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HomeMy WebLinkAboutCorporate Chefs @ Smith/Nephew 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:. CORPORATE CHEFS Whose place of business is: CORPORATE CHEFS @ SMITH & NEPHEW 130 FORBES ROAD PERSON(S) IN CHARGE: ED SANTANA, MANAGER Permit Expires: December 31, 2016 License Number: FS -10 Food Fee: $62.50 Milk & Cream 91 BOARD OF HEALTH AichaeC-%1cCCean, 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: CORPORATE CHEFS having a place of business at: CORPORATE CHEFS @ SMITH & NEPHEW 130 FORBES ROAD 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 12131/2016 unless previous to that time is suspended or revoked. Expires 12131/2016 License No.: FS -10 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY !� Date received: Date Inspected: Approved By: Permit # Issued FS -10 FOOD ESTABLISHMENT PERMIT APPLICATION (Applica ron must be subffiffe—cTat least 30 days b_&To_f6e'p anne opent ngVa-76) 1) Establishment Name CORPORATE CHEFS @ SMITH & NEPHEW 2) Establishment Address 130 FORBES ROAD 13) Establishment Mailing Address (if different) 22 PARKRIDGE ROAD HAVERHILL, MA 01836 4) Establishment Telephone No (608) 261-3710 5) Applicant Name & Title: KELLY KIJANKA, LICENSE ADMIN. -- - -- ------ 6) Applicant Address 22 PARKRIDGE ROAD, HAVERHILL, MA 01836 7) Applicant Telephone No.: (978) 372-7400 24 Hour Emergency No.: (970) 372.7400 8) Owners Name & Title CORPORATE CHEFS 9) Owner Address (if different from applicant) 22 PARKRIDGE ROAD, HAVERHILL, MA 01836 Owner's telephone number (978) 372-7400 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. W A Corporation Name Title Address El An Individual El A Partnership 0 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Tltle: C"0'-0CZ5Q_r [Address: Telephone No, -6 2 - 24 Hour Emergency No: (978) 372-7400 FAX: (978) 372-0150 E-mail: KKIJANKA(&,CORPORATECHEFS.COM ... .......... ... .. ... . Alt E -Mail: 13) District Or Regional Supervisor (if applicable) ----------------- Name & Title: SUE PELOQUIN, DISTRICT MANAGER ............ Address: 62 BLACKSTONE STREET, BLACKSTONE, MA 01504 I Telephone No: (508) 254-0398 24 Hour Emergency No: (978) 372-7400 (978)372 -0150 SPELQUIN@CORPORATECHEFS.COM E-mail: Food Establishment Information -------------- 14) WATER SOURCE: TOWN 16) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: 3 ......... .... :17)DAYS/HOURS: M -F 6:30 AM -3 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate 9*) Person Trained in Anti -Choking Procedures (if 25 Seats or more): 6V] ...... . ..... 20)' *Location: nv Permanent Location l 22) Establishment Type ❑ Caterer $12.50 Q Mobile Mobile Start Date: Q Retail Sq. Ft) Milk & Cream $5.00 Mobile End Date: Food Service up to 100 or F] Mobile Food & Concession $37.50 Mobile Comments: i up to 10' PHF display $62-50 ❑ Manufacture Frozen Dessertslice Cream I 21) Length of Permit: F-1 Food Service up to 101-200 $12.60/freezer 1 i Annual or up to 25' PHF display $75.00 n Pushcart $12.50 # of Pushcarts: F1 Seasonal Food Service up to 201 + E] Residential Kitchen $50.00 or 26'+ PHF display $137.50 Seasonal Dates: Retail Food $50.00 Food Service - Institution EJ Retail Snack Food $12.50 Temporary Temporary Start Date: Meals/Day) Tobacco Products $12,50 Temporary End Date: Temporary Time: ------------- Rain Date: Definitions. PHF- Potentially hazardous food (timellemperature controls required) 4-a) Food Operations Non-PHFs - non -potentially hazardous food(no time/temperature controls required) i(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) -S--ale of Commercially Pre -Packaged Non -P HFs 0-/ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ------- 4 for More Than a Single Meal Service ;07��Ie­ Of Commercially Pre -Packaged eid PH'Fs _R_ —Pre- pia Preparation I o- n- - of 0 H, F s For r H ot And ............. .... ....... .... ... Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑Delivery of Packaged PHFs Susceptible Population Facility .... ........ Sale of Raw Animal Foods Intended ------ E] Reheating of Commercially to be Prepared by Consumer E] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Ll Use of Process Requiring A Variance and/or HACCP Plan (including bare hand rElc�stomer Self -Service of Non PHF and Non- I l,/l Customer Self -Service Perishable Foods Only ontact alternative, time as a public health Ice Manufactured and Packaged for 'C'ntrol) Preparation of Non-PHFs Retail Sale .... . .. _ . ......... Other Food Operations ❑ Juice Manufactured and Packaged for El offers Raw Or Undercooked Food Of Retail Sale Animal Origin EI Prepares Food/Single Meals for ❑ Ufwrs­kt� P, H_—F *i�_66_1k' Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $62.60 Payment is due with application F] waived 1, the undersigned, attest to the accuracy of the information provided In this application and affirm that the food establishment operation will comply with 1105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cop1ps of 105 CMR 590:000 and the federal Food Code. 24) Signature of ApplicanlL _�—/ ) - L�1/. At_ -'— ="-'— Pursuant to MGL Ch.62C, see. 49A, I certi"nder the penalties of perjury that 1, 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: 04-2981626 P 26) Signature of Individual or Corporate Name: C_L1rJ0nY—C 'k t -)c Town of Town of Mansfield - Board of Health 6 Pak Rowansfieid 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: CORPORATE CHEFS @ SMITH & NEPHEW ADDRESS: 130 FORBES ROAD TELEPHONE AT LOCATION: (508) 261-3710 FAX NUMBER: (978) 372-0150 OWNER OF BUSINESS: CORPORATE CHEFS TELEPHONE OF OWNER: (978) 372-7400 FEDERAL ID/SS NUMBER: 04-2981626 FEE: $5.00 PERMIT NUMBER: FS -10 SIGNATURE: DATE: certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. * Signat re of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) �- zaS )I .2- ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the certification clause is signed by the applicant. ** Your Social Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A, The Commonwealth of N.lassachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, AM #2114-2017 wimmass,govIdla Workers' Compensation Insurance Affidavit: General Bush esses Applicant Information Please Print Legibly Business/Organization Nwne: c Address: 02 �L r ,cue R 1A . City/State/Zip: G 1$ 3 .� Phone#: T26- 37-a7, '7/0 0 Ar,.e, yo an employer? Check the appropriate box I . LtiJ l am a employer with employees (full and/ or part-time).* 2.0 1 am a sole proprietor or partnership and have no employees working for me in any capacity, [No workers' comp, insurance required] 3.0 We are a corporation and its ofHeers 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. n Retail 6, El Restaurant/Bar/Eating Establishment 7. Q Office and/or Sales (incl,.real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment. 10.0 Manufacturing 11.n Health Care 12,M Other *Any applicant that checks box ill must also fill cut the section below showing their workers' compensation policy information: **Cf the corporate officers have exempted themselves„ but the corporation has.other employees, a workers' compensation policy is required and such an organisation should check box #1. I ant an enrplayer t{cat rs providing woritets' cotnpecrsation ictsuraccce,fiir isxy ccrtployecs. Below is tice:�ioliey Pi{jvr�diirnt. Insurance Company Name: �_� M r v�vr Tr,svr ace �o Insurer's Address: J �/ -Ti�; ta t-t.v e City/State/Zip: Gu �L cn Policy # or Self ins: Lic. # CCG o0 t/-QQ,& Zo 2 aG l G A. Expiration Date: G/ G / a0 J 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 S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the i'orm of a STOP WORTS ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for htsurance covet•age verification. I do hereby certify,un�er�thhe pars and penalties of perjury that the hiforinat/oh provieled above Is:true and correct. Si.artature: %7t:!�-;37d- 7 Offteial use only. Do not write in this area, to be eoctpleted by city or town offiei'at City or Town: _ I'ermit/License # Issuing Authority (circle one): 1. Board of ffealth 2, Building Department 3. City/Towil Cleric 4, Licensing Board 5. Selectmen's Office 6, Other Contact Person www.mass.gov/dia Phone #: CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) PERIOD 10/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF''INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED, the pollcy(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 ori'this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER TGA Cross Insurance Inc. 401 Edgewater Place; Suite 220 Co"TACT . NAME:. TGA.Cross Insurance, Inc, PHONEExt), 781-914-1000 a/c 781-246-2601 WakeNo): Wakefield, MA 01880 EMAIL ADDRESS: switchboard CoNg across. com INSURERS) AFFORDING COVERAGE NAIC q WWW.fgaC(OSS.COm INSURER A; Harleysville Ins Co 23582 .10/3112016 INSURED Corporate Chefs, Inc. INSURER B: Liberty Mutual. Insurance Company 23043 INSURER C: New Ham shire Employers Insurance Co 13083 ABD Catering Elite Vending 22 Parkridge Road INSURER D: Capital Spec ialt Insurance Corp. INSURER E Haverhill MA 01835 INSURER F : CnVFRAr;FR noortrnwr --......_... •• cr r��roO',r i;. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED KtVISIUN NUMBER: NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 'OTHER DOCUMENT WITH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, INSURANCE AFFORDED BY THE POLICIES RESPECT TO WHICH THIS :DESCRIBED HEREIN IS SUBJECT TO ALL EXCLUSIONS AND CONDITIONS OF SUCH POLICIES."LIMITS' SHOWN MAY HAVE BEEN REDUCED THE TERMS, ?NSR BY PAID CLAIMS, ADDL S BR ' LTR TYPE OF INSURANCEwtn ` POLICY NOMBER MM/DD/YY1E'YY MMIDDmYY LIMITS A �/ COMMERCIAL GENERAL LIABILITY SPP00000035326U 10/31/2015 .10/3112016 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE ❑✓ OCCUR D79KGE O REN ED PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ GENERAL AGGREGATE $ 2,000,000 POLICY JECT ✓PRO-� LOC PRODUCTS •COMP/OP AGG $ 2,000,000 OTHER: Em 10 ee Benefits $ 1,000,000 A AUTOMOBILE LIABILITY BA00000035328U - MA 10/31/2015 10/31/2016 EOa aBINEU-SINGLE LIMIT $_ 1,000 000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Peraccident) S IRED AUTOS NON -OWNED - BA60000035327U 10/31/2015 10/31`!2016 N PROPERTY DAMAGEAUTOS Peraccidenl $ A NH BA00000031554W 10/31/2015 10/31/2016 $ B ✓ UMBRELLA LIAR ✓ OCCUR TH7651291668015 10/31/2015 10/31/2016 EACH OCCURRENCE s 10 000 000 EXCESS LIAB CLAIMS -MADE AGGREGATE S 10,000,000 DED ✓ RETENTION$ 10,000 C WORKERS COMPENSATION ECC 60040007092015 1/1/2016 1/1/2017 $ AND EMPLOYERS' LIABILITY Y/ N - STATUTE EERH E.L. EACH ACCIDENT $ 500,000 ANY OFFICER/MEMBER EXCLUDED? PROPRIETOR/PARTNERIEXECUTIVE a N / A (Mandatory in If yes, describe under E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below D Liquor Liability CS0244110502 10/31/2015 .10/31/2016 Each Claim 1,000,000 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space•Is required) Evidence Of Coverage 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 Thomas I Gregory: tV "I VtR1:LU'14 AUUKU GUKPUKA IIUN, All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 27135156 1 227080 1 15-16 GL, AU, UM, WC I Sue Petro 1 10/30/2015 3:10;01 PM (EDT) I Page 1 of 1 CORPORATE CHEFS OFFICERS 22 Parkridge Road Haverhill, MA 01832 978-372-7400 FEDERAL I.D. 04-2981626 Kenneth Bickford, President 96 Alpine Park Road Moultonb oro, NH 03254 Alan Ayres, Treasurer 34 Sable Run Lane Methuen, MA 01844 David DesRosiers, Vice President 167 Ocean Drive Seabrook, NH 03874 S � ( t }\ 2 « , # § q © u t-0 \ �d<«? \ §- e # \2 o ; » \ % m -Cq « . x.�\\���M��\ ..�\ 3.. .� y. a ? .. . 2 \ y�� © y� \/\y •4 <\\ z < . 2�- � 2 U 141 .. 0 A & Fi . Z Q a ( t }\ / \ « , # § q © u t-0 \ \wk'Coo \ §- e # \2 o ; » \ a ( f ƒ « , # § q � [ t-0 � % � ho ) e # \2 % ; » \ ƒ ( \ G \ � •4 � q a