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Home My WebLink AboutBertucci's - 12/31/2019a Commonwealth 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:. BERTUCCI'S RESTAURANT, LLC Whose place of business is: BERTUCCI'S 280 SCHOOL STREET PERSON(S) IN CHARGE: BILL HERREN, GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $300.00 License Number: FS-1 BOARD OF HEALTH MichaeCHeaCey, Chairman Milk & Cream xr 1-UK t3UAKU UI' hitAL 1 H USt UNLY Permit # Issued 1 VVV LV Il1U"IVI IIV] "I`1 i I "IAIVII I nI I "IVm I I V I (Application must be submitted at least 30 days before the planned ope�r�il a, 1) Establishment Name �� C�j S ---- ----- - 2) Establishment Address (,'5 .0 3) Establishment Mailing Address (if different) �� C c c.0 Ce^� �l✓� �� YOa 4) Establishment Telephone No '"7j 5 Applicant Name & Title: ---------- -- 6) Applicant Address 41 c.�,o AU LCe,)fj� f / �� .� /71� y U✓��ilc(� 1 7) Applicant Telephone No.: 24 Hour Emergency No.: 3 d' 8) Owners Name & Title ------------- 1- 9) Owner Address (If different from applicant) Owner's telephone number ) - L-) 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers L 1 An Association or partner. '.l A Corporation Name Title Address An Individual A Partnership 14i OtherJega_I Enter_-_.--- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 2 L L /�� ( Gel? e-4-c-t Mcn � (f2 Address: Telephone No: Pt q0) _ of 3 8� 24 Hour Emergency No: 77 `-r7-X-eF- 70,37 FAX: - - E-mail:- -- 'j..f� (- fir% Idlc J -- Alt E Mail: Li C.Q st 5 Col �c d j 13) District Or Regional Supervisor (if applicable) Name &Title: \,5u 2 e t,-t� Lc-lyo� j Address: 1 Telephone No: r% 7 , / _ _ .7 a7 24 Hou FAX: - - E-mail: CC:/S. Pi3 A!I 01 ,, d r Emergency No: 7 Food Establishment Information 14) WATER SOURCE:, 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: AA-,.� A) c, )ec q o o -SF/ r ci•_/, 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained In Anti -Choking Procedures (If 25 Seats or more): ` ��/��,� /J(/) Aei %e7 20) Location: `Permanent Location 22) Establishment Type E3 Caterer $25.00 Mobile Mobile Start Date. U Retail ( SclFt) Milk & Cream $10.00 Mobile End Date: Mobile Comments: 21) Length of Permit XAnnual [ I Seasonal Seasonal Dates: I iJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Food Service up to 100 or up to 10' PFIF display $126.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 [XFood Service up to 201 + or 25'+ PHF display $275,00 Food Service - Institution ( Meals/Day) C'o/') /cSUn/ &"---. Mobile Food & Consession $75.00 Manufacture Frozen Dessertsilce Cream $25,00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 0 Retail Food $100,00 Q Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: r- 23) Food Operations Oeflni(lons: PHF- Potentially hazardous food (tlmeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time Temperature controls required) !(Check all that apply): RTE-ready-lo-eat foods (Ex, sandwiches, salads, muffins which need no funherpmcessing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs I J Delivery of Packaged PHFs i' Reheating of Commerclally Processed Foods for Service Within 4 Hours - Customer Self -Service of Non - Perishable Foods Only _I Preparation of Non-PHFs Other Food Operations XPHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Ice Manufactured Retail Sale Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin Offers RTE PHF in Bulk Quantities iL] Prepares Food/Single Meals for Catered Events or Institutional Food Service 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 LJ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will cc ply with 105 CMR 590.000,and"all other applicable law. I have been Instructed by the board of health on how to oblifih copies of 105 CMR 590:600 and the federal Food Code. 24) Signature of Applicant: it f Pursuant to MGL Ch.62C, seik,,tW49A, ),e dify under the penalties of perjury that I, to my best knowledge and belief, have filed all slate tax returns and paid slate taxes require un (Taw. 25) Social Security Number r Federal ID: 26) Signature of Individual or Corporate Name: f� �' r'? (/l) C Gr S �-P S�C;t,C.'��-C'•'L'r 7 L-�—L. TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best imowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporat ff cer (Matzdatory, if Applicable) **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. R:\H,althkf a&s DocumeotAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doo The Commonwealill'of Massachusetts Department ofindustrialAccidems I Congress Street, Safte.100 Boston, MA, 0.1144017 www.)7jqsxgov1dia Workers' Compensaflo ajnsurance Affidavit: General Bpsinesses.. TO iii.)VILED %Trtl A.Pplicant , Information Please Print Legibly qu$,iness/ftanization Name'. Lci Adilmn p),Fo e_A:nI Are you An employer? Check the appropriate hoxt 114 lam a employer with (0? employees (full and/ or pad-lim'),* 1.0 J era A soleproprietoror parvcrship and have ME mum Phone hone A: o2rPl— 0371 5; "Retail 6. tZRostmarant/Bar/Eating Eslahli5liment 7. Qiftoo aoillpr satesl Oncl. real estate, Aqw, etc.) N.oa-profit 9, ❑ Entertainment 10J-1 Manuf4eturin& I J.n Health Care AIM Other I arts an empfter lhzqt:Is providing wwrkers' coppinAq1ton ingirgneefortity gn;pqpyee;, flelpiv 1s,flee p 11 , I f r wit It on Insurance11 Company Name:. ;?L'tAie-A Am,-.,p j -, CQ�- 51 Ie �q CS Co lngdrer's Addrdss: (_O(a C2 �Pollcy # Or Selfrhi§, Lie, ,Attach accipy of the workers' compensation policy Failurttosecoravoyerage as required under Section 2. fine tip to S1,500X 17 M161, c. 152 can lead,tollic imposition of criminal penalties OfA as civil. penalties in the r6rrn of a STOP WQRk ORDER and a fine, A copy oftliis SmIpment may pa forwarded to thQ'Offlce, of In this area, to be completed by c4Y or tonvit official. City -or Towru Parmit/Lkense# J!"idaW Authority (circle One); 1. Board Of tichith 2-Building Department 3. City/TqNvn Clerk 4. Licensing Board 5. Selectmen's Office, 6, Other Contact Person: Phooe #,, Page 1 of 1 �® CERTIFICATE OF LIABILITY INSURANCE °07 5i20 a" 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 Willis of Connecticut, LLC c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONEF o atl• 1-877-945-7370 o;1-888-467-2378 _ E-MAIL certificates@willis.00m ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Nashville, TN 372305191 USA _ INSURERA: Zurich Amerioan Insurance Company 16535 INSURED Bertuccils Restaurants, LLC.:.:. INSURER13: American Guarantee and Liability Insurance 26247 4700 Hillenia_Boulevard, Suite 400 INSURER C: INSURER O: Orlando, M 32839 _ INSURERE: NSURERF: COVERAGES CERTIFICATE NUMBER: W6851730 REVISION NUMBER: 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. INBR LTR TYPE OF INSURANCE ADOLSUBR POLICYNUMBER MWDDY� eyWDD EXP LIMITS X COMMERCIALGENERALLIABILITY EACHOCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE PREMISES EeEoccurr0ence $ 100,000 X NED EXP(Any one person) $ 5,000 A RETENTION: $250,000 PERSONAL B ADV INJURY $ 1,000,000 GM 8376969-16 07/01/2018 07/01/2019 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 POUCY D JECT1:1 LOC PRODUCTS - COMP/OP AGO $ 2,000,000 PER LOCATION AGO $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea aoddent $ 1,000,000 BODILY INJURY (Par parson) $ X ANYAUTO A AUTOS ONLY SCHEDULED BAP 8376990-16 07/01/2018 07/01/2019 BODILY INJURY (Per oxidant) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY H PROPERTY DAMAGE Per accident y $ H X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE AUC 6548039-09 07/01/2018 07/01/2019 EACHOCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 DEED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIEfORIPARTNEMEXECUTWE YIN OFFICER/MEMBERIXCLUOED7 No (Mandatory in NH) NIA WC 7969103-00 07/01/2018 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 07/01/2019r E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Liquor Liability GLO 8376989-16 07/01/2018 07/01/2019 Aggregate: $2,000,000 Each Common Cause: 01,000,000. SIR: 0250,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is mquiredl RE: Evidence of Insurance CERTIFICATE 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. AUTHORIZEDREPRESENTATIVE Bertucci's Corporation 155 Otis Street Fes' Northborough, INIA 01532 U 1UBB-LUTb AL:UKU OUKI'UKA I IUN. All rlgnts reServea. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD aR To: 16396462 B H: 775640 1{ 1 y i' w` O t a . x co LL w N O v d N Q c w o v v .P / � \ \ °H H \ G % d ( { � � \ � � \ ° t o \ / � e \ lull \ ) ) ! !E\ , )[3\ ƒ §[\\ t /i } Exhibit A Bertucci's Restaurants, LLC - Officers and Directors Liquor License holder for Bertucci's State of Incorporation - FL Current President Thomas Avallone Thomas Avallone 9211 Point Cypress Drive Orlando, FL 32836 Treasurer Bruce F. Hawkins Bruce F. Hawkins 1585 Chestnut Ave Winter Park, FL 32789 Secretary Jeffrey C. Sirolly Jeffrey C. Sirolly 1886 Meeting Place Orlando, FL 32814 CEO Brian K. Wright Brian K. Wright 80 Black Rock Drive Hingham, MA 02043 CFO Brian Connell Brian P. Connell 3 Patriot Lane Whitman, MA 02382-2379 Assistant Secretary Christine A. Moscaritolo Christine A. Moscaritolo 70 LaGrange Street West Roxbury, MA 02132 Bank # PktH TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: BOARD. OF. HEALTH... Date: 12/17/2018 Schedule: JED121718 From Whom Account Number Amount aERTUM'S 01512-445006 $ 25A0-- Cash $ 25,00 Checks $ Total $ 25.00 Online or Wire Receipt $ TOTAL: $ 25.00' Mansfield, MA 12/17/2018 To The Officer Making the Payments: The above is a detailed list of moneys collected b me, amountingin the a re ate to: $25.00 forihe e—d e n d i n 9 12/17/201 which I have paid to the Town Treasurer whose receipt I hold therefor. Em to ee or Dept Head r DEC 17 2018 CHEC10-C AMTv.._.,._.— °1y : l9