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Home My WebLink AboutTGI Fridays -12/31/2021CLI -#q�ogy _ %6,D. FOR BOARD OF HEALTH USE ONL F& Permit # I: FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned Establishment Name TGI Fridays Establishment Address 280 School Street, Suite A-100, Mansfield, MA 02748 Establishment Mailing Address (if different) 19111 N. Dallas Pkwy., Suite 165 Dallas, TX 75287 Attn: Legal- Licensing & Permits Establishment Telephone No (508) 261-4021 1 Applicant Name & Title: TGI Friday's Inc. a ni Ff i Ro l t' Applicant Address 19111 N. Dallas Pkwy., Suite 165, Dallas, TX 75287 Applicant Telephone No.: (972) 662-5400 24 Hour Emergency No.: Applicant Email licensingandpermits@fridays.com Owner Name & Title (If different from applicant) TGI Friday's Inc. Owner Address 19111 N. Dallas Pkwy., Suite 165, Dallas, TX 75287 Owner telephone number (972) 662-5400 Owner email: Establishment Owned By; I I An Association XI A Corporation An Individual A Partnership Other legal Entity 4u,;, j t If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address please see attached list Person Directly Responsible For Daily Operations (owner, person In charge, supervisor, manager etc.) Name & Title: Freddy Camacho, General Manager Address; 280 School Street, Suite A-100, Mansfield, MA 02048 Telephone No; (508) 261-4021 24 Hour Emergency No: (617) 980-6857 FAX; E-mall: licensingandpermits@fridays.com Alt E-Mall: District Or Regional Supervisor (If applicable) i Name & Title: Steven Rossetti, Director of Operations Addross; 19111 N. Dallas Pkwy., Suite 165, Dallas, TX 75287 Telephone No; (603) 315-4522 24 Hour Emergency No; (603) 315-4522 FAX; Email; sossetti@fridays.com Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DER Public Water Supply No: (If applicable) No. of Food Employees: 19 DAYS/HOURS: 7 Days/Week 11AM - 1AM Name of Person(s) In Charge Certified in Food Protection Management: Freddy Camacho Name of Person(s) In Charge Certified in Allergen Awareness Training Freddy Camacho 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. (XI Yes Does this establishment require a FOG permit? Length of Permit: IXI Annual I I Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Yes If yes, please attach the FOG permit application, Establishment Type: I I Retail Food $125.00 1 1 Food Service up to 100 INCLUDING FOOD TRUCKS $176,00 Food Service up to 101 •200 $260.00 'rX I Food Service up to 201 t $300.00 1 1 Supermarkets $400 X I Milk & Cream $10.00 Mobile Food Conseselon NO PHF PREPARED ON SITE $100.00 i I Manufacture Frozen Desserlafto Cream $25.00/(reezer ( l Pushcart $50,00 N of PushcarW ( ( Residential Kitchen $100.00 Caterer $35.00 Food Operallonw Dol/nlllonsPHF • Potentially horardars food plint0orrylorolure controls rorpikod) (Check all that apply): Non•PHF'a • non•polentlally hamMars food(no Ilnp4onywrniura controls ro4ulred) Pp y)' RTC • roadydn-sal tootle (Exsamhvlohos, aolnds, IMrelna which rworl no hidlror pceosalna) IX ( Solo of Commercially Pro -Packaged Non-PHFs ix I Sale of Commercially Pro -Packaged PHFs IXb Delivery of Packaged PHFs Xi Rahooling of Commercially Processed Foods for Service Within 4 Rowe `. ' Cuotomor Soif.$orvico of Non Pi ll7 end Non• Perishable Foods Only X' Preparation of Non -PI We Other rood Operations X I PHFCookad To Order iX I Hot PHF Cooked and Cooled or Hol Hold I I Preparation of PtIFe For Ilol And for More Then a Single Most Service Cold I lolding For Single Most Sorvlco k I PHF and RTE Foods Prepared For Highly I ! Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer iX I Use of Process Requiring A Variance ( Customer Sel(Sorvico and/or HACCP Plan (Including baro hand contact allomallvo, Ilan no a public hontth Ice Manufactured and Packaged for control) Relall Rein Juice Manufactured and Packaged for Retail Sale Oilers RTE PI IF in Bulk Quantities Retail Salo of Snivoge. Oul•OI•Dolo or Recondillonod Fowl Offers Raw Or Undercooked Food Of Animal Origin Vacuum Packaging I Cook Chill `. Propsroo Food/Single Monts rot Colored Events or Inslilullonnl Food Sorvico I, tho undomignod, allosl to the accuracy of Ilia Information provided In thin application and afNnn that Iho food establishment operation will comply wllh 106 CMR 500.000 and all othor oppllcebie low. I have boon Inslmclod by Iho board of health on how to oblate eopigs of 106 CMR 50.01.000 and the foderal Food Code ti gnaum of Applicant Jennifer Rote, VP/General Counsel Pursuanl to Mal, Ch 02C, sec. 40A. I car Midst Ills pot, of poqury, Mot 1, 10 my best knowledge and hotel. tin" filed till slate lax relunls are) paid slain taxes mg Ilder low Social Security Numbar or radars) ID. 13-2677117 Slgnatule of Individual or Corporate Nomtf TGI Fridays Ina. .. _. ..... ._ ... �FRIDAYS TGI Friday's Inc. — Current Officers Raymond Blanchette Director, CEO & President Giovanna Koning Director, Executive Vice President & Chief Financial Officer William Alexander Director, Sr. Vice President & Chief Development Officer John Neitzel President & COO — TGI Fridays -USA Sara Rosenberg Biltorf Chief Experience Officer Marty Ritson Chief Operating Officer - Friday's International Jennifer Rote Vice President, General Counsel & Corporate Secretary Brent E. Bundick Assistant Secretary Leanne Stendell Assistant Secretary w O W U w l W U V z z .4 z w P4 0 ~ G N N N N E U d LL d E � E a) 0 0 0 C1 0 d m Z CL 0 U 0 d Q i Q W 0 I w: a �v ti v o a w N N Q ti Q N p .r, . 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. TGI Friday's file. Signature of Individual or Corporate Name 13-2677117 "Social Security No. (Volunlor;y) or federal Identification Number 13y: C po ate Offi r (Mandatory, if Applicable) Jennifer Rote, VP/ General Counsel "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 IZCVemle to determine whether you have met tax filing of 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 i wle Alow IlecAlup Xcon's kp11111oN.d'm"1 IIn61bIu61nYulx, Iangr.l AN Cl It III II'A I U IN I Olt The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf rvww.niass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: TGI Friday's Inc. Address: Corp: 191 1 1 N. Dallas Pkwy., Suite 165 Store: 280 School Street. Ste. A-100, Mansfield, MA 02048 —Attn`Lzgai- L7cerrsi City/State/Zip: Dallas, TX 75287 Phone #: Corp.: (972) 662-5400 Store: (508) 261-4021 Are you an employer? Check the appropriate box: Business Type (required): 1.❑✓ 1 am a employer with 66 employees (full and/ 5. ❑ Retail In or part-time).* I have 6. ❑ Restaurant/Bar/Gating Establishment am It sole proprietor or partnership and no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Nan -profit 3.❑ [No workers' comp, insurance required] We arc a corporation and its officers have exercised 9. ❑lintertainment their right ol'excmption per c. 152, § 1(4), and we have 10.❑ Manufacturing 4.❑ no employees. [No workers' comp. insurance required]* We are a non-profit by I I,❑ Health Care organization, staf ed volunteers, with no employees. [No workers' comp. insurance req.] 12❑Other *Any appItern I that checks box BI must also lilt oil( the See[ lot] below showing their workers' compensation policy inPonnation. **II'lhc corporate officers have exempted Ihceselves, but the corporaion has other coq>loyces, it workers' compensation policy is required and such an organization should check box M. l ran tnt eutp/grer that l.v ptvmltllttg roarkors' coatpcn.vrrNon lasurance• n- tut), enrployeee. Ifcloun lv I/te pofle� LrfornuuLru. Insurance Company Name: Pennsylvania Manufacturers' Assoc Ins. Co Insurer's Address: 380 Sentry Parkway City/Slatc%Gip: Blue Bell, ^PA 19422-0754 Policy It or Self -ins. I,ic. I/ 202000-10T-90-53-9 Expiration Date: 07/15/2021 Aunch it copy of the workers' compensation policy declarallon page (showing the policy number and expiration (late). Failure to secure coverage ns required under Section 25A of M61, c. 152 can lend to the imposition of' Criminal penalties of it lineup to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form ol'a STOP WORK ORDER and it fine of up to $250.00 a day against the violalor. lie advised that it copy of this statement rally be forwarded to the Office of Investigations of the MA for insurance crweraue verification. l do hereby eer/gJ,. under the pales earl penaldex ttf pelf lrr that Ibe hi1ttrtnatlou provided above, Is True earl correct. Je tlilbr [tote, VIr / (icnerol Counsel 2 Q/11chd use only. Do not sedle In this area. to be eompleled by ehj• or Inu-it gQ7cial City or •fovea: 11crmll/I.Iccnxc ll Issuing Aulht rl", (circle one): I, Board of llcallh 2, Itrlldhug i)epnrinuml 3. Clly/Town Clerk 4, Llcensbug Board 5• SelecUmeu's Of nee 6, Other Contact Perxou: uu w pe 111044, µovtlls Phone N: INSURER: PENNSYLVANIA MANUFACTURERS' ASSOCIATION INSURANCE WORKERS COMPENSATIONRANCE POLICY AND —INFORMATION PI LITY INSURANCE AGE POLICY NO: 202000-10-90-53-9 RENEWAL OF: 201900-10-90-53-9A NCCI Company No: 11916 Account No: 1090539 N.J. Taxpayer Identification No. 132677117000 ITEM 1. NAMED INSURED AND MAILING ADDRESS: PRODUCER NAME AND ADDRESS: TGI FRIDAYS, INC. LOCKTON COMPANIES, LLC (KANSAS CITY) 19111 DALLAS PKWY 444 W. 47TH STREET STE 165 KANSAS CITY MO 64112-0000 DALLAS TX 75287-6928 PRODUCER NO.: 0201 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Extension Of Information Page) ITEM2. POLICYPERIOD: From: 07-15-2020 TO: 07-15-2021 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: AZ CA CO CT FL IL MA MD MN NH NJ NV NY PA RI TN TX VA WI B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 1,000,00o 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 the states, if any, listed here: AL AK AR DE DC GA HI ID IN IA KS KY LA ME MI MS MO MT NE NM NC OK OR SC SD UT VT WV D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. See Classification Schedule. FL Workers Comp. Insurance Minimum Premium: $ 802 Guaranty Assoc. Surcharge: FL WORKERS COMP. IN CHAR Audit Period: ANNUAL Total Estimated GUARANTY ASSOC. SURAR Annual Premium: 2,001,697 Issued At: 83 ILLINOIS Date: 07-23-20 Countersigned by WC 00 00 01 A Copyright 1987 National Council on Compensation InsufanCe INSURED COP! Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: TGI Fridays Address: 280 School St., Suite A-100, Mansfield, MA 02048 Mailing Address: TGI Friday's Inc., 19111 N. Dallas Pkwy., Suite 165, Dallas, TX 75287 Phone/Fax Number:_._.(972) 662-5400 Email: Iicensingandpermits@fridays.com Contact Person/Title for Grease Traps: Freddy Camacho, GM Name of Company scheduled to pump Internal grease trap(s) monthly: Baker Commodities Name of Company scheduled to pump external grease trap quarterly: Baker Commodities Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • 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 acknowledges that the Information submitted In these documents Is true, accurate and complete. Date 10/21/2020 Print Narne�-� Jennifer Rote, VP/General Counsel Mil I • . • 1 : ItiT • u i 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): 240 Seating Capacity (Actual Count): 235 Normal Hours of Food Preparation/Service: Monday _11 AM -.1 AM Tuesday 11 AM - 1 AM Thursday 11 AM - 1 AM Sunday 11 AM - 1 AM Friday 11 AM - 1 AM Wednesday 11 AM - 1 AM Saturday 11 AM - 1 AM 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 Attached to establishment GRU 3 3 3 compartment sink _ 4 4 Handwashing sink 1 1 Commercial Dishwasher 3 3 Bar sink 1 1 Mo Sink 0 ° Garbage Disposal 2 ° Ice Makin Machines 3 ° Violators 4 ° Grills or Ovens 0 o Exhaust Hoods 25 2S Floor drains Other: How are hood vents cleaned? (i.e., In three (3) bay sink, off site by private company): hood vents are cleaned in a 3 base sink daily with the entire system being professional cleaned once a month Is dinnerware pre•rinsed before being washed? x Yes If yes, at what station/sink? dish sink No Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 1 Please list fixtures attached to each grease trap Grease Trap 1 Dishwasher and 3 Bay sink 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)? x Yes No Size 4500 gallons Where is the existing outdoor GRU located? back dock near door 3 covers 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? outside parklnR lot automatic How often Is this grease storage unit emptied? 6-8 weeks Please list the vendor who removes the waste: Baker commodities IJ 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. if— l 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. if— l 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 (T-0 Date: 11 /3/2020 Applicant Name (please i clearly) Jennifer Rote ,NEW � � r r z U W4 *00� � .. r r -1 u � � � � � � � E 2 4 .y . Cl) a °ZJ � . °m. �� r .