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FOR BOARD OF HEALTH USE ONLY Permit # Issue
FOOD ESTABLISHMENT PERMIT APPLICATION oo
(Application must be submitted at least 30 days before the planned opening da`'
r
Establishment Name
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Establishment Address
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title
Applicant Address �15
Applicant Telephone No.: St-Z 5324 Hour Emergency No.:
Applicant Email pQ f\,vcwkv-06- cYBQ_'CAnfI
Owner Name & Title (If different from applicant) V'v-A T O�
Owner Address Q2Sb Ov • -Sutkk 1Lk00 V4xA0(, C?)a3*a
Owner telephone number 5 - j3'-) b
Owner email
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
11 An Association
partner.
VA Corporation
11
Name \ - Title 11 Address
An Individual
O A Partnership�
(�Vy)p�
11 Other legal Entity
Person Directly �R/esponsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: t-p V\ TCSMA3 —
C�
Address: �WA
t�
Telephone Na50&' �3 j%-Q, (o-t) 24 Hour Emergency No: W 43,° ) `"-01 I
FAX: 6b7'D(O (
E-mail: Y'4-UvLotC c�) U\r\AC CdV ,CS) 6Y\
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name &Title:
til
Address: 69
Telephone No:401- 63 24 Hour Emergency No: 900-3,;Q"6M tq
FAX:
E-mail: ��ac��to.�na t�®K tv��Ccesyd2 .1 0�
6-d-
Food Establishment Information
WATER SOURCE: '
SEWAGE DISPOSAL:
No, of Food Employees:
DEP Public Water Supply No: (If applicable) Odd
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training
(D tr1 ov nmlvckc-o�
Name of pest control company routinely Inspecting the premises for evidenc of pests
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. Yes
Does this establishment require a FOG permit? No If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
,,�r
�l'j Annual
F] Retail Food $126.00 0 Mobile Food Consession
I❑ Temporary
't❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 LI Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
T] Food Service up to 201 + $300.00 0 Pushcart $50.00 If of Pushcarts:
Temporary Time:
R Supermarkets $400 F1 Residential Kitchen $100.00
Rain Date:
Milk & Cream $10.00 0 Caterer $35,00
Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non-PHFs -non-potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
[i ] Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order F] Hot PHF Cooked and Cooled or Hot Held
I❑ Sale of Commercially Pre -Packaged PHFs I❑ Preparation of PHFs For Hot And for More Than a Single Meal Service
Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs Susceptible Population Facility
Sale Raw Animal Foods Intended
of
!❑ Reheating of Commercially to be Prepared by Consumer I❑' Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
VCustomer Self -Service of Non PHF and Non- Customer Self -Service contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for control)
Preparation of Non-PHFs Retail Sale � Offers Raw Or Undercooked Food Of
f❑ Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
I❑ Vacuum Packaging /Cook Chill
❑ Offers RTE PHF In Bulk Quantities Prepares Food/Single Meals for
E] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the
establishment operation will con
board of health on how to obtain
Signature of
of the information provided in this application and affirm that the food
sari 6ty1R 590.000 and all other applicable law. I have been Instructed by the
f 105 C R 590.000 and the federal Food Code.
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 Individual or Corporate Name:L & sf03't�e
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.
II 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.
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 res fines.
Applicant Signature
Applicant Name (please print clearly)
§ 180-16
ARTICLE III
Plastic Waste Reduction
[Added 4-10-2018 ATM by Art. 451
§ 180-16. Purpose.
§ 180-17
The purpose of this bylaw is to protect the Town's natural beauty and
irreplaceable natural resources by reducing the number of single -use
plastic check-out bags that are distributed and used in the Town of
Mansfield and to promote the use of reusable bags.
§ 180-17. Definitions.
The following words shall, unless the context clearly requires
otherwise, have the following meanings:
CHECK-OUT BAG — A bag provided by a store to a customer at
the point of sale. Check-out bags shall not include bags, whether
plastic or not, in which loose produce or products are placed by the
consumer to deliver such items to the point of sale or check-out area
of the store.
DEPARTMENT — The Mansfield Health Department.
HEALTH AGENT — The Health Agent for the Mansfield Board of
Health or their designee.
RECYCLABLE PAPER BAG — A paper bag that is 100% recyclable and
contains at least 40% post -consumer recycled content, and displays
in a visible manner on the outside of the bag the word "recyclable"
or a symbol identifying the bag as recyclable and a label identifying
the bag as being made from post -consumer recycled content and the
percentage of post -consumer recycled content in the bag.
RETAIL ESTABLISHMENT — Any business facility that sells goods
directly to the consumer, whether for or not for profit, including,
but not limited to, retail stores, restaurants, pharmacies, convenience
and grocery stores, liquor stores, seasonal and temporary businesses.
REUSABLE CHECK-OUT BAG — A sewn bag with stitched handles
that is specifically designed for multiple reuse and that:
A. Can carry 25 pounds over a distance of 300 feet;
B. Is machine washable; and
C. Is either:
(1) Made of natural fibers (such as cotton or linen); or
:1
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Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information ,1 Please Print Leeibly
Business/Organization Name: T// ltf�,I� �hs-c
Address
City/State/Zip:
#: 1-767- I-2Go6
Are
1.
ou an employer? Check the appropriate box:
I employees (full and/
Business Type (required):
5. ❑ Retail
am a employer with __tq_
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.
S• ❑ Non-profit
3.❑
[No workers' comp. insurance required]
We are a corporation and its officers have exercised
9. Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.F] Manufacturing
no employees. [No workers' comp. insurance required]*
I LQ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
12R Other
with no employees. [No workers' comp. insurance req.]
*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 #1.
l ant an employer tint is providing,workels' compensation insurance fo• toy en!ploy fesl PKloty isahe policy information.
Insurance Company Name:_L
Insurer's Address:-
City/State/Zip:
Policy # or Self -ins. Lic. # r1 (r I? Po I :J 'S k � Expiration
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 fonn of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby cgrtify, under f(te pans and penalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person:
www.mass.gov/dia
Phone
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
1AlcN�2.rl V:_ `\
Signature of Individual or Corporate Name By: Cor fficer (Mandatory, if Applicable)
(03--C)�I gGcp
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scott's Documcnts\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
CERTIFICATE OF LIABILITY INSURANCE
Page 1 of 2
WE (MMIDONYYYI
12/18/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed.
H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
PRODUCER
Willie Towers Watson Insurance Services Neat, Inc. fka Willie
Insurance Services of California, Inc.
c/o 26 Century Blvd
P.O. Box 305191
Nashville, TN 372305191 USA
INSURED
ItOBBG Corp.;
EinderCare Education LLC; EC PEE Holdings, Inc.;
And Their Wholly Owned Subsidiaries
650 WE Holladay street, Suite 1400
Portland, OR 97232
.lie Towers Watson Certificate Center
1-877-945-7378 JFAX
/-NoJI 1-888-467-2378
Arch Insurance Company
11150
Travelers Indemnity Company
AL Insurance America Inc
__
_ 25658
2q$5q
Arch Indemnity InsUrance Company
_...�_.
30830
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 BY PAID CLAIMS.
_.. -
__. .� _ ._ -__ _� _REDUCED
Wp TYPE OF MBURANCE AUU PO'LICYEFF. POQUYEXP
POLICY NUMBER MMIDO MMIDD LIMITS
X
I COMMERCIAL GENERAL LIABILITY
EACHOCCURRENCE
$ 5,000,000
E ems
PREM)SES(EaocwMgPe
S 5 000 000
CLAIMS -MADE P1 OCCUR
A
X
Abuse/Molestation-Claims Na h'
MED EXP gone peroonl
_,
$ Bxclud
$ 5,000,000
71GPP0512311
12/31/2019
12/01/2020
PERSONALS AOV INJURY
GENT
AGGREGATE LIMITAPPLIES PER:
GENERALAGGREGAT_E_
$ 10,000,000
POLICY ❑ n
1
JECT LOG
PRODUCTS COMPIOPAGG
S 5,000, 000
1
$
OTHER:
AUTONIBRELIABILITY
COMBINEDS IMIT
Lks Mal
= 2,000,000
X
iANYAVTO
BODILY(WURY(Per Person)
E
B
OWNED SCHEDULED
AUTOS ONLY AUTOS
NC26-GP-477N5687-TCT-19
12/O1/2019
12/O1/2020
'--"
BODILY INJURY (Per acdden0
------
S
HIRED NON -OWNED
ONLY AUTOS ONLY
11AUTOS
PRO DAMAGE
IPeraceldenq
_--
S
_
C
X
UMBREL UAB
X OCCUR
._
I
EACH OCCURRENCE
$ 2,000,000
_
EXCE88 LIAB
_ CWMS-MADEI
US00011222LI19A
12/31/2019
12/01/2020
AGGREGATE
_ _
2,000,000
OED
X RETENTION 30,000
S
WORKERS COMPENSATION
X PER T"'$
EMPLOYERS' LIABILITY YIN
S ER
E.L. EACHACCIOENT
1,000,000OFRCERAIEMBERFXCLUDED7
A 1prAND
ANYPROPRIETORIPARTNERIF.XECUTIVE
No
NIA
71NCI4952011 -
12/01/2019
22/01/2020
E.L.DISEASE-EAEMPLOVEE
$ 1, 000,000
(MandeterylnNH)
Un
Under
E.L. DISEASE-POLICYI BUT
$lRPTION 1,000,000
,daurbe
IPTION OPERATIONS twlow
D
Workers Compensation 6
74NCI.000611
12/OL/2019
12/01/2020
S.L. Each Accident
$1,000,000
Employers Liability -
I
E.L. Disease-Pol Lrat
41,000,000
Per Statute
E.L. Disease -Bach
$1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may hs adachsd R more spats Is required)
Legal Entities:
HIRING Corp.
EinderCare Education Holdings LLC
Enowledge Schools LLC
SZE ATTACHED
n nrwn r c nvwcrc 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.
AUTNORR%EEDREPR(]ESENTATNE
Posting Notice - ADS -M7�
®1988.2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
OR ID: 18967910 6ATCH: 1498571
AGENCY CUSTOMER ID:
LOC M:
LVKv ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY NAMED INSUREO --
�uv. KOEHG Corp. ,
EinderCare Education LLC, KC REM Holdings, Ion.;
POLICYNUMBER And Their Wholly Owned Subsidiaries
Sea Page 1 650 RE Holladay Strest, Suits 1400
CARRIER NAIC COON Portland, OR 91232
See Page 1 8ee Page 1 EFFECR9EDATE: See Page 1
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
'FORM NUMBER: 25 FORM TITLE: Certificate of Liabilit
KindarCate Education LLC
EU Education LLC
EinderCare Learning Centers LLC
KinderCare Education at Work LLC
KCE Champions LLC
KC REE Holdings, Inc.
HER Investment LLC
BEE Holden, Inc.
REE Midwest, Inc.
REE Southeast, Inc,
D/B/A
KinderCare Learning Center
KinderCare Education at Work
Knowledge Beginnings
The Grove School
Cambridge School
Champions
Rainbow Child Care Center
T's Learning Center
Workers' Compensation for all states except Monopolistic states,
Coverage for abuse, neglect and molestation is included within the Commercial General Liability Insurance policy
evidenced herein.
INSURER AFFORDING COVERAGE: Arch Insurance Company
POLICY NUMBER: 71WCX45153811 Err OATS: 12/02/2019
TYPE OF INSURANCE:
Workers Compensation and
Employers Liability -
Per Statute
101
LIMIT DESCRIPTION:
E.L. Each accident
E.L. Disease Policy
E.L. Disease Ea. Empl
EEP DATE: 12/01/2020
LIMIT AMOUNT;
$1,000,000
$1,000,000
$1,000,000
Ine ACUHU name and logo are registered marks of ACORD
SR ID: 18967910 BATCH: 1490571 CERT: W14459728
NAICU: 11150
All