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HomeMy WebLinkAboutClaire's 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: RETAIL SNACK FOOD 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:. CLAIRE'S BOUTIQUES, INC. Whose place of business is: CLAIRE'S #5324 280 SCHOOL STREET, SUITE #J150 PERSON(S) IN CHARGE: MICHELE PLANTE, DISTRICT SALES MANAGER Permit Expires: December 31, 2016 License Number: S-18 Food Fee: $12.50 BOARD OF HEALTH NichaeCvlcClean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-18 k t _-- - FOOD ESTABLISHMENT PERMIT APPLICATION - (App�cafion mush be subm►id aft sf 0 days beforeT(ie pTanned opening date) I 1) Establishment Name CLAIRE'S #5324 2) Establishment Address 280 SCHOOL STREET, SUITE #J150 3) Establishment Mailing Address (if different) 3 SW 129 AVENUE, SUITE 400 I j PEMBROKE PINES, FL 33027 4) Establishment Telephone No (508) 339-6185 1 5) Applicant Name & Title: SONIA TEJEDA, LICENSE SUPERVISOR F- --- — _ - 1 6) Applicant Address 3 SW 129 AVENUE SUITE 400, PEMBROKE PINES, FL. 33027 954 392-4433 800 CLAIRES (252-4737) 7) Applicant Telephone No.: ( > 24 Hour Emergency No.: ( ) 8) Owners Name & Title CLAIRE'S BOUTIQUES, INC. 9) Owner Address (If different from applicant) 3 SW 129 AVE. SUITE 400, PEMBROKE PINES, FL. 33027 ; Owner's telephone number 10 Establishment Owned By: l Y � 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. A Corporation Name Title �A%�_��Address _ d® P nP ElAn Individual ren -, o PL ❑ A Partnership1 _triju� s— Dn — vp- ❑ Other legal Entity 12) Person Directly Responsible For D ily perations (owner, person in char e, supervisor, manager etc.) Name & Title: MICHELE PLANTE, DISTRICT SALES MANAGER I Address: 280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No. 1(508) 695-1421 24 Hour Emergency No: (800) CLAIRES (252-4737 FAX: (954) 392-4456 - E-mail: ISONIA.TEJEDA(a),CLAIRES.COM - 1 Alt E -Mail: ADYSBEL.MORALES(cD_CLAIRES.COM 13) District Or Regional Supervisor (if applicable) Name & Title: MICHELE PLANTE, DISTRICT SALES MANAGER i Address: 280 SCHOOL STREET, #J150, MANSFIELD, MA 02048 Telephone No: 1(508) 695-1421 24 Hour Emergency No: (800) 252-4737 (CLa►RES) FAX: (954) 392-4456 E-mail: SONIA.TEJEDA@CLAIRE-S.COM I9 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 7 DAYS MALL HOURS 16) No. of Food Employees: 0 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: , Temporary Time: Retail ( 1,250 Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 ❑ Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Rain Date: 23 Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) ((Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non PRFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held — —__ — -- -- --i for More Than a Single Meal Service r❑ Sale of Commercially Pre -Packaged PRFs ❑ Preparation of PRFs For Hot And —_ - --- - - --- - -___ Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly f Delivery of Packaged PRFs Susceptible Population Facility ❑ rY ; ❑ ----y - {❑ -- ❑ Processed Foods meSery Service Within 4 Hours Solbe Prepared a �b aConsumlerended Vacuum Packaging/ Cook Chili - __--- ---- -- ----- --- ❑ Use of Process Requiring A Variance -d P 1 d f and/or HACCP Plan (includingbarehand ❑ Customer Self Service of Non PHF and Non ❑ Customer Self -Service Perishable Foods Onhr i contact alternative, time as a public health Preparation of Non -PRFs ❑ Ice Manufactured an ac cage or Retail Sale Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin — - "i ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF m Bulk Quantities I Catered Events or Institutional Food Service - - ❑Retail Sale of Salvage, Out -Of Date or Reconditioned Food FTo be completed by the Board of Health _-_ _ ---- ----- Total Permit Fee: $12.50 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 obtain coyiespf 10y CNT 590.001 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I rt"under the and paid state taxes required under la of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 36-202530 //�� {-� 1 �"( /'�` 26) Signature of Individual or Corporate Name: .I `A (1 e S �� 1 100 S 4 1 0 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. CIO r ' Sftv-an-CA1C ° * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 5�D ** 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 �1, — FY Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address:�� �) � � h �i . �� �� t� y r� Qem�ry i rV R 330D� City/State/Zip:�� ��I {L �l Phone Are you an employer? Check the appropriate box: Busin ss Type (required): 1.!am a employer wiih 5 Per employees (full and/ 5. (►Retail or part-time).* t toCovon 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7• n Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• E] Non-profit 3. ❑ We are a corporation and its officers have exercised 9, n Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.n Health Care 4, n We are a non-profit organization, staffed by volunteers, with no employees. [No workers'. comp. insurance req.] I 12.❑ Other *Any applicant that checks box 01 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 pro ding wor rs' compe(n^sation insurance for my e loyees�pBrelow is tf:e policy information. Insurance Company Name:E,Akci S ���V) 1 bf����t�J/ Inc. Insurer's Address: I qq waift kI eLr City/State/Zip: WA —Y - J�� � & n Policy # or Self -ins. Lic. # i�,UJC -Aa-7995 Expiration Date: 20 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 lhe,pains andpenalties 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 5. Selectmen's Office 6. Other Contact Person: www, mass, gov/dia Phone #: AC 1z ® CERTIFICATE OF LIABILITY INSURANCE DAT 01/26/2016 YYY) 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 Aon Risk Services Northeast, Inc. New York NY Office CONTACT NAME: PHONE -7122 FAX 800-363-0105 (AIC. No. Ext): (866) 283 (AIC. No.): E-MAIL ADDRESS: 199 Water Street New York NY 10038-3551 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED Claire's Boutiques, Inc. INSURERA: QBE Insurance Corporation 39217 INSURER B: General Casualty Company of Wisconsin 24414 2400 w. Central Rd. Hoffman Estates IL 60195 USA INSURER C: Praetorian Insurance Company 37257 INSURER D: Continental Casualty Company 20443 INSURER E: GENT AGGREGATE LIMIT APPLIES PER: X POLICY [—]PRO ❑ LOC JECT OTHER: INSURER F. PRODUCTS-COMP/OP AGO $10,000,000 COVERAGES CERTIFICATE NUMBER: 57006105/535 REVISION NUIVIBcrc: 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. Limits shown are as requested SR LTR TYPEOF INSURANCE D INSD S BR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR X SIR: $250,000 CGA3967893 SIR applies per policy terns - & condi i Ons EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $1,000,000 PREMISES Ea occurrence MED EXP (Anyone person) $10,000 PERSONAL& ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: X POLICY [—]PRO ❑ LOC JECT OTHER: GENERAL AGGREGATE $10,000,600 PRODUCTS-COMP/OP AGO $10,000,000 A B A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS CBA3967894 All other States CBA3971192 CT & HI CBA3967735 MA 01/29/2016 01/29/2016 01/29/2016 01/29/2017 01/29/2017 01/29/2017 COMBINED SINGLE LIMIT $2,000,000 Ea accident BODILY INJURY ( Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Peraccident DX uMBRELLALIA6 EXCESS LIAB X OCCUR CLAIMS -MADE L2099751412 01/29/2016 01/29/2017 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 DED X RETENTION $10,000 C C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/ PARTNER / EXECUTIVE N OFFICERWEMBER EXCLUDED? (Mandatory in NH) If yes, descdbe under DESCRIPTION OF OPERATIONS below NIA CWC3967895 All Other States ClyC3967746 Wisconsin SIR applies erpolicy ter p 01/29/2015 01/29/2016 s & condi Ol/29/2017X 01/29/2017 ions STATUTE oRH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Store no. 5324, Mansfield crossing, Mansfield, MA. As Per the Attached Additional insured Endorsement and Claire's Required Certificate Attachment. 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. Route 140 School street LLC AUTHORIZED REPRESENTATIVE WS Management, Inc. Attn: Lease Compliance 33 Boylston Street, Suite 3000 � t%7 ,J /��G ��a � Chestnut Hill MA 02467 USA �ra10 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. Designation of Premises (Part Leased to You): 2. Name of Person or Organization (Additional Insured): AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT i l 3. Additional Premium: INCLUDED (If no entry appears above, the information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the prem- ises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any "occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 13 Certificates of Insurance for Claire's Stores, Inc. Please be advised that although the attached certificate of insurance does not specifically list the requested additional insureds- there is additional insured coverage provided on a blanket basis for Claire's Stores. This means that any entity that has a written contract in place with Claire's Stores is automatically provided with additional insured coverage under the policy. There should be an endorsement included with this cover letter and certificate, titled: Additional Insured- Manager or Lessors of Premises. This endorsement provides additional insured status for any manager or lessor of premises with whom Claire's Stores has agreed to provide additional insured status for- in a written contract or agreement. Please keep in mind that an acord form certificate of insurance in and of itself does not alter coverage, or constitute any purpose other than evidencing the coverages shown, regardless as to what wording is used on it, and in fact, contains a very explicit disclaimer at the top of the form specifically stating its purpose: 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 DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. If you need further information or clarification, please contact us at the information provided below. Aon Client Services Tel: (866) 283-7122 Fax: (800) 363-0105 E -Mail. ACS Chicapo(5-)-ars.aon.com OFFICERS AND DIRECTORS OFFICER/TITLE NAME CFO J. PER BRODIN VICE PRESIDENT BLAINE ROBINSON SECRETARY STEPHEN SERNETT ADDRESS 3 SW 1297" AVE PEMBROKE PINES, FL 33027 3 SW 129TH AVE PEMBROKE PINES, FL 33027 3 SW 129TH AVE PEMBROKE PINES, FL 33027 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 is 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 1 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 local 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-MASSAFE Fax # 617.727-7749 www.mass.gov/dia Form Revised 5-26-05