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Home My WebLink AboutChipotle Mexican 12/31/2016Commonwealth 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 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:. M. STEVEN ELLS, LLC MANAGER Whose place of business is: CHIPOTLE MEXICAN GRILL #1113 287 SCHOOL STREET, BUILDING B, SUITE 110 PERSON(S) IN CHARGE: LISA FERREIRA, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -78 Food Fee: $62.50 Milk & Cream 0 BOARD OF HEALTH MichaeCMcCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: M. STEVEN ELLS, LLC MANAGER having a place of business at: CHIPOTLE MEXICAN GRILL #1113 287 SCHOOL STREET, BUILDING B, SUITE 110 Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -78 Scott Leite, Heaah ,Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued j FS -78 � { FOOD ESTABLISHMENT PERMIT APPLICATION (Application must -be sub—mitfed at least 3g -days before the planned opening date) 1) Establishment Name CHIPOTLE MEXICAN GRILL #1113 j 2) Establishment Address 287 SCHOOL STREET, BUILDING B, SUITE 110 3) Establishment Mailing Address (if different) 1401 WYNKOOP STREET SUITE 500, ATTENTION: LICENSING DENVER, CO 80202 j 4) Establishment Telephone No (508) 339-2061 5) Applicant Name & Title: CHIPOTLE MEXICAN GRILL OF COLORADO, LLC t 6) Applicant Address 1401 WYNKOOP STREET, SUITE 500, DENVER, CO 80202 7) Applicant Telephone No.: (303) 6954000 24 Hour Emergency No.: (516) 5a7-0366 8) Owners Name & Title M. STEVEN ELLS, LLC MANAGER 9) Owner Address (If different from applicant) j Owner's telephone number 303-222-6044 10) Establishment Owned By: ' 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. O A Corporation f Name Title Address ❑ An Individual ❑ A Partnership 2 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: LISA FERREIRA, GENERAL MANAGER Address: Telephone No: 11774) 526-7063 24 Hour Emergency No: (516) 587-0356 ,FAX: 4508) 339-1687 E-mail: ma.1111mansfield(cDchipotle.com } Alt E -Mail: Licensing@chipotle.com 13) District Or Regional Supervisor (if applicable) Name & Title: VIRANDA MCNALLY, AREA MANAGER Address: Telephone No: %(508) 498-6155 24 Hnur FmRmannv Nn' (516) 587.0356 Food Establishment Information 14) WATER SOURCE: 'TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: 21 17) DAYS/HOURS: MON-SUN 11:00 AM -10:00 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590,003(A) Please attach copy of certificate ❑ Temporary 19) Person Trained in Anti -Choking Procedures (if 25 Seats or more): 20) Location: Q Permanent Location 22) Establishment Type Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: Q Food Service up to 100 or Mobile Comments: up to 10' PHF display $62.50 21) Length of Permit: F1 Food service up to 101-200 Q Annual or up to 25' PHF display $75.00 E] Seasonal ❑ Food Service up to 201 + ❑ Caterer $12.50 Q Milk & Cream $5.00 ❑ Mobile Food & Consession 537.50 ❑ Manufacture Frozen DessertsiIce Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 i Seasonal Dates: or 25+ PHF display 5137.50 ❑Retail Food $50.00 ❑ Temporary ❑ Food Service - Institution ❑ Retail Snack Food $12.50 Temporary Start Date: I ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: i Temporary Time: Rain Date: ❑ Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand 23) Food Operations ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Definitions., PHF - Potentially hazardous food (Urneriempersture controls required) Retail Sale control) Other Food Operations Non-PHFs - non -potentially hazardous tood(no timenemperature controls required) (Check all that apply): Retail Sale Animal Origin RTE ready -to -eat foods (Ex. sandwiches, salads, muffins which need no rurtherprocessing) ❑ Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To OrderI d❑ Hot PHF Cooked and Cooled or Hot Held — - ❑ Sale of Commercially Pre -Packaged PHFs - - - for More Than a Single Meal Service Q Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ❑ ry -- - -- - Susceptible Population Facility s ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially ; to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- E] Customer ❑ Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for contact alternative, time as a public health ❑ Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for' E] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sate of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $62.50 Payment is due with application ❑ 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 to obta�copies of 105 CMR 590.000 and the federal Food Code. )d., l:, Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: CHIPOTLE MEXICAN GRILL #1113 ADDRESS: 287 SCHOOL STREET, BUILDING B, SUITE 110 TELEPHONE AT LOCATION: (508) 339-2051 FAX NUMBER: (508) 339-1687 OWNER OF BUSINESS: M. STEVEN ELLS, LLC MANAGER TELEPHONE OF OWNER: (303) 222-2524 FEDERAL IDISS NUMBER: 84-1485992 FEE: $5.00 PERMIT NUMBER: FS -78 SIGNATURE: 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 (Mandatory) By: Corporate Officer (Mandatory, if applicable) 84-1485992 ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. 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 Applicant Information Please Print Legft Business/Organization Name: Chipotle Mexican Grill of Colorado, LLC Address: 1401 Wynkoop Street, Suite 500 City/State/Zip: Denver, CO 80202 Are you an employer? Check the appropriate box: LM I am a employer with employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, g1(4), and we have no employees. (No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers', comp, insurance req.] 'Any applicant that checks box HI 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, I am an employer that is providing workers' compensallon insurance for my employees. Below is the policy information. Insurance Company Name: Safety National Casualty Corporation Phone #: (303) 222-2524 Business Type (required): 5. ❑ Retail 6. 0 Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 l.❑ Health Care 12.❑ Other Insurer's Address: 1832 Schuetz Road City/State/Zip: St. Louis, MO 63146 Policy # or Self -ins. Lic. # LDS4047264 Expiration Date: 10/1/2016 Attach wcopy ofthe;;workers'=compensation polley 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 penalties of perjury 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 S. Selectmen's Office 6 nth— ACO ® ih� CERTIFICATE OF LIABILITY INSURANCE Page 1 of .1 DATE(MMIDDIYYYY) 09/29/2015 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, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must 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 CONTACT PHONE 877_945-7378 FAX 888-467-2378 Willie of Colorado, Inc. c/o 26 Century Blvd. P.O. Box 305191 E-MAIL certificatesIDwillis.com INSURER(S)AFFORDINGCOVERAGE NAIC# Nashville, TN 37230-5191 INSURERA:Safety National Casualty Corporation 15105-001 10/1/2015 INSURED Chipotle Mexican Grill, Inc. And all Wholly -Owned Subsidiaries 1401 Wynkoop Street, Suite #500 Denver, CO 80202 INSURER B: Scottsdale Insurance Company 41297-001 INSURER C: INSURERD: INSURER E: INSURER F: COVERAGES t rmIHrn WiC iiunnw Gn. 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. E OF INSURANCE DDL MRD SUB WVD_ POLICY NUMBERPOLICY EFF POLICY EXP LIMITS AUTHORIZED REPRESENTATIVE ERCIAL GENERAL LIABILITY OCCUR �•-� GL4047266 10/1/2015 10/1/2016 EACHOCCURRENCE $ 1 000 000 (occur..)$1 000 000 ppM%J?RENTEDAIMS-MADE MEDEXP(Anyoneperson) $ udes Licruor Liab PERSONAL& ADV INJURY $ 1 000 000 GENERAL AGGREGATE $ 2 000 000 EGATELIMITAPPLIESPER: FAUTOMOBILE PRODUCTS-COMP/OPAGG $ 2 000 000 Y PRO LOC JECT X$ :COMBINED LIABILITY UTOBODILYINJURY(Perperson) CAS4047262 10/1/2015 10/1/2016 SINGLE LIMITE (Ea accident) $ 1,000,000 $ BODILY INJURY(Per accident) $ WNEDSCHEDULED AUTOS HIR DSAUTOS US AOT OWNED X $1000 Comp X $1000 Coll Ded. Ded. PROPERTY DAMAGE (ParaccldZ $ $ B X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE UMS0027978 10/1/2015 10/1/2016 EACHOCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 AOS LDS4047264 PS4047265 10/1/2015 10/1/2015 10/1/2016..: 10/1/2016 $ X PER T - X RETENTION $ 10,00C RS COMPENSATION PLOYERS' LIABILITY OPRIETOR/PARTNER/EXECUIlVt: NNIAWI R/MEMBEREXCLUDED? E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 rDEREED tory,in NH)scribeunder IPTION OF OPERATIONS below Work Comp -OK SP4053813 10/1/2015 10/1/2016s E.L. DISEASE -POLICY LIMIT $ 1,000,000 $1,000,000 Bach Accident $1,000,000 Polciy Limit $1,000,000 Each Employee OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additonal Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDtK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sample �•-� nnA A Anf\Dn f r%DDADATIr1N AH rin h}c r'PCPNP(f Coll:4Y'/431U 'XP1CJ.77/607 l iV:G�vvzvcz v,vw r �..----•• ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Named Insureds Chipotle Mexican Grill, Inc. (First Named Insured) Chipotle Mexican Grill Holdings GmbH (Switzerland) Chipotle Mexican Grill Management GmbH (Switzerland) Chipotle Mexican Grill U.S. Finance CO, LLC Chipotle Services, LLC Chipotle Mexican Grill of Colorado, LLC Chipotle Mexican Grill Canada Corp. CMGGC, LLC ShopHouse, LLC ShopHouse Maryland, LLC PL Restaurant, LLC PL Restaurant Holdings, LLC PLRH of Kansas, LLC Chipotle Mexican Grill Texas Holdings LLC Chipotle Mexican Grill of Kansas, LLC Chipotle Mexican Grill of Berwyn Heights, LLC CMG of Prince Georges, LLC Chipotle Mexican Grill of Maryland, LLC Chipotle Texas, LLC Chipotle Mexican Grill UK Limited Chipotle Mexican Grill France SAS CMG Purchasing Co. LLC CMG Purchasing Partners, LLP Chipotle Mexican Grill Germany GmbH (Germany) Chipotle Cultivate Foundation CMG Strategy Co., LLC CMG Pepper, LLC CMG Concessions, LLC LianShan Food and Beverage Management (Shanghai) 6 O l6 � n r m Lai. v p O ;r; .:. M u V r _ O 'r a` U o LO CD LL C w CN C u C O i C1 cu C o rte+ C a a V o Z aQ .. m a o r. f0M u N :C t d - 7 a u 4o a o` W Z 'II = CC C cud O .�� N m a.r _O a LL CL O u r� y i 6 z z H c/1 W W P4 A, �2 5 m oo W 0 W a a LL � cn o� ai cuj ,0 o 0 o 4-4 o U 4) p Q A, �2 5 m oo W 0 o� t3 .N 1 iu o' a r t S, --I v e r Arned . call (.-�PR AED Heart Association Lisa Ferreira the At A (AIR A, �10 ,Uj�gjj of 1hr), tjol wwk("d castWn[[O0/2015 o1oltuo'es , t1fx't Cp2 "VOIL"!I lost UH t, � t) -11/2017 Date m w - r -MI -P -PRO, AM-. lra Lyons ArnbUlance MAO Nj CeM er N Danvers, MA 01923 Into McNeffly EMS Educators 9782783008 Course Location Gto!- BriA r, Inst, ID Name Holcic-'r's Signatme -K 11"j I 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire, express or implied, oral or written," An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer," MGL chapter 152, §25C(6) also states that "every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year, Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e, a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit; The Office of Investigations would like_ to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number., The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05