The URL can be used to link to this page

Home My WebLink AboutCorporate Chefs @ Smith & Nephew - 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:. CORPORATE CHEFS, INC. Whose place of business is: CORPORATE CHEFS @ SMITH & NEPHEW 130 FORBES BLVD. PERSON(S) IN CHARGE: ANN MARIE HATHAWAY Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -11 BOARD OF HEALTH MichaeCHeatey, 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 openin e Establishment Name: Corporate Chefs @ Smith & Nephew e' Establishment Address: 130 Forbes Road Establishment Mailing Address(if different): 22 Parkridge Road Haverhill, MA 01835 Establishment Telephone No.: 508-261-3710 Applicant Name & Title: Kelly Kijanka - License Admin Applicant Address: 22 Parkridge Road, Haverhill, MA 01835 Applicant Telephone No.: 978-372-7400 24 Hour Emergency No.: 978-372-7400 Applicant E-mail: kelly.kijanka@corporatechefs.com Owner Name & Title (If different from applicant): Corporate Chefs, Inc. Owner Address: 22 Parkridge Road, Haverhill MA 01835 Owner Telephone No.: 978-372-7400 Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. ❑O A Corporation Name Title Address 0 An Individual See attached owners O A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Ann Marie Hathaway Address: 130 Forbes Road Telephone No: 508-261-3710 24 Hour Emergency No: 978-372-7400 FAX: 978-372-0150 E-mail: corporatechef.cafeteria@smith-nephew.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Sue Peloquin - District Manager Address: 22 Parkridge Road, Haverhill MA 01835 Telephone No: 508-254-0398 24 Hour Emergency No: 978-372-7400 FAX: 978-372-0150 E-mail: sue.peloquin@corporatechefs.com Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 3 DAYS/HOURS: Monday -Friday 6:30am to 3:OOpm Name of Person In Charge Certified in Food Protection Management Ann Marie Hathaway (attached) If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): It/1 Ann Marie Hathaway (attached) Location: Q Permanent Location ]Moblie Mobile Start Date: Mobile End Date: Mobile Comments: Length of Permit: Q Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type ® Retail ( Sq. Ft) ❑� Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 EJ Food Service up to 101 -200 $250.00 (.7 Food Service up to 201 + $300.00 Fol Supermarkets $400 E3 Caterer $35.00 ❑N Milk & Cream $10.00 iJ Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/ice Cream $25.00/freezer Q Pushcart $50.00 # of Pushcarts: Q Residential Kitchen $100.00 Retail Food $125.00 n Retail Snack Food $50.00 Food Operations Definifions: PHF- Potentially hazardous food (timellemperature controls required) P Non-PHF's - non -potentially hazardous food(no fimeltemperature controls required) (Check all that apply): RTE -ready-to-eat foods (Exsandwiches, salads, mums which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations Q PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Q Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Customer Self -Service Ice Manufactured and Packaged fo Retail Sale r Juice Manufactured and Packaged Retail Sale ® Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date 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 Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $185.00 Payment is due with application r 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 in c pi so f 105 CMR 590.000 /and the federal Food Code. Signature of Ap�pl'Fa .�./ �P�✓ i� h�P %Z`v-6y!'{�1 Pursuant to MGL Ch.62C, sec. 49A, 1ify 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. Corporate Chefs, Inc. Signature of Individual or Corporate Name: Social Security Number or Federal ID: 04 2981626 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. Corporate Chefs, Inc. Signature of Individual or Corporate Name ✓ 6y: Cp%%rate Officer (Mandatory, if Applicable) 04 2981626 "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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORNI.doc ,,I -d,. n m �I , 1 1 , ;1 , i 1 I. .............. �y N M4 1 bf) >tW 1 v r+ co a r,� u� 0 q t �r oU , , ' '\ The Commonwealth of MassachuieJIS g Department of IndustrialAccidents I Congress Street, Suite 100 Boston, NIA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FH,ED WITH THE PERMITTING AUTI�J6RITY. Applicant Information Please I rint Le ibl Business/Organization Name: Corporate Chefs, Inc. Address: 22 Parkridge Road City/State/Zip: Haverhill, MA 01835 Phone #:978-371--/400 ployer? Check the appropriate box: Business Type (,,equired): employer with employees (full and/ 5.' Retailtune)'* Ft'e 6. EjRestaur&n't/EarBatingEstablis ole proprietor or partnership and have noIees j• ❑Office ahtUor Sales nt working forme in any capacity, (incl. real es rkers' insurance g.' [] Non-profit e, auto, etc.) comp, required] .eare a corporation and its officers have exercised 9. ❑ Entertaithhent their right of exemption per c. 152, §I(4), and we have 10.❑ Manufactkring no employees. [No workers' comp, insurance required]* .4.❑ Weare a non-profit organization, staffed by volunteers, I,IE Health C}a e with no employees. [No workers' comp, insurance req ] 12l[] Othei *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy informeUon. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers i compensation policy is requi a and such an organization should check box #1. l I am an employer that isproviding workers' compensation Insurance for my employees. Below is thepoli information. Insurance Company Name: Sentry Insurance a Mutual Company Insurer's Address: P.O. Box80232 i City/State/Zip: Stevens Point, WI 54481 Policy # or Self -ins, Lic. # 9018840 Expiration Date: 09/01/201 Attach a copy of the workers' compensation policy declaration page'(showing policy number and e' iration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to [(ie imposition of crimin penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the foram of a STOP WORK ER 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 Iffice of Investigations of the DIA for insurance coverage verification. I do hereby certio, under the pains and penalties ofperjury that the information provided above Is true an orrect. Signature: 6'4a4ii L �P �� Date �; Phnnr+. 11. 978-372-7400 Official use only. Do not write in this area, to be completed by city or 'town: offrciai City or Town: Permit/License #' '! Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing loard 5. Selectmen's 6. Other Contact Person: Phone www.mass.gov/dia ATE A� o® CERTIFICATE OF LIABILITY INSURANCE 9/1/201. 8/30/2018DIDDIYYYY) 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 ED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INS RER(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 prolisions 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 Lockton Companies 3280 Peachtree Road NE, Suite #250 Atlanta GA 30305E-MAI (404)460-3600 CONTACT NAME, PHONE Fqg E.111 A/C Not: L° ADDRESS, INSURERS AFFORDING COVERAGE NAIC# N INSURER A: Sen Casually an Com 28460 90-18840-06 INSURED Corporate Chefs, Inc. 1433057 Elite Vending, Inc. ABD Catering, LLC 22 Parkridge Road INSURER B: Sen Insurance a Mutual Com an 24988 INSURER C: XL Insurance America, Inc. 24554 INsuRER D. Gemini Insurance Com an 10833 Haverhill MA 01835-7278 1 INSURER E INSURER F; COVERAGES CERTIFICATE Nl1MRFR- tn[nncnn ------- _.--- - ncvralvn rvurvtoI=M; AAAAAAA 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. ]NSR ADD SUERPOLICYEFF POLICYEXP LTR TYPE OF INSURANCE INSO D POLICY NUMBER MMIDD/VYYY MMIDDNYYY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE O OCCUR N N 90-18840-06 9/1/2018 9/1/2019 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 1 000,000 MEDEXP Anyone pars n) $ 5,000 PERSONAL&ADV INJU V $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑PRO ❑ ECT LOC PRODUCTS-COMPIOPAGG $ 2-0 OO OOO OTHER: $ BB AUTOMOBILE LIABILITY N N 90-18840-04 (AOS) 9/1/2018 9/1/2019 Ee 81NED SINGLE LIMIT $ 10-00000 X ANY AUTO 90 -18840 -OS MA 9/1/2018 9/1/2019 BODILY INJURY (Per pej son) $ XX}(XXj{J{ OWNED SCHEDULED NLY AUTOS -- BODILY INJURY (Per accident) $ XXXXXXX D HIRED HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ XXXXXXX Per accident X Drive other OVE1002079011X1 ( ) 9/1/2018 9/1/2019 Excess Limit � $ 1,000,000 C X UMBRELLA LIAR X OCCUR N N US00086357LI18A 9/1/2018 9/1/2019 EACH OCCURRENCE $ 10.000000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 10,000,000 DED ].RETENTION $0 $ XXXXXXX I WORKERS COMPENSATION N X 1 10Ek AN EMPLOYERS' LIABILITY YIN 90-18840-01 9/1/2018 9/1/2019 STATUTE E.L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE90-18840-02(Retro) OFFICERIMEMBER EXCLUDED? � NIA 9/1/2018 9/1/2019 E.L. DISEASE -EA EMPLOYEE $ 1000000 (Mandatory In NH) Dyyes, un E.L. DISEASE -POLICY IMIT $ 1,000,000 IPTIOeantler DESCRIPTION OPERATIONS below B Liquor Liability N N 90-18840-06 9/1/2018 9/1/2019 Each Cl'aim:$ 1,000,600 Aggregate: $2,000,00'0 or Orc,w„ON6 r LV (;Nuvau 1 vh"mLE3 (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION 14540504 I Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES EIE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ©1988.2015 ACI ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CORPORATE CHEFS OFFICERS 22 Parkridge Road Haverhill, MA 01832 978-372-7400 FEDERAL I.D. 04-2981626 Kenneth Bickford, President 96 Alpine Park Road Moultonboro, NH 03254 Alan Ayres, Treasurer 34 Sable Run Lane Methuen, MA 01844 David DesRosiers, Vice President 167 Ocean Drive Seabrook, NH 03874