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Home My WebLink AboutCosi 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:. COSI, INC. Whose place of business is: COSI 280 SCHOOL STREET PERSON(S) IN CHARGE: STAN LORING, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -11 Food Fee: $62.50 Milk & Cream BOARD OF HEALTH 'AlichaeCNcClean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: COSI, INC. having a place of business at: COSI 280 SCHOOL STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -11 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 -11 .'�I�1:j�t�'ial�lla►1■J;wiyl1s;d;dlg pp ica ion mus esu m► e a eas ays a ore e p anne opening a e 1) Establishment Name COSI 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 261-8740 5) Applicant Name & Title: COSI, INC. 6) Applicant Address 294 WASHINGTON STREET, #510 BOSTON, MA 02108 7) Applicant Telephone No.: (857) 416.6031 24 Hour Emergency No.: (hos) 367-5633 8) Owners Name & Title COSI, INC. 9) Owner Address (If different from applicant) 294 WASHINGTON STREET, #510, BOSTON, MA 02108 Owner's telephone number (857) 415-5000 10) Establishment Owned By: ❑ An Association V A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 171 Parcnn nirartly RPsnnnsible For Dailv Operations (owner, person In charge, supervisor, manager etc.) Name & Title: STAN LORING, GENERAL MANAGER Address: 3 FRANLIN STREET, HUDSON, MA 01749 Telephone No: (508) 261-8740 24 Hour Emergency No: (508) 367-5633 (508) 261-8742 (860) 539-225 FAX: E-mail: XCB00209 0@ GETCOSI-COM Alt E -Mail: MELISSA.CURRY@-GETCOSI.COM 13) District Or Regional Supervisor (if applicable) Name & Title: STAN LORING, AREA DIRECTOR Address: 3 FRANKLIN STREET, HUDSON, MA 01749 Telephone No: (617) 620-5590 24 Hour Emergency No: (617) 970-4913 FAX: (508) 435-2148 _J E-mail: STANIORING@GETCOSI.COM Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 30 DEP Public Water Supply No: (if applicable) 17) DAYS/HOURS: 7 AM -10 PM 7 DAYS 18) Name of Person In Charge Certified in Food Protection Management: PATRICK R. DUNN 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 CORRIE L. SMITH certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: V Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ❑Q Milk & Cream $5.00 Mobile End Date: ❑Q Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Mobile Comments: up to 10' PHF display $62.50 ❑ Food Service up to 101-200 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer 21) Length of Permit: ❑Q Annual or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (timelemperature controls required) Non-PHFs - non -potentially hazardous food(no time/lemperature controls required) 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 Heid for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs W Preparation of PHFs For Hot And Cold Holding For Single Meal Service E]PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs F] 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 ❑ customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) E] 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 ❑ Offe TE PHF in Bulk Quantities ❑ Re all Salt; of Salvage, Out -Of -Date Food To be completed by the Board of Health 4oronditioned Total Permit Fee: $62.50 r Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the irlt&mati nKvidt establishment operation will comply with 105 CMR 590.0 0 all board of health on how to obtain copies of 105CMR 590. ids 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the p and paid state taxes required under law. 25) Social Security Number or Federal ID: 06-1393745 26) Signature of Individual or Corporate Name: and affirm that the food 1. 1 have been instructed by the my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Create Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: COSI ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 261-8740 FAX NUMBER: (508) 261-8742 OWNER OF BUSINESS: COSI, INC. TELEPHONE OF OWNER: (857) 415-5000 FEDERAL ID/SS NUMBER: 06-1393745 FEE: $5.00 PERMIT NUMBER: FS -11 SIGNATURE: DATE: 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. * Signature of Individ I or,, Corporate Name ( andatory) By: Corpotatd, ffider — (Mandato , if applicable) ** 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 IV www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lesribly Business/Organization Name:�,7�\ , C Address:'" City/State/Zip: C _�ttLn Phone # i k_ t iC (�) Are you an employer? Check the appropriate box: 1. L� 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. [estaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) & ❑ Non-profit 9. ❑ Entertainment 10. El Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box # 1 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 ft I am an employer that is providing workers' compensation Insurance for my employees, Below is file policy information. Insurance Company Name: Insurer's Address, Address: FV City/State/Zip: r,t t 1 C ` C'ci Policy # or Self -ins. Lic. # �` �1� Expiration Date:t- Attach a copy of the workers compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage s uired tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 an year risonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a d� ag the viola r. Be advised that a copy of this statement may be forwarded to the Office of Investigations of tjre DI o suranc erage verification. I do hereby cerjify, and e s a les of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do n t 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: Phone #: www.mass.gov/dia INSURER: THE NORTH RIVER INSURANCE COMPANY HOME OFFICE: TOWNSHIP OF MORRIS, NJ A STOCK INSURANCE COMPANY 1. THE INSURED AND MAILING ADDRESS: COSI INC. (SEE NAMED INSURED ENDT) 294 WASHINGTON ST BOSTON MA 02108 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY - INFORMATION PAGE POLICY NO: 4087276344 RENEWAL IOF: 4087255545 NCCI CO NO: 14508 INSURED ID NO(S): CLIENT NO: 3056641 PRODUCERINO: 83357 PRODUCER NAME AND ADDRESS: HAYS INSURANCE BROKERAGE SERVICES 133 FEDERAL STREET, 3RD FLOOR BOSTON MA 02110-0000 INSURED ENTITY: CORPORATION BUSINESS OF INSURED: RESTAURANT OTHER WORKPLACES NOT SHOWN ABOVE: (See Extension of Information Page) 2. POLICY PERIOD: FROM 12-18-2015 TO 12-18-2016 Effective 12:01 A.M. Standard Time at the Insured's Mailing Address. 3. COVERAGE: A. Workers' Compensation Insurance: Part One of the Policy applies to the Workers' Compensation Law of the States Listed here: CT DE IL MA MD MI MN NJ NY PA VA WI B. Employers' Liability Insurance: Part Two of the Policy applies to work in each state listed In Item 3A. The Limits of our liability under Part Two are: Bodily Injury by Accident: $ 1,000,000 Each Accident Bodily Injury by Disease: $ 1,000,000 Policy Limit Bodily Injury by Disease: $ 1,000,000 Each Employee C. Other States Insurance: Part Three of the Policy applies to All States of the United States, except those listed in Item 3A above and in: ND, OH, WA, WY and in any additional states listed below: D. This Policy includes these Endorsements and Schedules: As per schedule of forms and endorsements. 4. THE PREMIUM for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page. AGENCY BILL Total Estimated Minimum Premium: $ 807 Annual Cost: $ 501,936 Audit Period: ANNUAL Deposit Premium: $ 501,936 Issued At: BOSTON MA Date: 12-22-15 DATE Authorized Representative WC 00 00 01 A (2190) Copyright 1987 National Council on Compensation Insurance WC 00 00 01 C (7197) /� CERTIFICATE OF LIABILITY INSURANCE iC40%20® (MMIDDNYYY) DATE 06/08/2016 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 1-617-723-7775 Hays Companies of New England 133 Federal Street CON EACT Seamus King NAM PHONE FAX A/C No Ex A/C No): EMAIL akin @ha scorn anies.com ADDRESS: g Y P INSURERS AFFORDING COVERAGE NAIC # 2nd Floor Boston, MA 02110 INSURERA: MASSACHUSETTS BAY INS CO 22306 INSURED INSURERB: Hanover Ins Co Grpl 884 INSURERC: UNITED STATES FIRS INS CO 21113 Cosi, Inc. INSURERD: 294 Washington Street INSURER E: Suite 510 INSURER F Boston, MA 02108 n C r]Tlffl ATC K111RR==O. A' n7i KnR KCVimi Vlv lmulvl=CM. 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. ^ '----' -"-'- RANCE ADDL SUER POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD/Y LIMITS AUTHORIZED REPRESENTATIVE ..d LIABILITY ZDY8955089 12/18/1 12/18/16 EACH OCCURRENCE $1,000,000 DAMAGETO RENTED1,000,000RAL PREMISES Ea occurrence $� MED EXP (Any one person) $ 10,000 OCCUR N—FF PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 $ OMBINeDSINGLELIMIT 1,000,000 A I MX- POLICY PRO LOC AUTOMOBILE LIABILITY ADN8913253 12/18/1 12/18/16 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ B UMBRELLA LIAB I X JOCCUR UHNA507464 12/18/1 12/18/16 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25, 000, 000 EXCESS LIAR ri CLAIMS -MADE DEO RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE $ WCYLATU- OETH- X TCR C 4087255546 12/18/1 12/18/16 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Property N / A ZDY8955089 12718/1 12/18/16 E.L. DISEASE -POLICY LIMIT $ 110001000 50,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance. GtK 111-I1+A I c nVLUCR ^ '----' -"-'- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ..d kw 1 V00'4V 1 V P%%owm — y..av ........ ...... ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SeamusK 47071508 W-4 O w 0 z z W z 3 d z W W a d 6 d 03 oho N N a a � Z U A A L2