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HomeMy WebLinkAboutChipotle Mexican Grill #1113 - 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:. CHIPOTLE MEXICAN GRILL OF COLORADO, LLC Whose place of business is: CHIPOTLE MEXICAN GRILL #1113 287 SCHOOL STREET, BLD. B, SUITE 110 PERSON(S) IN CHARGE: JOELL VASQUEZ Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-7 BOARD OF HEALTH MichaeCHeaCey, Chairman Milk & Cream (41 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: L'krPO tc Mf'�cca"L t1 &'tt/3 �°tlb 'Idi g �urle 1P0 Establishment Address: 7g � S = coo d S+�` �' (�"` r t Establishment Mailing Address (if different): - •--• Please Change Mailing Addles )� �._ gi Establishment TelephoneNc 60g`33q-2.0(,1 c/o: Licensing Dept. G P.O. Box 182566 e, Applicant Name & Title: G rm Ke t l-ey ` '¢ Columbus, OH 43218-2566 Applicant Address: 9860 L,4y-k1)r 5+t.150 Col�wclnua16H y32'f® Applicant Telephone No.: &W - 31 S'- 2`i?"L 24 Hour Emergency No.: Applicant Email: Ctvts(tto� e 6ki 00 Hf cam Owner Name & Title (If different from applicant): CyjepoFfe McKr`u+ve Crv,'tt o{ Cc7Qraoro LLC Owner Address: 616 PV,#j po rI- Berl tee Or-. (slew Poi i- '`4 CPS 42ta ((e a Owner telephone number: 61 `l " Owneremail: EscPS�S/✓t� �CsiflatdG- 6 t Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. A Corporation Name Title Address El An Individual — ------ ------ A Partnership [Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Toll i UQS'? d L 1� Address: 2 8' 1 5chvo / 54-j Ste it Telephone No: Sob -SS?- 20G f 24 Hour Emer Emergency No: g y 6tr{-31 FAX: E-mail: jiU_k5iviojeclx-joo+le.Cvm Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: ()Aeri 'h F her" MU 5-0 a Address: Telephone No: 1/2 - q 3 ri 24 Hour Emergency No: FAX: E-mail: CfnU4�(la �((1eOoKC.Com I Food Establishment Information WATER SOURCE: (ausv SEWAGE DISPOSAL: rowel DEP Public Water Supply No: (If applicable) No. of Food Employees: 2 DAYS/HOURS: 7� s pty Jec� jo gSAM_ EQ,aarrt 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: Rr Permanent Location Establishment Type: i Caterer $35.00 Ej Mobile Mobile Start Date: Retail -NO FOOD PREP ( Sq. Ft) $125 Milk & Cream $10.00 Mobile End Date: Mobile Comments: Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Q Food Service for 101 -200 seats $250.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Q Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: (� Annual --------------------- Q Seasonal Seasonal Dates: ❑ Food Service for 201+ seats $300.00 Q Supermarkets $400 (] Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 Tobacco Products $150.00 I] Temporary Temporary Start Date: Retail Snack Food $50.00 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 time/temperature controls required) RTE -ready-to-eat foods (Ex. sandwiches, salads, muRns which need no furtherprocessing) 0 Sale of Commercially Pre -Packaged Non-PHFs (] 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 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer Q PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs ---- Reheating of Commercially Processed Foods for Service Within 4 Hours E] Vacuum Packaging f Cook Chill 0 Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) 0 Customer Self -Service of Non PHF and Non- Perishable Foods Only Customer Self -Service Ej Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations i] Juice Manufactured and Packaged for Retail Sale Ej Offers Raw Or Undercooked Food Of Animal Origin ❑ 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 To be completed by the Board of Health Total Permit Fee:' / �S Payment is due with application Q 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of_�105 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 state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of of Individual or Corporate Name: \ /- -�"— 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. cllwoke McPrag 614"[f of C.at®radelLtC. Signature of Individual or Corporate Name By: C orate Officer (Mandatory, if Applicable) gy—Iq{ -s4C1z "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 FORM.doc The Commonwealth of Massachusetts Department of IndustrlalAceidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO DE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Chipotle Mexican Grill Address: 1401 Wynkoop Street, Suite 500 City/State/Zip:_Denver, CO 80202 Phone #: 303-595-2213 Are you an employer? Check the appropriate box: Business Type (required): 1. 1 am a employer with employees (full and/ 5. ❑ Retail orpart-time).* 6. ZRestaurantBar/EatingEstablislunent 2.® I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. S. ❑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 10.0 Manufacturing no employees. [No workers' comp, insurance required]* 4. El We are a non-profit organization, staffed by volunteers, 11.❑ Health Cate with no employees. [No workers' comp. insurance req.] 12.❑ Other •Any applicant that checks box NI must also fill out the section below showing their workers' compensation policy information. Y*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 Nl. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:_ Safety National Casualty Corporation Insurer's Address: 1832 Schuetz Road City/State/Zip: St. Louis, MO 63146 Policy # or Self -ins, Lie. # LDS4047264 Expiration Date: 10/01/2019 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. Signature:..______ Date: f�1(3AF Iq-318- 2q76 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. Cityfrown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact wwwanass.guv/dia Ac6mO® CERTIFICATE OF LIABILITY INSURANCE DAT09/28/28//20 1'YYY) 18 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, ANDTHE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(his) 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 endorsements . PRODUCER MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC. 5080 Spectrum Dr., Suite 900E CONTACT NAME` A/C No Exit: 469-232-2100 FAX No: EMAIL ADDRESS: Addison, TX 75001 INSURER(S) AFFORDING COVERAGE NAIC4 _ INSURER A:Safiety National Casualty Corporation 15105 INSURED INSURED Mexican Grill, Inc. INSURER B:James River Insurance Company 12203 INSURER C: 1401 Wynkoop Street, Suite #500 Denver, CO 80202 INSURER D : INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER:VL49Q824 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. TR TYPE OF INSURANCE AMSUD POLICY NUMBER MM/DDPOLICTYYYY EFF OLICY MM/DD E%P LIMITS A X COMMERCIAL GENERAL LIABIUTY GL4047266 10/01/2018 10/01/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XI OCCUR PREMISES Ea ccurnmcal $ 1,000,000 X MED EXP(My one Person) $ Liquor Liab$1M Each Occ/Aggregate PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO POLICY ❑ PRO- LOG PRODUCTS $ 2,000,000 Policy Max General Agg: $ 25,000,000 OTHER: A AUTOMOBILE LIABILITY CAS4047262 10/01/2018 10/01/2019 COMBINED MBI dEDISINGLE LIMIT 100,000 X BODILY INJURY (Par rmsan) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Par eccldant) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY O etl00 Comp X $1,000 Coll Ded PROPERTYDAMAGE Peracciden! $ R $ B UMBRELLA LIAB X OCCUR 000793741 10/01/2018 10/01/2019 EACH OCCURRENCE $ 5,000,000 X AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDEW O (Mandatory in NH) NIA LDS (ADS) PS4047265 1) SP4059381 Excess OH) 10/0112018. 10/01/2019 `X STATUTE OEH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) 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. For Information Only AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) Page 1 of 1 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1 .. Cl) O N O c ,O M E LM Oommom O vID oQ 0 `.V T V C\ n C n 0 0 0 0 Z f.alrr>31�,� RESOLUTIONS DULY ADOPTED BY THE BOARD OF DIRECTORS OF CHIPOTLE MEXICAN GRILL, INC. DECEMBER 5, 2018 Dele$atfon_of Authority for Licensers _Permlt Applicatlons and Sbnilar Operatinz_Filings WHEREAS, the Company and certain of its subsidiaries, both domestically and abroad (the "Restaurant Ooeratine Companies"), operate retail restaurants, and in so doing are required to secure and maintain certain operating permits, licenses, registrations and other authorizations to do business, including licenses to sell alcoholic beverages (collectively, "Operating Licenses and Permits"); WHEREAS, the obligations of the Restaurant Operating Companies to secure and maintain Operating Licenses and Permits are managed and discharged by a licensing department, which is overseen by the Licensing Manager, a position currently held by Timothy Luskin; and WHEREAS, the Board desires to facilitate the Restaurant Operating Companies' securing and maintaining Operating Licenses and Permits by authorizing the Licensing Manager to execute applications for, renewals of, and other documentation pertaining to Operating Licenses and Permits, for and on behalf of the Restaurant Operating Companies. NOW THEREFORE, BE IT RESOLVED, that Timothy Luskin, for as long as he serves as Licensing Manager, and any individual succeeding Timothy Luskin as Licensing Manager, is hereby authorized and empowered to execute and deliver for and on behalf of the Company and the other Restaurant Operating Companies, any applications for, renewals of and other documentation pertaining to Operating Licenses and Permits necessary for the operation of restaurants in the ordinary Course of business of the Restaurant Operating Companies, and to perform all suchactsand to execute such additional documents as may be necessary of appropriate in connection Will) Such Operating Licenses and Permits. CH1pOTI..E,mEXicAN Ca2ILL INC SECRETARY'S CERTII; ICA rE The undersigned, bung the duly -appointed General Counsel and Corporate Secretary of CHIPOTLE MEXICAN GRILL, INC., a Delaware, corporation (tile "Comp my"), hereby certifies as follows: (1) That'l imothy Luskin is the duly appointed and qualified Licensing Manager of the Company as of the chic of hereof. (2) That attached as Exhibit A is a u'ue copy of resolutions duly adopted by (he [Board of Directors of the Company ellective December 5, 2018, in accordance with the Restated Bylaws of Clue Company and the Delawarc General Corporation Law; and such resolutions remain in full force and effect as of the date hereof. IN WITNESS WHEREOF, the undersigned has each executed this certificate as of the day of 201 . — CIHPOd'LE MCEXICAN GRILL, INC., a Delnayaa��a��ation lf� rye C Rogc °Tlac�dorcdis Its �iieral COUasel and Corporate Secretary