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HomeMy WebLinkAboutCosi #209 - 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:. COSI, INC. Whose place of business is: COSI #209 280 SCHOOL STREET PERSON(S) IN CHARGE: LISA ARDOLINO, GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -12 BOARD OF HEALTH MichaeCHeaCey, Chairman V, Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued 261610imr., mak, (Application must be submitted at least 30 days before the planned opening date) Establishment Name: COSI #209 Establishment Address: 280 SCHOOL STREET, MANSFIELD, MA 02048. �b milcvc Establishment Mailing Address(if different): Cosi #209 500 Rutherford Avenue, Ste. 130 lots r` Charlestown, MA 02129 Establishment Telephone No.: 508-261-8740 Applicant Name & Title: VICKI BAUE, VICE PRESIDENT BY; Applicant Address: Cosi, 500 Rutherford Ave.nue, Ste. 130, Charlestown, MA 02129 Applicant Telephone No.: 312-310-1336 24 Hour Emergency No.: Vicki Baue 312-310-1336 Applicant E-mail: CosiLicenses@getcosi.com Jaclyn Doucet, Area Director 781-588-4086 vbaue etcosic.om Owner Name & Title (If different from applicant): COSI, INC. Owner Address: 500 Rutherford Avenue, Ste. 130, Charlestown, MA 02129 Owner Telephone No.: 857-415-5000 Owner E-mail: CosiLicenses@getcosi.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. CXA Corporation Name Title Address El An Individual Vicki Baue, VP, 500 Rutherford Ave., Ste. 130, Charlestown, MA 02129 El A Partnership David Polonitza, EVP, 500 Rutherford Ave., Ste. 130, Charlestown, MA El Other legal Entity 02129 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Jaclyn Doucet, Area Director Address: 500 Rutherford Ave., Ste. 130, Charlestown, MA 02129 Telephone No: 781-588-4086 24 Hour Emergency No: 781-588-4086 FAX: 847-580-4964 (On-site - Jeff Carboni, General Manager, E-mail: Jaclyn.Doucet@getcosi.com Cosi #209 (Mansfield), 280 School Street, Alt E -Mail: vbaue@getcosi.com Mansfield, MA 02048; restaurant phone # 508-261-8740 District Or Regional Supervisor (if applicable) Name & Title: Jaclyn Doucet, Area Director Address: 500 Rutherford Ave., Ste. 130, Charlestown, MA 02129 Telephone No: 781-588-4086 24 Hour Emergency No: 781-588-4086 FAX: 847-580-4964 E-mail: Jaclyn.Doucet@getcosi.com 11 Food Establishment Information WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) SEWAGE DISPOSAL: TOWN No. of Food Employees: 15 DAYS/HOURS: Mon - Frid 7:30am-9:00pm, Sat 7:30am-8pm, Sat. 8:30am-8:00pm Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Lisa Ardolino, GM Person Trained in Anti -Choking Procedures (if 25 Seats or more): Location: Pg Permanent Location FlMoblie Mobile Start Date: Mobile End Date: Mobile Comments: Establishment Type Retail ( Sq. Ft) Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 Q Food Service up l0 201 + $300.00 i] Supermarkets $400 i Caterer $35.00 [?g Milk R Cream $10.00 i Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/lee Cream $25.00/freezer Q Pushcart $50.00 # of Pushcarts: E] Residential Kitchen $100.00 El Retail Food $125.00 n Retail Snack Food $50.00 Length Of Permit:171 L jX Annual - --- 'I] Seasonal Seasonal Dates: 0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions:PHF- Potentially hazardous food(tlmeltemperature controts required) Non-PHF's -non-potentially hazardous rood(no timettemperature controls required) RTE - ready-toeat foods (Ex. sandwiches, salads, muhins which need no rudherprocessing) in Sale of Commercially Pre -Packaged Non-PHFslin PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot 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 Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours Do Vacuum Packaging / Cook Chill - -- 0 Use of Process Requiring di 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 fo Ice Manufactured and Packaged r Retail Sale .' Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations Cosi reheats food but doesn't Cook f00d Onsite. I] Juice Manufactured and Packaged for Retail Sale E] Prepares Food/Single Meals for Catered Events or Institutional Food Service E] Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food FTobecompleted by the Board of Healfh Permit Fee:ent is due with application i waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that thefood 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 .v of 105 GMR 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 state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: Cosi, Inc. Social Security Number or Federal ID: 06-1393745 Town of Town of Mansfield - Board of Health 6 Park Rowansfleld Mansfield, MA 02048 Application for Note: Wasn't in 2019 packet so not sure if this separate form is still needed. Copied blank from from 2018 packet. Wilk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: COSI ADDRESS: 280 SCHOOL STREET Mansfield, MA 02048 TELEPHONE AT LOCATION: (508) 261-8740 FAX NUMBER: (847) 580-4964 OWNER OF BUSINESS: COSI, INC. TELEPHONE OF OWNER: (857) 415-5000 FEDERAL ID/SS NUMBER: 06-1393745 FEE: $10.00 PERMIT NUMBER: FS -14 Licensing Contact: Vicki Baue, VP Tel: 312-310-1336 Fax: 847-80-4964 email: CosiLicenses@getcosi.com alt. email: vbaue@getcosi.com SIGNATURE: `^"%A DATE: 12/11/18 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. Cosi, Inc. Signature of Individual or Corporate Name 06-1393745 *"Social Security No. (Voluntary) or Federal Identification Number ULL&kx Vim% , Vice President By: Corporate Officer (Mandatonj, if Applicable) *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:\Usm\sleite\Desktop\Scott's Doemnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations k1wi 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Cosi, Inc. Address: 500 Rutherford Avenue, Ste. 130 City/State/Zip: Charlestown, MA 02129 Phone #: 857-415-5000 Are you an employer? Check the appropriate box: Business Type (required): 1. ® I am a employer with 1,000 employees (full and/ 5. ❑ Retail or part-time).* 6. X❑ 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.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4. Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.❑ 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 #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: The North River Insurance Company Insurer's Address: c/o Hays Companies, 133 Federal Street, 4th Floor City/State/Zip: Boston, MA 02110 Policy # or Self -ins. Lic. # 4087340532 Expiration Date: 5/10/2019 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 gceerrtiify,�under (tthe pains and penalties ofperjury that the information provided above is true and correct Signature: Date: 12/11/18 312-310-1336 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/ma i'1 - XF `; A�� CCERTIFICATE OF LIAQILITY INSURANCE DATE,MM/°°"""' CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 5/11/20118 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 CONTACT NAME: MOira Crosby Hays Companies PHONE FAX _(A/CA,NNo Ext): _ (AIC, NJ: 133 Federal Street, 4th Floor EMAIL mcrosb Qhs scorn anies. com ADDRESS: y y P _INSURER I S) AFFORDING COVERAGE NAIC Boston MA. 02110 _ _ _H_ INSURER A:Liberty Mutual Fire Ins. Co. INSURED INSURER B American Guarantee and Liability 26247 Cosi, Inc. _ INSURERC:Th_eNorth River Insurance Company 21105 500 Rutherford Ave INSURER D: Suite 130 $ 500,000 INSURER E: Charlestown MA 02129 INSURER F: COVERAGES CERTIFICATE NIIMRFR•5.10.18-2.1.19 GL Antn aU mnoco. 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 --.._ -..-- --ADDL SUER ..-- -... POLICY EFF -POLICY EXP- LTR TYPE OFINSURANCE POLICY NUMBER MM/DD/YVYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 A CLAIMS -MADE X_ OCCUR DAMAGE TORELTED PREMISES (Ea occurrence)__ $ 500,000 MED EXP (Any oneperson) $ 10,000 TB5-Z11-B67G9H-028 2/1/2018 2/1/2019 __....._ PERSONAL &ADV INJURY $ 1,000,000 __ AGGREGATE LIMIT APPLIES PER: GENT GENERAL AGGREGATE "" _- __.... $ 2,000,000 X PRO- POLICY .. .._ JECT LOC PRODUCTS - COMP/OP AGO $ 2,000,000 _$ OTHER: _...._ _....__ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) _..__ 1, 000, 000 A X ANY AUTO BODILY BODILY INJURY (Per person) _..... _ $ ALL OS X SCHEDULED AUTOS AUTOS AS2-Z11-B67G9H-018 2 1/2018 / 2/1/2019 BODILY INJURY Per accident ( ) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE _ "--- $ Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ B _.__ EXCESS LIAB CLAIMS -MADE AGGREGATE _25,000,000 -- $ 25,000,000 JDED_F1 RETENTION$ $ AUC 0696679-00 2/1/2018 2/1/2019 WORKERS COMPENSATION _ X FRH AND EMPLOYERS' LIABILITY YIN STATUTE EL EA_C_H ACCIDENT $ 11000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE �N/A C OFFICER/MEMBER EXCLUDED' _ E.L. DISEASE EA EMPLOYE _ $ 11000,000 (Mandatory in NH) 408-734053-2 5/10/2018 5/10/2019 If yes, describe under -- -- - -... DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1 000,000 A Business Personal Property YU2-Z11-B67G9H-098 2/1/2018 2/1/2019 BPP Limit $39,504,781 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Evidence of Insurance Town of Mansfield Attn: Health Department 6 Park Row Mansfield, MA 02048 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 Hays/MCROSB © 1988.2014 ACORD CORPORATION. All riahts rpssprv.w ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD ���,�, %hUMYKflMS7En INSURER: THE NORTH RIVER INSURANCE COMPANY HOME OFFICE: TOWNSHIP OF MORRIS, NJ A STOCK INSURANCE COMPANY 1. THE INSURED AND MAILING ADDRESS: COSI, INC. (SEE NAMED INSURED ENDT) 133 FEDERAL STREET BOSTON MA 02110 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY • INFORMATION PAGE POLICY NO: 4087340532 RENEWAL OF: 4087312056 NCCI CO NO: 14508 INSURED ID NO(S): CLIENT NO: 3521722 PRODUCERNO:83357 PRODUCER NAME AND ADDRESS: NAYS INSURANCE BROKERAGE SERVICES 133 FEDERAL STREET, 3RD FLOOR BOSTON MA 02110-0000 INSURED ENTITY: CORPORATION BUSINESS OF INSURED: RESTAURANTS OTHER WORKPLACES NOT SHOWN ABOVE: (See Extension of Information Page) 2. POLICY PERIOD: FROM 05-10-2018 TO 05-10-2019' Effective 12:01 A.M. Standard Time at the Insured's Mailing Address. 3. COVERAGE: A. Workers' Compensation Insurance: Part One of the Policy applies to the Workers' Compensation Law of the States Listed here: CT DC IL MA MD NJ NY PA VA WI B. Employers' Liability Insurance: Part Two of the Policy applies to work In each state Ilsted In Item 3A. The Limits of our Ilabillty 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 C. Other States Insurance: Part Three of the Policy applies to All States of the United States, except those listed in Item 3A above and In: ND, OH, WA, WY and in any additional states listed below: DE MI MN D. This Policy includes these Endorsements and Schedules: As per schedule of forms and endorsements. 4. THE PREMIUM for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below is subject to verification and change by audit. See Extension of Information Page. AGENCY BILL Total Estimated Minimum Premium: $ 762 Annual Cost: $ 291,232 Audit Period: ANNUAL Issued At; BOSTON MA Deposit Premium: $ 291,232 Date: 05-14-18 DATE Authorized Representative WC 00 00 01 A (2190) Copyright 1987 National council on Compensation Insurance WC 00 00 01 C (7197) r4) a N z 0 Q V � Z ELInk- W O � W ZE kill LO Q n LO Z � G — E LO a v N w O C N cy) w 1 00`o O .2 �E N W� O 4 N ~ ¢� x W YR,r c2 ELInk- � kill LO INS LO O O,0 LO � E D 4 i 1 o o S W W-� 0 W-4 � � u � � � old, L Q� z � z � I � � � z w P4 � � � � I \: M-11 /j Ol \ -J< \= %}! LU \`[ § & C+y \ )f \ 3 / \ \ \ 4 \ x g = Q Ol \ -J< \= %}! LU \`[ § & k 9 C+y \ )f \ 3 / & k 9 1 Q m `Z `Z Q w v N O O O a X � Jane Doucette From: Amy Donovan -Palmer Sent: Thursday, December 27, 2018 10:44 AM To: Jane Doucette Subject: FW: Emailing: Cosi #209 (Mansfield) 2019 Food Service Establishment Permit From: Doucet, Jaclyn [mailto:Jaclyn Doucet@_ etcosi com] Sent: Thursday, December 27, 2018 10:29 AM To: Baue, Vicki; Amy Donovan -Palmer Subject: Re: Emailing: Cosi #209 (Mansfield) 2019 Food Service Establishment Permit Lisa Ardolino yes, please let me know if I can help in any way! Respectfully, Jackie Jaclyn Doucetl Area Director I Cosi, Inc 781.588.40861Jaclvn.Doucet(@Retcosi.com C 0 SIW From: Baue, Vicki Sent: Thursday, December 27, 2018 10:20 AM To: Amy Donovan -Palmer; Doucet, Jaclyn Subject: Re: Emailing: Cosi #209 (Mansfield) 2019 Food Service Establishment Permit Amy - It looks like we have the wrong General Manager's name on this License. Do we need to change it, and if so, can it just be updated and re -issued or what do you need from us? Sorry for this. Jackie - What is the General Manager's name at Mansfield? Thank you, Vicki Vicki Baue V. P. & General Counsel, CCO Cosi, Inc. Tel: (312) 310-1336 Fax: (847) 580-4964 vbaue@getcosi.com Cosi, Inc. (& affiliated entities) New Address as of 10/01/97: 500 Rutherford Ave., Suite #130 Charlestown, MA 02129 Main Tel. No.: 857.415.5000 www.getcosi.com The information contained in this eourrrunieafioo may be confidential, is intended only for the use or ille recipient narned above, and may be legally privileged. if the reader of this message is not the intended recipient, you are hereby notified that any disscraination, distribution, or copping of this cool ill till ication, or anY (if its contents, is sh'iefl,p prohibited. If you have received this aim to it ll ieat for in error, please re -send this comotunieation to the sender and delete file original message and any C01))' ()fit IYon }lour computer systern. 'Thank you. From: Amy Donovan -Palmer <adoalmer@mansfieldma com> Sent: Thursday, December 27, 2018 9:55 AM To: Doucet, Jaclyn; COSILICENCES@GETCOSLCOM; Baue, Vicki Subject: Emailing: cosi Please find your 2019 Food Service Establishment permits for the Town of Mansfield attached. Thank you for your patience this year as we transition to electronic communication. Sincerely, Amy WWWk****W*****W W* Amy Donovan -Palmer, MPH, RS Health Agent Town of Mansfield 6 Park Row Mansfield, MA 02048 508-261-7366 lc� Lo