS POLICY NO. ❑ Individual ❑ Partnership ❑ Association Symbol: WLR Number: C64413144 N Corporation ❑ Joint Venture ❑ Other Legal Entity Item 1. INSPIRE BRANDS, INC. Inter/Intrastate ID No.: 910016903 Named 1155 PERIMETER CENTER WEST Insured ATLANTA GA 30338 Federal Employer ID No.: 452485293 Mailing Address Employer's ID No.: PIIC CODE: 5812 For other named insured see Extension of Information Page — Schedule of Named Insured, WC 99 99 99 A For other workplaces see Extension of Information Page — Schedule of Other Workplaces, WC 99 99 99 B Item 2. Policy period: From 06-29-2018 To 06-29 2019 12:01 A.M., standard time at the named insured's mailing address. Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: A L, AR, AZ, CA, C O, CT, D C, D E, F L, G A, H I , IA, I D, I L, I N , KS, KY, LA, MA, M D, M I, M N , M O, M S, N C N E,NJ, NM, NV, NY, PA,RI,SC,TN,TX,UT,VA, W V Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3A. 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 policy limit Bodily Injury by Disease $ 1,000,000 each employee Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: ALL STATES EXCEPT ND,OH,WA,WY, AND STATES DESIGNATED IN ITEM 3.A Item 3D. This Policy includes these endorsements and schedules: See schedule of Forms and Endorsements WC999999D Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE —CLASSIFICATIONS If indicated here, interim adjustments of premium will be made: Minimum Premium collected in CA $ 1000. ❑ Semi -Annually E] Quarterly ❑ Monthly Total Estimated Premium $ 2244586. Deposit Premium $ PRODUCER NAME AND MAILING ADDRESS MARSH USA INC 3560 LENOX ROAD SUITE 2400 ATLANTA GA 30326 PRODUCER CODE: 244022 36-1436000 ATU MARKETING OFFICE: ATLANTA BRANCH ISSUE DATE: 07/25/2018 Authorized Representative WC 00 00 01A (05/88) Copyright 1987 National Council on Compensation Insurance INSURED COPY 1 M �� a 0 � 0 o 0 0 0 0 0 0 q O W LO LO u> i0 00 co 00 co � �O 00 00 z LO LO Lo Lo qLO LO Lo LO a 00 LO 0o 0 C11 M M <D �c q 0 co�c 00 U CO 0 xM a� CO ak) rrKK y O � oo CO p l7v a? co K LO M l0 Q N C11 �n cn a) ro q O O Qxw �w ca.) q H O �UZUUpO.,�U�W 0 w 0 wl� 0 W-4 � u 0-04 W-� � � � � (4� z � z � It �^/ / / w { 3 J �$, « (B % 7777E x � .(��ƒ\7 &{ *. { « 2 \ \ Jane Doucette From: Sent: To: Subject: Attachments: Here are the certificates. FOWN Buffalo Wild Wings 321 School St. Mansfleld, MA 02048 508.339.4035 Mansfield, MA <482@buffalowildwings.com> Wednesday, December 19, 2018 2:46 PM Jane Doucette Food Permit Buffalo Wild Wings Allergen Certificate.pdf; Serve Safe Food.pdf "Alone we can do so little, together we can do so Winch " - Helen Keller Enrique Diaz - General Manager Ann Enos - Assistant General Manager Maria Curran - Service Manager Mike Frenze- hospitality Manager Paul Comperchio - Shift Manager t