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HomeMy WebLinkAboutGeneral Nutrition Center 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:. GENERAL NUTRITION CORPORATION Whose place of business is: GENERAL NUTRITION CENTER #8844 280 SCHOOL STREET PERSON(S) IN CHARGE: J. SCOTT, MANAGER Permit Expires: December 31, 2016 License Number: RF -100 Food Fee: $50.00 BOARD OF HEALTH 'IichaeCMcCtean, Chairman 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. COQ * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 11 ** 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 fall 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 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ������ L A,1 u7W 177 ©A/ C -fl 1,?1P Address: So City/State/Zip: 72f ,11 6ale�-_'-'ffl y�94 1SZ2Z Phone #: �lZ`2�� ' 46r6 Z Are yo employer? Check theappropriate box: 1. I 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 officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business (required): 5. M4etail 6. 0 Restaurant/Bar/Eating Establishment 7. 0 Office and/or Sales (incl. real estate, auto, etc.) 8. 0 Non-profit 9. 0 Entertainment 10.0 Manufacturing 11.0 Health Care 12.0 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 Ill. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: `Pp yJ 1 I A/ / 0 N `%V W 4r , A) City/State/Zip: 22Z Policy # or Self -ins. Lic. # '� 0 6 53-1-10 / Expiration Date: / —,? / -201�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 certify, under the pains and penalties of perjury that the information provided above is truce and correct. Signature: /V �� ��G2/�GZ/ Date: Phone #: 4� 2 - 2 sw J (.., 2 - Official 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: Phone #: www.mass.gov/dia CERTIFICATE OF LIABILITYINSURANCE DAT 04101/2011) 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 endorsemenL A statement on this certiflcate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Aon Risk services Central, inc. Pittsburgh PA Office Dominion Tower, 10th Floor 625 Liberty Avenue Pittsburgh PA 15222-3110 USA CONTACT NAME (A/CNo.Ext1; C866) 283-7122 ac No: 600-363-0105 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE MAIC 0 INSURED INSURER A: sentry Ins A Mutual company 24988 GNc corporation 300 6th Avenue 11th Floor Pittsburgh PA 15222-2514 USA INSURER B: sentry casualty company 28460 INSURER C: INSURER D: PERSONAL &ADV INJURY INSURER E: GENERAL AGGREGATE INSURER F: 19._9171 5 1111111 olaittild 1A11ivrl` AllM YIP11.1 7 Ci:kT1E1141iI&11111141MA► 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. Limits shown are as requested LTR TYpEOFINSURANCE IVSD WVD POUCYNUMaER jMWDDAyMILIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � llll���llll OCCUR _.MMQp= EACH OCCURRENCE DAMA PREMISES Ea occurrence MED EXP (Arty one person) PERSONAL &ADV INJURY GEN'L AGGREOATE LIMIT APPLIES PER POLICY [:]PRO ❑ LOC JECT I OTHER: GENERAL AGGREGATE PRODUCTS - CDlJP10P AGG A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON -OWNED AUTOS 90-05341-03 01/31 2016 01/31/2017 CDSINGLE LIMIT $2,000,000 Eaetc1decddeM BODILY INJURY ( Per pemon) - BODILY INJURY (Per accident) PReOPPEERRTY�DAMAGE UMBRELLA LIABOCCUR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED RETENTION B B WORKERS COMPENSATION AND EMPLOYERS' LUU31UTY ANYPROPRIETOR/PARTNER /EXECUTIVE YIN OFFICERIMEMBEREXCLUDED? N (Mandatory In NH) If yes describe under DESCRIPTION OF OPERATIONS below NIA 900534101 AOS 900534102 Hi, WI 01 31/201 01/31/2016 1 31 2017" 01/31/2017 X sPETRA,I,U,� OTH- - E,L EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E. E.L.DISEASE -POLICYLIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Addillonal Remarks Schedule, may be attached If more apace is required) Evidence of Coverage, z a) v ri L) CERTIFICATE HOLDER CANCELLATION 22 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. _ GNC corporation AUTHORIZED REPRESENTATIVE DO - 300 6th Avenue 11th Floor Pittsburgh PA 15222 USA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2094101) The ACORD name and logo are registered marks of ACORD GENERAL NUTRITION CORPORATION 300 Sixth Avenue Pittsburgh, PA 15222 10/29/03 - PA TAX IDENTIFICATION NO. 25-1124574 (412) 288-4662 Michael Archbold, Chief Executive Officer 300 Sixth Avenue Pittsburgh, PA 15222 Tricia Tolivar, Executive Vice President & CFO 300 Sixth Avenue Pittsburgh, PA 15222 James M. Sander, Sr. Vice President, Chief Legal Officer & Secretary 300 Sixth Avenue Pittsburgh, PA 15222 Michael C. Smith, Vice President 300 Sixth Avenue Pittsburgh, PA 15222 David J. Sullivan, Assistant Secretary 300 Sixth Avenue Pittsburgh, PA 15222 FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF -100 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at leastdays be -To -re the planned opening date) 1) Establishment Name GENERAL NUTRITION CENTER #8844 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 300 SIXTH AVENUE, RETAIL OPERATIONS PITTSBURGH, PA 15222 4) Establishment Telephone No (508) 261-8707 5) Applicant Name & Title: ROSEANNE FABINA, SR. TAX ADMINISTRATOR 6) Applicant Address 300 SIXTH AVENUE, PITTSBURGH, PA 15222 7) Applicant Telephone No.: (412) 288-0662 24 Hour Emergency No.: (877) 840-1719 8) Owners Name & Title GENERAL NUTRITION CORPORATION 9) Owner Address (if different from applicant) 300 SIXTH AVENUE, PITTSBURGH, PA 15222 Owner's telephone number 4122884662 10) Establishment Owned By: ❑ An Association W 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 �j Title Address L- E-�AO Lf 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: J. SCOTT, MANAGER Address: 280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-8707 24 Hour Emergency No: (877) 840-1719 (412) 338-8878 FAX: E-mail: 700110(a_GNC-RETAIL.COM Alt E -Mail: ROSEANNE-FABINACa�GNC-HQ.COM 13) District Or Regional Supervisor (if applicable) Name & Title: JEFF PEREIRA, MANAGER Address: Telephone No: (508) 415-6247 24 Hour Emergency No: (877) 840-1719 FAX: (412) 338.8878 E-mail: 700110@G NC -RETAIL. COM Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 16) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 2-4 17) DAYS/HOURS: . MON-SAT 10 AM -9 PM SUN 11 AM -5 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 10/9/2001 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: 0 Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Mobile Mobile Start Date: Retail (1,280 Sq. Ft) F] Milk &Cream $5.00 Moblie End Date: ❑ 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: ❑,/ Annual or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 n./ Retail Food $50.00 ❑ Seasonal 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 Dernitions, PHF-Potentially hazardous food (timellemperature controls required) Non-PHPs - non -potentially hazardous food(no timeRemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) V Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service IJ Use of Process Requiring A Variance Perishable Foods Only and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service LJ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health 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 comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies o� 105 CMR 590.000 and the feral Food Code. / I--/ , 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under 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: 25-1124574 / Q 26) Signature of Individual or Corporate Name: ���� %`� Z- N&( %XC �Cw Cor"/