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HomeMy WebLinkAboutCold Stone Creamery 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:. ASHWANI RATHOR Whose place of business is: COLD STONE CREAMERY 280 SCHOOL STREET PERSON(S) IN CHARGE: ASHWANI RATHOR Permit Expires: December 31, 2016 License Number: FS -82 Food Fee: $62.50 BOARD OF HEALTH Michae(McCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: DELICIOUS TREATS LLC having a place of business at: COLD STONE CREAMERY 280 SCHOOL STREET D161 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 12131/2016 License No.: FS -82 Scott leite, Health .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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 wholesalelretail manufacture of frozen desserts and ice cream mix. This license expires December 31st of each year. License Number: FS -82 Freezers: 1 TOTAL: $12.50 MANSFIELD BOARD OF HEALTH Scott Leite, H eaah .Agent FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION opening da"e 1) Establishment Name COLD STONE CREAMERY 2) Establishment Address 280 SCHOOL STREET D161 VU 3) Establishment Mailing Address (if different) 82 ROSEMARY ROAD NORTH ATTLEBORO, MA 02760 4) Establishment Telephone No 5) Applicant Name & Title: = ASHWANI-RATHOR, (MANAGER) Alt E -Mail: 6) Applicant Address 1-1,W+ii-T-E-OAK-W-AY--,-NORTH-ATTLE13-0-Ror,"TO-A-W760 7) Applicant Telephone No.: (508) 598-8841 24 Hour Emergency No.: (508) 598-8841 (508) 826-3893 8) Owners Name & Title ASHWANI RATHOR 9) Owner Address (if different from applicant) 11 WHITE OAK WAY, NORTH ATTLEBORO, MA 02760 Owner's telephone number 5085988841 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ❑ A Corporation Name Title Address ❑ An Individual A-v�urjl,�A C, 2 V A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: ASHWANI RATHOR 11 WHITE OAK WAY, NORTH ATTLEBORO, MA 02760 Telephone No: (508) 598-8841 (508) 826-3893 24 Hour Emergency No: (508) 598-8841 (508) 826-3893 FAX: E-mail: DTREATSLLC(cD_GMAIL.COM Alt E -Mail: E-mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN 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: ASHWANI RATHOR DEEPAK BHATIA 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 MEENAKSHI RATHORE certificate SUSHMITA BHATIA 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $5.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 E]Food Service up to 101 -200 ❑i Manufacture Frozen Desserts/Ice Cream $12.50/freezer 21) Length of Permit: Annual or up to 25' PHF display $75.00 ❑ Food Service up to 201 + ❑ Pushcart $12.50 # of Pushcarts: 0 ❑ Residential Kitchen $50.00 ❑ Seasonal or 25'+ PHF display $137.50 ❑ Retail Food $50.00 Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $12.50 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - 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-PHFs ❑ 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 ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially ❑ Vacuum Packaging / Cook Chill — Processed Foods for Service Within 4 Hours --- ----- —--- ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods OnlynV contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Animal Origin ❑ 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: $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 obtain ca)gs at,105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: _ Pursuant to MGL Ch.62C, sec.9A !certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required un law. 25) Social Security Number or Federal ID: 81-1289193 26) Signature of Individual or Corporate Name: � �'- L � C 1 0 US 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: COLD STONE CREAMERY ADDRESS: 280 SCHOOL STREET D161 TELEPHONE AT LOCATION: FAX NUMBER: OWNER OF BUSINESS: ASHWANI--RATHOR T �A TELEPHONE OF OWNER: 5085988841 FEDERAL ID/SS NUMBER: 81-1289193 FEE: $5.00 PERMIT NUMBER: FS -W SIGNATURE: DATE: �d Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board of Health at the Town c?f Artansfield: In accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license fir a WHOLESALEIRET4IL nramrfacture gffr•ozen desserts and ice cream rnix and submits the following information: 1. Full name of applicant: COLD STONE CREAMERY w - 2. Business address 82~ROSEMARY-ROAD" NORTH -ATT L-EBORO~MA-027-60 ,, i ..=,. -r 1 3. f applicant is an individual: Full name: ASHWANI RATHOR (MANAGER) Residence: 11 WHITE OAK WAY, NORTH ATTLEBORO, MA 02760 3a. If applicant is a partnership, fill name and residence of all partners: n 2 3b. 1l'applicant is a corporation: State of incorporation: MASSACHUSETTS— Date of incorporation: JANUARY 30, 2016 Full name and address Qf : Principal office: 82 ROSEMARY ROAD President ASHWANI RATHOR — — — Treasurer: DEEPPAK BHATIA — Clerk: 4. Location of Plants: SWEET CREAM & CHOCOLATE BASE, 100 MILK LANE, NEWINGTON, CT 06111 (PHONE S. Names gl'brands and trade or corporation name, if any, under which the products are to be sold: COLD STONE CREAMERY 6. Number and capacity gffi•eezers andfees: 1 Fee: ($12.50 per.freezer) $ 12.5 7. Is the mix purchased? YES If so, from whom purchased? — — 8. Is the mix pasteurized of riot? YES 9. Number ofgallons offrozen desserts and/or ice cream mix to be sold in Massachusetts during the licensing period 10, Number of gallons of frozen desserts and/or ice cream mix sold in 11assachuseus during the previous licensing period H. Is the plant constructed and equipped as provided in the regulations? YES --_ 12. Ls the water supply public or not? PUBLIC _ — 13. Hm�e you received a copy of the regulations? I hereby certtfy that the frozen desserts and/or 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 conditions. I attest that the information stated in this application is true and accurate under the pains and penalties of perjury. t �I Rev,►-��-�.\� ���� —-0—C I-4— (Company owner/officer's signature) (DATE 1AM (Title) o. (City or Town) f 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. * Sir Wre of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) I - i2-�9Ig(-� ** 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 Legibly l Business/Organization Name: L LA L 1 O V -S ` j R l•AT� LLC (0111 Address: `2 PC) �CkC/O � S ��ytS'�k'� M � ~Liff City/State/Zip: Are you an employer? Check the appropriate box: 1.0' I am a employer with j 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.] Phone #: Business Type (required): 5. ❑ Retail 6. E] Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 3. ❑ Non-profit ). ❑ Entertainment 10.0 Manufacturing 11. ❑ Health Care 12.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy mtormanon. **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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: `jyak1-e_� Insurer's Address: City/State/Zip: Policy # or Self -ins. Lia #, Q ad C! i~i'j —7 F 1 Expiration Date: Is2ti 1 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 c� of"y", under the pains and penalties ofperjury that the information provided above is true and correct. -_. "- --- bate: 06 1111 C Phone #: 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.gowaia Phone ACORL�® AGENCY Hylant - Toledo 811 Madison Ave. Toledo, off 43604 INSURANCE BINDER INSURED AND MAILING ADDRESS Delicious Treats, LLC dba Cold Stone Creamery 82 Rosemary Road North Attleboro, MA 02760 COLLIAM DATE(NAWPY" 5/16/2016 COMPANY BINDER # Travelers Prop Cas Co of Amer 1 14277 _— EFFECTIVE nnTE EXPIRA7fON TIM AM u 12:01 AM 5124/2016 12:01 PM 5/241201% I I NOON THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY #. DESCRIPTION OF OPERATIONS VEHICLES I PROPERTY W#duding Locaftn) t80 School St, Mansfield, MA 02048 !00 New London Ave., Cranston, 8102920 . r _— MORTGAGEE ADDITIONAL INSURED LOAN # AUTHORIZED REPRESENTATIVE Page 1 of 2 ©1993-2013 ACORD CORPORATION. All rights reserved. ACORD 75 (2013109) The ACORD name and logo are registered marks of ACORD DELITRE-01 COLLIAM ,441..OR®- CERTIFICATE OF LIABILITY INSURANCE DATE1121DD/YYYI) 51u2o1s 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 H [ant -Toledo Y 811 Madison Ave.G Toledo, OH 43604 &E Kristy Gregory PHONE FAx Al No Ext, AI No o h ADDRESS: Krjs ty. reg ry@ Ylantcom INSURER(S) AFFORDING COVERAGE 1MC # INSURER A: Ohio Security Insurance Co 24082 1,000,00 INSURED INSURER B :Travelers Prop Cas Co of Amer 25674 INSURER C: Delicious Treats, LLC dba Cold Stone Creamery CLAIMS-MADE MED EXP (Any one person) $ 82 Rosemary Road INSURER D: INSURER E: North Attleboro, MA 02760 INSURER F : GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEO- 1:1 LOC PRODUCTS-COMPIOPAGG $ __ .�rincrnn ►IiIVQCC• COVERAGE5 L cm I tri%,A i r- rwumu-t- — LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS sm POLICY EFF POLICY EXP LIMITS ItNTRR TYPE OF INSURANCE INSD W!D POLICY NUMBER MWD MMIDD 1,000,00 EACH OCURREN A X COMMERCIAL GENERAL LIABILITY CCE $ T OCCUR X X BZS57225361 05124/2016 05/2412017 PREMISES Ea occurrence) $ 1,000,00 CLAIMS-MADE MED EXP (Any one person) $ 15,00 PERSONAL& ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEO- 1:1 LOC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER: COOMBBIIN D SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY BZS57225361 06=2016 05/24/2017 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS PPeracOPE DAMAGE $ NON -OWNED X X HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLALU\B OCCUR EXCESS UAB CLAIMSMADE AGGREGATE $ ,. $ DED RETENTION$ X ER WORI�RS COMPENSATION STATUTE 1 000,00 AND EMPLOYERS' LIABILITY YIN UB001HI97141 05/24/2016 05/24/2017 :EL.EACHACCIDENT $ B ANY PROPRIETORIPARTNERIEXECUTIVE N I p 1,000,00 OFFICERIMEMBER EXCLUDED? EL DISEASE - EA EMPLOYE $ (Mandatory in NH) ff yes describe under EL DISEASE- POLICY LIMIT $ 1,000,00 DESG�RIPTION OF OPERATIONS below BZS57225361 05124/2016 05124/2017 Deductible $500 300,00 A Business Pers Prop BZS57225361 05/2412016 05/24/2017 Spoilage 10,00 A BIIEusi ALS -12 Month DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Rernarks Schedule, may be attached if more space is required) 9311 E. Via De Ventura, Scottsdale, Arizona 85258 are Kahala Franchising, L.L.C., Kahala Brands, Ltd., their subsidiaries, officers, directors, and employees, listed as additional insured/grantor of franchise in regards to covered locations: 280 School SL, Mansfield, MA 02048 400 New London Ave., Cranston, RI 02920 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: DELITRE-01 COLLIANI 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 the binder asproof of insurance fo.00 when r actual of is damages sustained uired: (A) Shall be fined not more than $500.00, and (B) is liable to the party presenting 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 (2013109) ' "' DELITRE-01 COLLIAM 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 CONTACT NAME: Kristy Gregory PHONE FAX A/c Ext): (A/C. No E-MAIL SS: Kristy.Gregory@hylant.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Ohio Security Insurance CO 24082 INSURED Delicious Treats, LLC dba Cold Stone Creamery 82 Rosemary Road North Attleboro, MA 02760 INSURER B: Travelers Prop Cas Co of Amer 25674 INSURER C: INSURER D: INSURER E: INSURER F: f ^%ICCA!_`Cc rtrRTIGIC TE NUMBER, REVISION NUMBER: ., 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 OF INSURANCE ADDLSUTYPE INSD BR WVD POLICY NUMBER MMIDDIIYYYY MMIDDY/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN I ED PREMISES Ea occurrence $ 1,000,008 CLAIMS-MADEFX] OCCUR X X BZS57225361 05/24/2016 05/24/2017 MED EXP (Any one person) $ 15,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 - COMP/OP AGG $ 2,000,000 POLICY PES F—] LOC —PRODUCTS 5 OTHER: AUTOMOBILE LIABILITY Ea accdeCMBINEntSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO BZS67225361 05/24/2016 05/24/2017 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS X HIREDAUTOS X AUTOS ED E Pena accident) $ $ UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED RETENTION $$ B WORKERS COMPENSATION ANDEMPLOYERS' LIABILITYYIN ANY PROPRIETOR/PARTNER/EXECUTIVE F--- OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA UB001H197141 05/24/2016 05/24/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ , If yes, descr be under DESCRIPTION OF OPERATIONS below A Business Pers Prop BZS57225361 05/24/2016 05/24/2017 Deductible $500 300,000 A BUEE ALS -12 Month BZS67225361 05/24/2016 05/24/2017 Spoilage 10,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 GtK I II-IGA I t hIULUtK , I - Kahala Brands, Ltd., Kahala Franchising, LLC 9311 E. Via De Ventura Scottsdale, AZ 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 'F - 3 (V IUlit5-LU14 AVUKL) t1um!"UMA 11VIV. /111 IHuIIW ICOCI VCU. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD COLLIAM —�1 �►coRt7°h INSURANCE BINDER �-. DATE(MMIDD/YYYY) 511 612 01 6 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT SUBJECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY COMPANY BINDER # Hylant - Toledo Ohio Security Insurance Co 14285 811 Madison Ave. Toledo, OH 43604 EFFECTIVE DATE TIME EXPIRATION DATE TIME EACH OCCURRENCE $ 1,000,000 X AM X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR RETRO DATE FOR CLAIMS MADE: 12:01 AM $ 15,000 PERSONAL & ADV INJURY $ 5/2412016 12:01 GENERAL AGGREGATE $ PM 5/24/2017 �Xd NOON H NNo Ext : (419) 255-1020 AX No):419 255-7557 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY #: CODE: 345229 SUB CODE: AGENCY DELITRE-01 CUSTOMER ID: DESCRIPTION OF OPERATIONS / VEHICLES / PROPERTY (Including Location) BODILY INJURY Perperson) 280 SCh001 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 L:UVtKAUr_0 TYPE OF INSURANCE PROPERTY CAUSES OF LOSS BASIC F-1 BROAD a SPEC X Replacement Cost COVERAGE / FORMS Business Personal Property Business Income Actual Loss Sustained -12 Month Spoilage Employee Dishonesty DEDUCTIBLE 500 500 COINS % AMOUNT $300'00000 $10,000.00 $25,000.00 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO $ 1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR RETRO DATE FOR CLAIMS MADE: MED EXP (Anyoneperson) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 VEHICLE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) $ ANY AUTO ALL OWNEDAUTOS BODILY INJURY Per accident $ SCHEDULEDAUTOS PROPERTY DAMAGE $ MEDICAL PAYMENTS $ X HIREDAUTOS PERSONAL INJURY PROT $ X NON-OWNEDAUTOS UNINSURED MOTORIST $ VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISION: STATEDAMOUNT $ OTHER THAN COL: GARAGE LIABILITY AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: ANY AUTO EACH ACCIDENT $ 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 TAXES $ CONDITIONS / OTHER COVERAGES I ESTIMATED TOTAL PREMIUM 1 $ NAMt tk AUUKCJJ MORTGAGEE ADDITIONAL INSURED LOSS PAYEE LOAN #: AUTHORIZED REPRESENTATIVE Page 1 of 2 U 199 -ZU1U AUUKU CURPUKA11U1V. Ali rigmb resrlvuu. ACORD 75 (2013/09) The ACORD name and logo are registered marks of ACORD 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) Page 2 of 2 COLLIAM '4'c'®ter®p INSURANCE BINDER FDATE(MMIDD/YYYY) DEDUCTIBLE 5/16/2016 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT SUBJECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY COMPANY BINDER # Hy►ant - Toledo Travelers Prop Cas Co of Amer 14277 811 Madison Ave. EFFECTIVE EXPIRATION Toledo, OH 43604 DATE TIME DATE ME __[X PERSONAL & ADV INJURY $ X AM PRODUCTS - COMP/OP AGG $ VEHICLE 12:01 AM COMBINED SINGLE LIMIT $ 5/24/2016 12:01 PROPERTY DAMAGE $ MEDICAL PAYMENTS $ 5/2412017 UNINSURED MOTORIST $ 5 VEHICLE PHYSICAL DAMAGE DED COLLISION: OTHER THAN COL: ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE STATEDAMOUNT $ GARAGE LIABILITY ANY AUTO PM AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: NOON AICNNo Ext): (419) 255-1020 IX No ; 419 255-7557 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY PER EXPIRING POLICY #: CODE: DHL20 I SUB CODE: AGENCY DELITRE-01 CUSTOMER ID: DESCRIPTION OF OPERATIONS I VEHICLES / PROPERTY (including Location) 280 SCh001 $t., Mansfield, MA 02048 SELF-INSURED RETENTION INSURED AND MAILING ADDRESS 400 New London Ave., Cranston, RI 02920 Delicious Treats, LLC dba Cold Stone Creamery E. L. EACH ACCIDENT $ 1,000,000 82 Rosemary Road E.L. DISEASE - POLICY LIMIT 1,000,000 North Attleboro, MA 02760 FEES $ TYPE OF INSURANCE COVERAGE / FORMS DEDUCTIBLE COINS % AMOUNT PROPERTY CAUSES OF LOSS BASIC F-1 BROAD ❑ SPEC LOAN #: AUTHORIZED REPRESENTATIVE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ DAMAGE TO RENTED $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ 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 $ 5 VEHICLE PHYSICAL DAMAGE DED COLLISION: OTHER THAN COL: ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE STATEDAMOUNT $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: EACH OCCURRENCE $ AGGREGATE $ SELF-INSURED RETENTION WORKER'S COMPENSATION AND1,000,000 EMPLOYER'S LIABILITY X I PER STATUTE E. L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT 1,000,000 SPECIAL Owners are exempt in RI and MA per State Law CONDITIONS / OTHER COVERAGES FEES $ TAXES $ ESTIMATED TOTAL PREMIUM $ Page 1 of 2 ©1993-2013 ACORD CORPORATION. All rights reserved. ACORD 75 (2013109) The ACORD name and logo are registered marks of ACORD MORTGAGEE LOSS PAYEE ADDITIONAL INSURED LOAN #: AUTHORIZED REPRESENTATIVE Page 1 of 2 ©1993-2013 ACORD CORPORATION. All rights reserved. ACORD 75 (2013109) The ACORD name and logo are registered marks of ACORD 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) Page 2 of 2 Mi:c:oa r 4ca6on Examination, Protection (CFP). PV 0 0 .ort,. o.. Cal*4 v ah ques&. of 17S W 1od— Pfd. Sie 1500, Chk go, L 60604 a SwS� @redw.eae org EANSTI� 4GGAfOtT:O PAOGA4td f rY:n FO!vxW S�:Cat6z L!a :e ai0h4Gw�cent+afe�dR .c'+a� n t: .,rvSafe ITIFRATION DEEPAK BHATIA for successfully completing the standards set forth for the ServSafe® Food which is accredited by the American National Standards Institute (ANS 316995 UMBER 3/7/2 DATE OF E Local laws apply. Ch trodt n�laoE tM WAM 1 EX 3/7/2021 DATE OF EXPIRA for recertification requirements. 4cation Examination, Protection (CFP). Conbens vel, questi— m 175 W lad— &a Ste 1500, Chicago, L 60604 a S—SA6r 4—a.ag FANSaItA" ddm[reani to __.:TIFICATION MEENAKSHI RATHORE for successfully completing the standards set forth for the ServSafe® Food which is accredited 6y the American National Standards Institute (ANS 16994 3/7/2Mq DATE OF I Local laws apply. BER EX 3/7/2021 DATE OF EXPIRA for recedification requirements. iification Examination, Protection (CFP). 0 kod-wis of the taAff. G.d.d.vah q—r.. d 175 w Jadwn BW, Ste 15W, Chk a., L60604 xS—S.W—k ad.crg CERTIFICATE OF ALLERGEN AWARENESS TRAINING The above-named person is hereby issued this certfcate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). this certiiate will be valid for five (5) years from date ofeompletion. Issued By: MR81 NATIONAL e RESTAURANT ASSOCIATION, Massachusetts Restaurant Acsodation 800.765.2122 333 Turnpike Road, Suite 102 www.restaurant.org Southborough, MA 01772 508-303-9905 www. mares taurantassoc.org