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HomeMy WebLinkAboutFive Below 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment' Type: RETAIL FOOD In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. FIVE BELOW, INC. Whose place of business is: FIVE BELOW #408 280 SCHOOL STREET PERSON(S) IN CHARGE: DARLENE, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: RF -7 Food Fee: $50.00 BOARD OF HEALTH AichaeCvicCCean, Chairman FOR BOARD OF HEALTH USE ONLY it Date received: Date Inspected: Approved By: Permit # Issued RF -7 L FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at /east 30 days before the planned opening dato 1) Establishment Name FIVE BELOW #408 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 1818 MARKET STREET, SUITE 2000 PHILADELPHIA, PA 19103 4) Establishment Telephone No i-- - - , - - - - - 5) Applicant Name & Title: KENNETH R. BULL 6) Applicant Address 1818 MARKET STREET, SUITE 2000, PHILADELPHIA, PA 19103 7) Applicant Telephone No.: (215) 546-7909 24 Hour Emergency No.: (508) 472-6444 8) Owners Name & Title FIVE BELOW, INC. 9) Owner Address (If different from applicant) 1818 MARKET STREET, SUITE 2000, PHILADELPHIA, PA Owner's telephone number 2156467909 10) Establishment Owned By: 11) if a corporation or partnership, give name, title, and home address of officers Lj An Association or partner. W A Corporation Name Title Address ❑ An Individual -1 L A Partnership El Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: DARLENE, GENERAL MANAGER Address: 280 SCHOOL STREET, SUITE 130, MANSFIELD, MA 02048 Telephone No: 1(508) 339-1832 24 Hour Emergency No: (508) 472-5444 FAX: 1(508) 339-1850 E-mail: IBRUCE.GEMMILLPFIVEBELOW.COM Alt E -Mail: MAUREEN.MULLIGEN(cDFIVEBELOW.COM 13) District Or Regional Supervisor (if applicable) Name & Title: _T Address: Telephone No: (508) 472-5444 24 Hour Emergency No: (506) 472-5444 TIMOTHY. MILLER@FIVEBELOW.COM E-mail: FAX: (216) 546-1696 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No of Food Employees: 15-20 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): F] 20) Location: Ev] Permanent Location 22) Establishment Type ❑ Mobile Moblie Start Date: I [� Retail ( Sq- Ft) Mobile End Date: F] Food Service up to 100 or u to 10' PHF dis la $62 50 ❑ Caterer $1'2.50 [ i Milk & Cream $5.00 I � [] Mobile Food & Consession $37.50 Mobile Comments: P P y Manufacture Frozen Desserts/Ice Cream ` --- - — 21) Length of Permit: ❑ Food Service up to 101 -200 $12.50/freezer I (�J Annual I or up o 25' PHF display $75.00 t Pushcart $12.50 1t of Pushcarts: ❑ I Q Seasonal ❑ Food Service up to 201 + [)Residential Kitchen $50.00 or 25'+ PHF display $137.50 [J] Retail Food $50.00 Seasonal Dates: ❑Temporary ❑ Food Service - Institution ❑Retail Snack Food $12.50 Temporary Start Date: ( Meals/Day) [ ] Tobacco Products $12.50 ;Tem ora ryEnd Date: � I Temporary Time: Rain Date: 23) Food Operations Definitions: PHP - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no timeAemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) E] Sale of Commercially Pre -Packaged Non -PRFs I ❑ PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre Packaged PRFs [] Preparation of PRFs For Hot And for More Than a Single Meal Service ._- ___ . -_ _ _ __-_ __ _ ----- ---- - - -- Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Q Delivery of Packaged PHFs ____ _ __..__ ______ - Susceptible Population Facility ------- - -- Q Reheating of Commercially [] Sale of Raw Animal Foods Intended to be Prepared by Consumer -' n Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours- i [ ) Use of Process Requiring A Variance �' ❑Customer Self -Service of Non PHF and Non- Q Customer Seif-Service i and/or HACCP Plan (includingbare hand Perishable Foods Only [] Ica Manufactured and Packaged for contact alternative, time as a public health -- - -- - 0 a ra-tionof Non-PHFs _I Retail Sale control) -Prep - Other Food Operations } n Juice Manufactured and Packaged for'[-] Undercooked Food Of Retail Sale AnimalROrigor - -- - Offers RTE PHF in Bulk Quantities L] Offers � ❑ Food/Single Meals for -_ Catered Events or Institutional Food Service F Retail Sale of Salvage, Out -Of -Date -- ---- - or Reconditioned Food ; To be completed by the Board of Health E " Total Permit Fee: $50,00 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 complyv 105 � 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cop of 5 JCMR 590.000 and the federal Food Code. 24) Signature of Applicant: ' Pursuant to MGL Ch.62C, sec 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law. 25) Social Security Number or Federal ID: 75-300037 Y/ 26) Signature of Individual or Corporate Name: ` (=LwLJ _� I certify under the penalties of perjury that I, to my best knowledge and beliet, have filed all State tax returns and paid all State taxer required under law. * Signature of Individual or Corporate Name (Mandatory) y; Corporatb Officer ' (Mandatory, 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 rnade under the authority of Mass. General laws, Chapter 62C, Section 49A. 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 Individual or Corporate Name (Mandatory) y: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the certification clause is signed by i 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 ofll7assachusetts Department of Industrial Accidents - Office of lnvestiyaborts 600 Washington Street Boston, _AM 02.111 W wmp ntass,gov/dia Workers' Compensation Insurance Affidavit General Businesses Applicant Information Please Print Leibl r Business/Organization Name: \j \ Address:<�\<K _y�Cct'(_ �� svvc�� Qht G Y� ci I U` i c rab c City/State/Zip: i,��%i b_�_— Phone #: 2lS- y ��� �_IC� _�2 Are yo n employer? Check th appropriate boa: L I am a employer with- )_ employees (hill ard/ 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, ei ctatl 6. ❑ Rest aLi-in t/Bar/Fating Establishment 7, ❑ Office and/or Sales (incl S. ❑ Non-profit 9, ❑ Entertainment 10.❑ Manufacturing 1 l,❑ Health Care 12, El Other real estate, auto, etc.) *Any applicant that checks box pl must also fill out the section below showing their workers' compensation policy information. **lf 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 N. I am an employer that is providing workers' compensation insurance for my employees. Belo iv is the policy information. T Insurance Company Name: \,_}{1 t=\ -e <k- -\-Pe,( �� nyY� Y� �✓ Insurer's Address: City/State/Zip: -U CS rte h,: 7 n I— -------------- - -- Policy f{ or Self -ins. Lie, kd t iY (.9 Fxpiration 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 TNIGL 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 tine 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 DTA for insurance coverage verification, _ _ _ Ido hereby ce,riafj') rind tit anis turd penalties of perjury that the information provid d abo ,e is true and correct V — Cam Siffnature €'!%-- ---- ---Date._—�-! v-�(s}--- Official use only, Do not write In this area, to be completed by city or town ofr"cial City or Town: Permit/License 4 Issuing Authority (circle one): 1, Board of Health 2. Building Department 3, City/Town Cleric 4, Licensing Board 5. Selectmen's Office 6, Other Contact Person: Phone mww. mass. gcvW is-- --- !'1.....447. 477ro4a 1.rnFIVEBEt .,,., , , -- -- -- ,r. ,�,, DATE (MM/DD/YYYY) ACORD,., CERTIFICATE OF LIABILITY INSURANCE 8/02/2016 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(les) 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 CONTACT Donahoe --- BB&T - The Addis Grou p — —___Matt- -- ' - - --- -- FAX PHONE 610 279-8550 I 6102798543 2500 Renaissance Blvd Suite100 E-MAIL ADDRESSmdonahoe bbandt.corn _-- -,-- ----'--- King Of Prussia, PA 19406-2639 - - --- INSURERS) AFFORDING COVERAGE NAIC# 610 279-8550 INSURER A: Liberty Mutual Insurance Compan23043 _ INSURED INSURER B: Zurich American Insurance Compa 1,27855 Five Below Inc. 1818 Market Street Ste 1900 INSURER C : Philadelphia, PA 19103 INSURER D : -_--- - - INSURER E: INSURER F: COVERAGES CERTIFICATE 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 CONTRACTOR 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 TYPE OF INSURANCE _ ADDL INSR SUBR WVD POLICY NUMBER __ _ POLICY EFF JMM/DD/YY_YY) POLICY EXP (MMIDD/YYYY)_ _ _ LIMITS EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S CLAIMS -MADE FIOCCUR PREMISES__(_Ea occurrence; ___ MED EXP (Any one person) 3 _ PERSONAL _& A_DV INJURY— GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL _AGGREGATE_ S PRO- r 1 POLICY [--] JECT I—I LOC A----- PRODUCTS-- COMP/OP AGG S _ OTHER: _ _ _ _ _ _ _ _ $ - _ --COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY JEa accident) . _ _- _- _ S__, BODILYINJURY (Per person)ALL ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED - - -- PROPERTY PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAB H IOCCUR EACH OCCURRENCE S AGGREGATE _ S EXCESS LIAB CLAIMS -MADE DED I RETENTIONS S B WORKERS COMPENSATION WC008104200 06/01/2016 03/011201 X PERT OTH- E.L. EACH ACCIDENT S1,000,000 AND EMPLOYERS' LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L. DISEASE - EA EMPLOYEEI S1,000 OUO OFFICERIMEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE -POLICY LIMIT 1 $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below _ ___ _ __ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of coverage. Five Below, Inc. 1818 Market Street Philadelphia, PA 19103 ACORD 25 (2014/01) 1 of 1 #S16613092/M16247867 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 ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD