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Home My WebLink AboutChipotle Mexican Grill - 12/31/2021FOR BOARD OF HEALTH USE ONLY APermit # Issued I \, FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening datef ° I Establishment Name Chipotle Mexican Grill #1113 Establishment Address 287 School Street, Mansfield MA 02048 Establishment Mailing Address (if different) ATTN: Licensing, PO Box 182666, Columbus OH 43218 Establishment Telephone No 508 339.2061 Applicant Name & Title: Sidney Calicoat, Licensing/Agent Applicant Address ATTN: Licensing, PO Box 182566, Columbus OH 43218 Applicant Telephone No.: 380.222.7066 24 Hour Emergency No.: Applicant Email licensing@chipotle.com Owner Name & Title (If different from applicant) Chipotle Mexican Grill of Colorado LLC I i Owner Address 610 Newport Center Dr, Newport Beach CA 92660 Owner telephone number 614.318.2482 Owner email: licensing@chipotle.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. O A Corporation Name Title Address EJ An Individual Helen Kaminski, LLC Manager - 2690 Pala Mesa Ct, Costa Mesa CA 92627 A Partnership V Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Brandon Mercaldo, General Manager Address: 566 Tremont St, Rehoboth MA 02769 Telephone No: 508.339.2061 24 Hour Emergency No: 774.823.6462 (Cell Phone) FAX: 608.339.1687 (store only) E-mail: licensing@chipotle.com Alt E-Mail: ma. 1113.mansfield@chipotle.com District Or Regional Supervisor (if applicable) Name & Title: Christopher Musella, Field Leader Address: 969 Bald Hill Rd, Warwick RI 02886 Telephone No: 508,339.2061 24 Hour Emergency No: 646.942.7934 (Cell Phone) FAX: N/A E-mail: licensing@chipotle.com a Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (If applicable) No. of Food Employees: 25 DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Brandon Mercaldo, General Manager �I Name of Person(s) In Charge Certified in Allergen Awareness Training Brandon Mercaldo, General Manager l Name of pest control company routinely inspecting the premises for evidence of pests Ecolab If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. V Yes Does this establishment require a FOG Yes If please attach the FOG permit application. permit? yes, Length of Permit: Establishment Type: V Annual ] Retail Food $125.00 Mobile Food Consession Temporary IA Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ❑Food Service up l0 101 -200 $250.00 $25.001freezer Temporary End Date: Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: 'E] Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time4emperature controls required) (Check all that apply): Non-PHFs - non-potentiallyhazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sanolviches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs ( Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly 0 Sale of Raw Animal Foods Intended Susceptible Population Facility 0 Reheating of Commercially to be Prepared by Consumer 0 Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand ] Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only [ Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale n Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities ( Prepares Food/Single Meals for [] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply, it h 105 CMR 590.00 and all other applicable law. I have been instructed by the board of health on how to obtain c r of 105 41�2 59 0 a061he federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49. 1 certify nde and paid state taxes required and law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: Ch the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Mexican Grill of Colorado LLC. 84-1485992 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. Chipotle Mexican Grill of Colorado LLC Signature of Individual or Corporate Name By: Cy4orate 9)fficer (Mandatory, if Applicable) 84-1485992 *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\sleae\Desktop\Scott's Doceanents\Food EslablishmGlls-Tcmp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts =: Department of Industrial Accidents _ Office of'Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ADDlieant Infortuation Please Print Legibly Business/Organization Name: Chipotle Mexican Grill of Colorado LLC Address: 610 Newport Center Drive City/State/Zip: Newport Beach CA 92660 Phone #: 380,222.7066 Are you an employer? Check the appropriate box: Business Type (required): Lg I am a employer with 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 (met. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit In 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]** 11 ❑ 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 checic box #1. I ant 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 Rd. City/State/Zip: St. Louis MO 63146 Policy # or Self -ins. Lie. # LDS 404 7264 Expiration Date:_ 10/1/2021 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, a that the information provided above is true and correct. 11 /16/2020 Of fielat 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): I. Board of I3ealth 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: wwcv.mass.gov/dia tr M �. 1,, Business/ Food Establishment Name: Chipotle Mexican Grill #1113 Address:287 School Street, Mansfield MA 02048 Mailing Address: ATTN: Licensing, PO Box 182566, Columbus OH 43218 Phone/Fax Number:380.222.7066 Email: licensing@chipotle.com Contact Person/Title for Grease Traps: Primary: Keana Basket, Keana.Basket@rubicon.com Secondary: Sidney Calicoat, Licensing Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: ® Most recent waste hauler receipt or waste hauler manifest Wind River Wind River ® Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledees that the Print Name Sio0ey Cal in these documents is true, accurate and complete. Date 11/16/2020 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): 100 Seating Capacity (Actual Count): 62 Normal Hours of Food Preparation/Service: Monday 10:45AM-10:OOPM Thursday 10:45AM - 10:00PM Sunday 10:45AM-10:OOPM Tuesday 10:45AM - 10:00PM Friday 10:45AM - 10:00PM Wednesday 10:45AM - 10:OOPM Saturday 10:45AM - 10:OOPM Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 1 3 compartment sink 1 Handwashing sink Commercial Dishwasher Bar sink 1 Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens 1 Exhaust Hoods 2 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): In multiple component sink sprayed with degreasing solution Is dinnerware pre -rinsed before being washed? V Yes No If yes, at what station/sink? Mulitple section sink for scraping, washing, and sanitizing 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 0 Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size 1500 gallons Where is the existing outdoor GRU located? GRU is located in the back of builidng If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: _ Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit Please list the vendor who removes the 3 TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature Applicant Name nt clearly) Sidney Calicoat 11 /16/2020