The URL can be used to link to this page

Home My WebLink AboutCold Stone Creamery 05/31/2016Commonwealth 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:. ASHWANI RATHOR Whose place of business is: COLD STONE CREAMERY 280 SCHOOL STREET D161 PERSON(S) IN CHARGE: ASHWANI RATHOR Permit Expires: May 31, 2016 License Number: FS -34 Food Fee: $160.00 Milk & Cream V BOARD OF HEALTH NichaeCNcClean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: ASHWANI RATHOR having a place of business at: COLD STONE CREAMERY 280 SCHOOL STREET D161 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 513112016 unless previous to that time is suspended or revoked. Expires 5/31/2016 License No.: FS -34 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Manufacture Frozen Desserts and/or Ice Cream Mix The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made hereunder, hereby issues COLD STONE CREAMERY 280 SCHOOL STREET D161 a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This license expires December 31 st of each year. License Number: FS -34 Freezers: 1 TOTAL: $12.50 MANSFIELD BOARD OF HEALTH Scott Leite, Heaah .Agent FOR BOARD'OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit# issued r6-34 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name �6yq C /V\ cc Ipbs 2) Establishment Address g'O C V, -u_/ 3) Establishment Mailing Address (if different) LO 11 Telephone No: 4) Establishment Telephone No 5) Applicant Name & Title: vi ttwl j pet 'V\'A�� 6) Applicant Address 7) Applicant Telephone No.: g S -q go &P 24)g� Hour Emergency No.: ��l 9 lye S-41 13 r( 4 92-6 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation artnershi give name, title, and home address of officers 11 An Association or partner. El A Corporation El An Individual Name Title Address 1,Ir 14 If., Pr5hWtxVV1 )�a&olmaffl s_i k, aR-ov (evioe-) [<A Partnership 0"etPedc / #hV El Other legal Entity _3ST 2 041 Name & Title: AS rl4'W'I Address: -- `5 - 4� �� _ t� 0- Telephone No: --- f 24 Hour Emergency NO: FAX: 24 Hour Emergency No: E-mail: FAX:E-mail: Alt E -Mail: 1.,i) ni-.trint Or Reaional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX:E-mail: ME; Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No, of Food Employees: 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: %S� 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 ❑ Caterer $25.00 ❑ Moblie Moblie Start Date: [❑ Retail ( 12--P Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 ❑ Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: ❑ Food Service up to 101 -200 $25.00/freezer []'Annual or up to 25' PHF display $150.00 ❑ Pushcart $25 # of Pushcarts: Seasonal ❑ Food Service up to 201 + ❑ Residential Kitchen $100.00 or 25'+ PHF display $275.00 ❑ Retail Food $100.00 Seasonal Dates: Temporary ❑ Food Service - Institution E]Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: R 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 for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs -- Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill - --- Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food [To be completed by the Board of Health Total Permit Fee: 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 v�ith 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copibs of,105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: J Pursuant to MGL Ch.62C, sec. 494, Mrtify 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. 25) Social Security Number or Federal ID:� `. t �''&S 26) Signature of Individual or Corporate Name: 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: I U`tvw( yea ADDRESS: SS PC? C ��Q�� G O @-�l/�� i TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: DELI C 10 U S ' &AT5 U -C TELEPHONE OF OWNER: 5-0 ?S 41 FEDERAL ID/SS NUMBER: t 61 3 FEE: $5.00 PERMIT NUMBER: SIGNATURE: DATE: I Town of Mansfield Town of Mansfield ® Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts andlor Ice Cream A To the Board ql"Health at the 7-nivn qf1lans/ield: Ira accordance with the provisions of'section 65H of C"hopler 94 oj'the General Lmvs, as most recently amended, and the regulations made, thereunder, the undersigned hereby applies for a license for a WHOLESALEIRETAII, manufacture of frozen desserts and ice cream mix and submits the following information: '\ T\Ik Full name of applicant: A S k \/,30' Y" k-�k vv 2. Business address 3. ll'applicant is an individual: Full name: Residence: 3m If applicant is a partnership,./ull natne and vsidence qfal/ partners: Vr I kou W 3b.Il'(ipl)Iieaiiiisacoi-pot-atiot?: State of incorporation: 5in, '3 0___ PAK Date of incorporation: 1&\" Full name and address 0 Principal office: ,fS �- R .0 & YN—), td i President Treasurer: Clerk: S0 ek"* C Yk (VII - 4. Location of Plants: 11,10 M11L CU W' r. I M6- d2-766 I f6,x - 94"o-616 () �i I ) 5. Names ot"brands and trade or corporation name, iflary, under Aich the products are to be sold: (d(A ciffreezersand 6. Number and capacity j a' fees: Fee: ($25.00 perfi-eezet) 7. Is the nfiy purchased?'exj ff so,firom whom purchased? ( 6 e% -e k Is the mix pasteurized (Y'not?'- 9. Number q1 -gallons off ozen desserts anellor ice cream mix to be sold in Allassachusetts during the licensing period 10. Manber oj'gallons Offrozendesserfs and/or ice cream mix solei iii,,Vf6issachitselisduring the previous licensing period 1. Is the plant constructed and equipped as provided in the regulations'' 12. Is the water supply public or not? P ('k 13, Have you received a copy of the regulations? I hereby certify that the frozen desserts andlor Ice cream mix I sell In Massachusetts will be manufactured In compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary cor idit7ons. I attest that the information stated in this&app3 is true and accurate under the pairs and penalties of perjury. 6 (Co owner/officer's signature) — M 14 qeA/ (Title) 0 (City or Town) 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. .. - N& � \'c� 6 u - *nature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number L,/ * 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 I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia A„ I Vdy`OW Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /° Please Print Legibly Business/Organization Name: PFL 1 C 10 US �eE6—s SLC (D eA (00_0Ca''ec1,W�� Address: S 61(? M V-7C6 City/State/Zip: Iq 86,4\ �A_ 2�Qj,�P-AP7Phone #: .S � Are you an employer? Check the appropriate box: I. ❑I I am a employer with ` employees (full and/ or part-time).* 2. ❑ I 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, § 1(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.] Business Type (required): 5. ❑ Retail 6, Q Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 1011 Manufacturing 11.0 Health Care 12.❑ Other *Any applicant that checks box 41 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 #11 . I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: = r Zoj C S Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # Q g — a 0 / >r-1 19 7) � I Expiration Date: 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 herebh certify, under the pains and penalties of perjury that the information provided above is true and correct. G)► / � 6 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # _�_/ CIZ ) 2e),6 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 #: DELITRE-01 COLLIAM 1 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 5/12/2016 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 Hy/ant -Toledo 811 Madison Ave. Toledo, OH 43604 ACT NAME: Kristy Gregory FAX PHONE A1C No Ext E-MAIL ADDRESS: Kristy.Gregory@hylant.com INSURER(S) AFFORDING COVERAGE NAIC # CLAIMS -MADE a OCCUR INSURERA:Ohio Security Insurance Co 24082 X INSURED INSURER B: Travelers Prop Cas Co of Amer 25674 INSURER C : Delicious Treats, LLC dba Cold Stone Creamery 82 Rosemary Road INSURER D: INSURER E: North Attleboro, MA 02760 INSURER F: 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. INSR LTR A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY DDL INSD BR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS EACH OCCURRENCE $ 1,000,000 PREMISES Eaoccurrence $ 1,000,000 Scottsdale, AZ CLAIMS -MADE a OCCUR X X BZS57225361 05/24/2016 05124/2017 MED EXP (Any one person) $ 15,000 PERSONAL B. ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY Ea acccidentSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIREDAUTOS X AUTOS BZS57225361 05/2412016 05/24/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE _ $ STATUTE EER X STH DED I I RETENTION $ WORKERS COMPENSATION E.L. EACH ACCIDENT $ 1,000,000 B AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERIMEMBER EXCLUDED9 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A UB001 H197141 05/24/2016 05/24/2017 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE- POLICY LIMIT $ 1,000,000 A A Business Pers Prop BI/EE ALS -12 Month BZS57226361 BZS57225361 05/2412016 05/24/2016 05/24/2017 05/24/2017 Deductible $500 300,000 Spoilage 10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Kahala Franchising, L.L.C., Kahala Brands, Ltd., their subsidiaries, officers, directors, and employees, 9311 E. Via De Ventura, Scottsdale, Arizona 85258 are listed as additional insured/grantor of franchise in regards to covered locations: 280 School St., Mansfield, MA 02048 400 New London Ave., Cranston, RI 02920 GtR:I IFIGA I t MULUCR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Kahala Brands, Ltd., Kahala Franchising, LLC ACCORDANCE WITH THE POLICY PROVISIONS. 9311 E. Via De Ventura Scottsdale, AZ AUTHORIZED REPRESENTATIVE OW "P/1 --1(e 1'] A TIl1LI A 11 - .. Mie. rrce�ie r� V IJV V -LV ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD COLLIAM A41.:74!:>/ZA" INSURANCE BINDER DATE(MMIDDIYYYY) 511612016 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT SUBJECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY Hylant - Toledo COMPANY Ohio Security Insurance Co BINDER # 14285 811 Madison Ave.D EFFECTIVE E E EXPIRATION Toledo, OH 43604 AMOUNT $300,000.0 $10,000.00 $25,000.00 X EACH OCCURRENCE X 1,000,000 DAMAGETO $ RFNTEn PREMISES- 1,000,000 MED EXP An one person)$ 15,000 AM 1,000,000 GENERALAGGREGATE 12:01 AM 2,000,000 5/24/2016 12:01 PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT PM 5/24/2017 VEHICLE LIABILITY NO PHONE 419 255-1020 ) FAX 419 255-7557 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY AIC No Ext): ac No : PER EXPIRING POLICY #: CODE: 345229 SUB CODE: AGENCY DELITRE-01 DESCRIPTION OF OPERATIONS / VEHICLES / PROPERTY (Including Location) CUSTOMER to: 280 School St., Mansfield, MA 02048 INSURED AND MAILING ADDRESS 400 New London Ave., Cranston, RI 02920 Delicious Treats, LLC dba Cold Stone Creamery 82 Rosemary Road North Attleboro, MA 02760 COVERAGES TYPE OF INSURANCE PROPERTY CAUSES OF LOSS BASIC 0 BROAD T SPEC X Replacement Cost COVERAGE I FORMS Business Personal Property Business Income Actual Loss Sustained -12 Month Spoilage Employee Dishonesty DEDUCTIBLE 500 500 COINS % AMOUNT $300,000.0 $10,000.00 $25,000.00 GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE T OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGETO $ RFNTEn PREMISES- 1,000,000 MED EXP An one person)$ 15,000 PERSONAL& ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT $ $ 2,000,00 1,000,000 VEHICLE LIABILITY RETRO DATE FOR CLAIMS MADE: BODILY INJURY Perperson) $ ANY AUTO ALLOWNEDAUTOS BODILY INJURY Per accident $ SCHEDULEDAUTOS PROPERTY DAMAGE $ X HIREDAUTOS MEDICAL PAYMENTS $ X NON -OWNED AUTOS PERSONAL INJURY PROT $ UNINSURED MOTORIST $ VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES Ll SCHEDULED VEHICLES ACTUAL CASH VALUE STATEDAMOUNT $ COLLISION: OTHER THAN COL: GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ANY AUTO OTHER THAN AUTO ONLY: EACHACCIDENT $ AGGREGATE EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ UMBRELLA FORM OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION PER STATUTE E.L. EACH ACCIDENT $ WORKER'S COMPENSATION E.L. DISEASE - EA EMPLOYEE $ AND EMPLOYER'S LIABILITY E.L. DISEASE - POLICY LIMIT SPECIAL FEES CONDITIONS I TAXES $ I ESTIMATED TOTAL PREMIUM $ OTHER COVERAGES NAME & ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN #: AUTHORIZED REPRESENTATIVE TIA\t All .i Nage i ort V 1y`J3-LV IJ HIiVRL/ vvf\rvr�n ,v,., y .w . ACORD 75 (2013/09) The ACORD name and logo are registered marks of ACORD I AGENCY CUSTOMER ID: DELITRE-01 COLLIAM CONDITIONS This Company binds the kind(s) of insurance stipulated on page 1 of this form. The Insurance is subject to the terms, conditions and limitations of the policy(ies) in current use by the Company. This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company. Applicable in Arizona Binders are effective for no more than ninety (90) days. Applicable in California When this form is used to provide insurance in the amount of one million dollars ($1,000,000) or more, the title of the form is changed from "Insurance Binder" to "Cover Note". Applicable in Colorado With respect to binders issued to renters of residential premises, home owners, condo unit owners and mobile home owners, the insurer has thirty (30) business days, commencing from the effective date of coverage, to evaluate the issuance of the insurance policy. Applicable in Delaware The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the binder includes or is accompanied by: the name and address of the borrower; the name and address of the lender as loss payee; a description of the insured real property; a provision that the binder may not be canceled within the term of the binder unless the lender and the insured borrower receive written notice of the cancellation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid receipt of the full amount of the applicable premium, and the amount of insurance coverage. Chapter 21 Title 25 Paragraph 2119 Applicable in Florida Except for Auto Insurance coverage, no notice of cancellation or nonrenewal of a binder is required unless the duration of the binder exceeds 60 days. For auto insurance, the insurer must give 5 days prior notice, unless the binder is replaced by a policy or another binder in the same company. Applicable in Maryland The insurer has 45 business days, commencing from the effective date of coverage to confirm eligibility for coverage under the insurance policy. Applicable in Michigan The policy may be cancelled at any time at the request of the insured. Applicable in Nevada Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is required: (A) Shall be fined not more than $500.00, and (B) is liable to the party presenting the binder as proof of insurance for actual damages sustained therefrom. Applicable in Oklahoma All policies shall expire at 12:01 a.m. standard time on the expiration date stated in the policy. Applicable in Oregon Binders are effective for no more than ninety (90) days. A binder extension or renewal beyond such 90 days would require the written approval by the Director of the Department of Consumer and Business Services. Applicable in the Virgin Islands This binder is effective for only ninety (90) days. Within thirty (30) days of receipt of this binder, you should request an insurance policy or certificate (if applicable) from your agent and/or insurance company. ACORD 75 (2013/09) rage z or Z COLLIAM AcvRa' �. INSURANCE BINDER DATE (MMIDDIYYYY) 5/16/2016 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT SUBJECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY COMPANY BINDER # Hylant - Toledo Travelers Prop Cas Co of Amer 14277 811 Madison Ave.D EFFECTIVE EXPIRATION E Toledo, OH 43604 ME D ATE ---TIT X X MED EXP (Any oneperson) $ AM 12:01 AM GENERAL AGGREGATE $ 5/24/2016 12:01 PM 5/24/2017 NOON PHONE C NNo Ext): (419) 255-1020 No : 419 255-7557 THIS BINDER IS ISSUEDTO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY E: CODE: DHL20 S�FAX PER EXPIRING POLICY #: AGENCY -01 DESCRIPTION OF OPERATIONS / VEHICLES / PROPERTY (Including Location) CUSTOMER ID: 280 School St., Mansfield, MA 02048 INSURED AND MAILING ADDRESS 400 New London Ave., Cranston, RI 02920 Delicious Treats, LLC dba Cold Stone Creamery 82 Rosemary Road North Attleboro, MA 02760 ALL VEHICLES Lj SCHEDULED VEHICLES wloi .._ COVERAGES TYPE OF INSURANCE COVERAGE I FORMS DEDUCTIBLE COINS % AMOUNT PROPERTY CAUSES OF LOSS BASIC BROAD [:] SPEC MORTGAGEE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ DAMAGE TO $ RENTED PREMISES MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ AUTHORIZED REPRESENTATIVE VEHICLE LIABILITY ANY AUTO ALLOWNEDAUTOS SCHEDULEDAUTOS HIREDAUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY Perperson) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ MEDICAL PAYMENTS $ PERSONAL INJURY PROT $ UNINSURED MOTORIST $ VEHICLE PHYSICAL DAMAGE DED COLLISION: ALL VEHICLES Lj SCHEDULED VEHICLES ACTUAL CASH VALUE STATEDAMOUNT $ OTHER THAN COL: AUTO ONLY - EA ACCIDENT GARAGE LIABILITY ANY AUTO OTHER THAN AUTO ONLY: EACHACCIDENT $ AGGREGATE EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ AGGREGATE $ SELF-INSURED RETENTION WORKER'S COMPENSATION EMPLOYER'S LIABILITY X PER STATUTE E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,00 SPECIAL Owners are exempt in RI and MA per State Law CONDITIONS / OTHER COVERAGES FEES $ TAXES ESTIMATED TOTAL PREMIUM $ NAME & ADDRESS MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN #: AUTHORIZED REPRESENTATIVE Page 1 Ot z V Tyy3-LV"13 Ht,VRv �,vrtrvr�r+i wrv. nn nynw icacvia+. ACORD 75 (2013109) The ACORD name and logo are registered marks of ACORD 3 AGENCY CUSTOMER ID: DELITRE-01 COLLIAM CONDITIONS This Company binds the kind(s) of insurance stipulated on page 1 of this form. The Insurance is subject to the terms, conditions and limitations of the policy(ies) in current use by the Company. This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in accordance with the policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the Company. Applicable in Arizona Binders are effective for no more than ninety (90) days. Applicable in California When this form is used to provide insurance in the amount of one million dollars ($1,000,000) or more, the title of the form is changed from "Insurance Binder" to "Cover Note". Applicable in Colorado With respect to binders issued to renters of residential premises, home owners, condo unit owners and mobile home owners, the insurer has thirty (30) business days, commencing from the effective date of coverage, to evaluate the issuance of the insurance policy. Applicable in Delaware The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the binder includes or is accompanied by: the name and address of the borrower; the name and address of the lender as loss payee; a description of the insured real property; a provision that the binder may not be canceled within the term of the binder unless the lender and the insured borrower receive written notice of the cancellation at least ten (10) days prior to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid receipt of the full amount of the applicable premium, and the amount of insurance coverage. Chapter 21 Title 25 Paragraph 2119 Applicable in Florida Except for Auto Insurance coverage, no notice of cancellation or nonrenewal of a binder is required unless the duration of the binder exceeds 60 days. For auto insurance, the insurer must give 5 days prior notice, unless the binder is replaced by a policy or another binder in the same company. Applicable in Maryland The insurer has 45 business days, commencing from the effective date of coverage to confirm eligibility for coverage under the insurance policy. Applicable in Michigan The policy may be cancelled at any time at the request of the insured. Applicable in Nevada Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is required: (A) Shall be fined not more than $500.00, and (B) is liable to the party presenting the binder as proof of insurance for actual damages sustained therefrom. Applicable in Oklahoma All policies shall expire at 12:01 a.m. standard time on the expiration date stated in the policy. Applicable in Oregon Binders are effective for no more than ninety (90) days. A binder extension or renewal beyond such 90 days would require the written approval by the Director of the Department of Consumer and Business Services. Applicable in the Virgin Islands This binder is effective for only ninety (90) days. Within thirty (30) days of receipt of this binder, you should request an insurance policy or certificate (if applicable) from your agent and/or insurance company. ACORD 75 (2013/09) rage 4 v1 4 rvSafeo ASHWANI RATHOR for successfully completing the standards set forth for the SetvSafe® Food which is accredited by the American National Standards Institute (ANS 16997 3/7/2Mq DATE OF I Local laws apply. FANS/ ACM.1- DGRAtA xawean ka�raasa ra.o-ssnae. aro eR caax.,.:e w. rows rea,Um, 1: b aaadonm widr ALvii'em MBER ae ered.,-6 of the tom. EXA 3/7/2021 DATE OF EXPIRA for recertification requirements. fification Examination, Protection (CFP). G.0.d us wA q.X,-, d 175 W Jod— 94d. Ste 150o, chk go, 0..60604 « 5—Sa! O—k-cd-g. ANSI AGCAFDnED PADGAAM tmcrra� W^:�W SixiG�Bf Assr�tdr s:rb F'e CaNam:ek+foW k++u:na C, F: b mad.— i6 emrtk. 02015 Ni" RmiwmW a tTIfICATION F9144MMMUNIFT11 for successfully completing the standards set forth for the ServSafe® Food which is accredited 6y the American National Standards Institute f ANS 16995 3/7/2Mq DATE OF I Local laws aPPIy. MBER k.k-6 d tha NRAff. 3/7/202 DATE OF EXPIRA for recertification requirements. C.oMod us viah questimr d 175 W lad— SW, SFe 1500, Chico, L 60 A or S—SA@rash —% CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: oEEPAK BHATiA Certificate Number:2244305 Date of Completion: 3/712016 Date of Expiration, 377/2021 The above-named person is hereby issued this cert ficate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Healtb in accordance with 105 CMR 590.009(G)(3)(a). This certificate will be valid for five (5) years from date of completion. Issued Bl oil NATIONAL 1 RESTAURANT ASSOCIATION, Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 www.restaurant.org Southborough, MA 01772 508-303-9905 www.marestaurantas soc.org /1NSt M,�'� ACCNEDREO VPDGPRM emawn e��w s�.ms,aa bK,osr s: F,—d—wA,M rii— :rvSafe MFICATION MEENAKSHI RATHORE for successfully completing the standards set forth for the ServSafe® Food which is accredited by the American National Standards Institute (AN§ 16994 3/7/2Mq DATE OF E Local laws apply. MBER «a o-odawrbot Poe t�Aff. 3/7/202 DATE OF EXPIRA for recertification requirements. Conkd m viah V-Jims of 175 w k4* Bbd. Ste 1500, Chimgo, 0..60604 or SwSofc@re bmW.aq. ANS/ ALLREOITfO PROLRRM x,�an xas+ws� esmw�t< �+or<caremec x.cooarw�.m, , s: 1, A, hi it®ve 02015 N.6-1 Rnihmad krvSafe __.;TIFICATION SUSHMITA BHATIA for successfully completing the standards set forth for the ServSafe® Food which is accredited by the American National Standards Institute (ANS Ij*01*11- 3/7/2DI DATE OF I Local laws apply. MBER oEe node,„eEbof the NRAff. 3/7/202 DATE OF EXPIRA for recertification requirements. C.,l.d us viA "stia,s m 175 W kJ— ". Sr, 1500, Chi mV, L 60604 a ScrSa(e@sestow�A.ag CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: suSHMiTA 6HATIA Certificate Number: 1211123 Date of Completion: 3nn01e Date of Expiration: 3m2021 The above-named person is hereby issued this cert*ate for completing an allergen awareness train ing program recognized by the Massachusetts Department of PublicHealib in accordance with 105 CMR 590.009(G)(3)(a). 7h is certificate will be valid for five (5) years from date ofcompletion. Issued By: NATIONAL a RESTAURANT ASSOCIATION. Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 wwwrestaurant.org Southborough, MA 01772 508-303-9905 www. marestaurantassoa org 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 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 not 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 Reviscd 5-26-05