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HomeMy WebLinkAboutKinder Care 12/31/2016Commonwealth 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: KNOWLEDGE LEARNING CORPORATION KINDERCARE EDUCATION having a place of business at: KINDER CARE 515 WEST STREET 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 -126 Scott Leite, HeaCth Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Date received: I I� 1) Establishment Name FOR BOARD OF HEALTH USE ONLY I Date Inspected: Approved By: Permit # Issued FS -126 FOOD ESTABLISHMENT PERMIT APPLICATION - KINDER CARE 2) Establishment Address 515 WEST STREET 3) Establishment Mailing Address (if different) 515 WEST STREET 4) Establishment Telephone No MANSFIELD, MA 02048 (508) 337-8600 5) Applicant Name & Title: MICHELE LORD, CENTER DIRECTOR 6) Applicant Address 515 WEST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: 24 Hour Emergency No.: (800) 322-0 199 l lQY( 8) Owners Name & Title KNOWLEDGE LEARNING CORPORATION r - �Q,rCt�,re� C 9) Owner Address (If different from applicant) 650 NE HOLLADAY ST., SUITE1400, PORTLAND, OR 9723 Owner's telephone number (508) 337-8600 - - - - - -- -- ---- -T - -- - - 10) Establishment Owned By: 111) If a corporation or partnership, give name, title, and home address of officers ElAn Association or partner. V A Corporation ' Name Title Address I ❑ An Individual ❑ A Partnership ❑ Other legal Entity --- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)_ i Name & Title: MICHELE LORD (HADLOCK), CENTER DIRECTOR Address: 1515 WEST STREET, MANSFIELD, MA 02048 — - 0199 Teleohone No: I(508) 337-8600 24 Hour Emergency No: ($oo) 322- FAX: 1(508) 261-1395 - - - - - E-mail: !MLORD@KLCORP-COM - Alt E -Mail: - - 303012(,KLCORP.COM 13) District Or Regional Supervisor (if applicable) � Name &Title: i �a QAddress: Aft "� 15 -- Telephone NO: Ui3� d `t l 1 24 Hour Emergency No: (800) 322-019 !-- ---- - I E-mail o- i�C�ncireAh � klc.orp,cohn FAX:- - Food Establishment Information - ------------- 14) WATER SOURCE: 15) SEWAGE DISPOSAL: - -1 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: 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): ❑ ---------- 20) Location: Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: I ❑ Food Service up to 100 or up to 10' PHF display $62.50 Moblie Comments: 21) Length of Permit: 0 Annual ❑ Seasonal Seasonal Dates: j Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑Preparation of Non PHFs _--_ E] PHFCooked To Order F1 Hot PHF Cooked and Cooled or Hot Held - for More Than a Single Meal Service ❑ Preparation of PHFs For Hot An - - --- -- _ - ------------- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly - Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended- -- - to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance ❑ Customer Self -Service { and/or HACCP Plan (including bare hand - - contact alternative, time as a public health ❑ Ice Manufactured and Packaged for ! control) Retail Sale - - -"- - - ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Other Food Operations I Retail SaleAn—- imal Origin - - _- -------- -- ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service r ❑ Retail Sale of Salvage, Out -Of -Date --- -- -- or Reconditioned Food To be completed by the Board of Health -- i Total Permit Fee: $5.00 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 of 105 CMR 590.000 and t e deral Food Code. 24) Signature of Applicant: �certify Pursuant to MGL Ch.62C, sec.er the penalties and paid state taxes required u er law 25) Social Security Number or Federal ID: 63-C 26) Signature of Individual or Corporate Name: �<j - that I, to 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 Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: KINDER CARE ADDRESS: 515 WEST STREET TELEPHONE AT LOCATION: (508) 337-8600 FAX NUMBER: (508) 261-1395 OWNER OF BUSINESS: KNOWLEDGE LEARNING CORPORATION TELEPHONE OF OWNER: (508) 337-8600 FEDERAL ID/SS NUMBER: 63-0941966 FEE: $5.00 PERMIT NUMBER: FS -126 SIGNATURE: DATE: 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. kJ MerC',ra � �d uCa ti OYt * Signature of Individual or Corporate Name (Mandatory) ,orate r ndatory, 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 Gsuspension or revoction. This eneral Section request is made under the authority of Mass.eneral Laws, Chapter 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 Business/Organization Name: U nL_ n Address:5 15W nyt si yf,e f, City Phone #: Are ou an employer? Check the appropriate box: Business Type (required); 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees, [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'. comp. insurance req.] 12. Other l l *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 #l. I am an employer that is providing workers' compensation insurance for my en loyerr . Below is the policy information. Insurance Company Name: Insurer's Addrt City/State/Zip: Policy # or Self -ins. Lic, Expiration Date: 12-1111 (.0 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 vprification. I do hereby certify, under the pains and that the information provided above is frue and correct 1 11 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www,mass.gov/dia Phone KNOWUNI-01 ESPINESENMI S DATE (MMIDDIYYYY) �►��R® CERTIFICATE OF LIABILITY INSURANCE 1 11/1712015 OF IGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATEES NOT AFFIRMATIVESAMLYTOR NEGATIVELY AMEND, AMEND,ION LCONFERSY AND EXTENDOR ALTER THE THE AFFORDED BY THE OLICE! S CERTIFICATE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: endorsed. tD, sNIhcertificate INSURED, conferrightst the the terms conditions the policy, certain policies mayequia an endorsement, A statement on this certificate doses no certificate holder in lieu of such endorsement(s). CONTACT Certificate Center PRODUCER NAME: (888) 467-2378 PHONE (877) 945-7378 A1C, No Willis Insurance Services of California, Inc. AJ No WillisExt C/o 26 Century Blvd E-MAIL certificates@willis.com P.O. Box 305191 ADDRESS: INSURERS) AFFORDING COVERAGE NAIC # Nashville. TN 37230-5191 11150 INSURED KUEHG Corp. Knowledge Universe Education LLC 650 NE Holladay Street, Suite 1400 Portland, OR 97232-2096 A:Arch Insurance Company B: Travelers Indemnity Comp: c :XL Insurance America, Inc. D: E: .OVERAGES CERTIFICATE NUMBER: EN ISSUED TO THE INSURED BE DCONDIIT AOF OF INSUNCEINDICATED. ---_ - NAMED ABOVE EO WITH RVE SPECT TO WHICH THIS ONBELOW THIS IS TO CERTIFY THAT I HE VULIL;IES ANY CONTRACT OR OTHER DOCUMENT ANY REQUIREME NTT,, TERM! OR DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, NOTWITHSTANDING CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES HAVE BEEN REDUCEDOCYEBY PAID EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY POLICY XP LIMITS TR ADD BR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY TYPE OF INSURANCE INSD WVD EACH OCCURRENCE $ 1,500'( k X COMMERCIAL GENERAL LIABILITY 71GPPOS12300 12/01/2015 1210112016 D N E T E TED $ PREMISES Ea occurrence 1,500,1 CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,500'1 GENERAL AGGREGATE $ 5,000,' GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/Op AGG $ 3,000' ❑ PRO- T LOC POLICY JECT $ COMBINED SINGLE LIMIT $ 2,000, OTHER: Ea accident AUTOMOBILE LIABILITY HC2E-CAP-477M5687-TCT-15 1210112015 12101/2016 BODILY INJURY (Per person) B X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE $ Per accident NON -OWNED $ HIRED AUTOS AUTOS EACH OCCURRENCE $ 2,000 X UMBRELLA LIAB X OCCURUS00011222LI15A 12/0112015 1210112016 AGGREGATE $ 2,000 C EXCESS LIAB CLAIMS -MADE $ X DED RETENTION$ 10,000 OTH- X ffIR ATUTE ER WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 71WC14952007 12101/2015 120112016 Y� E.L. EACH ACCIDENT $ 1,000 1,00( A ANY PRO PRIETOR/PARTNERIEXECUTIVE N 1 A E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? $ 1,00( (Mandatory In NH) E.L. DISEASE - POLICY LIMIT If yes, describe under DESCRIPTION OF OPERATIONS below 71WCX4953807 12101/2015 12/01/2016 See Attached: A Workers Compensation s required) DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space i Norkers' Compensation for all states except Monopolistic states. See Attached: ATTACHED ACORD 101 S BE ELLED THE EXPIRATIONDATEDA EV THEREOF, NOTICEEWIILLCBECBEFORE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Postin_q Notice - AOS ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: KNOWUNI-01 LOC #: A��►c� ADDITIONAL REMARKS SCHEDULE NAMED INSURED AGENCY Nillis Insurance Services of California, Inc. KCorp. Knowledge dge Universe Education LLC POLICY NUMBER 650 NE Holladay Street, Suite 1400 SEE PAGE 1 Portland, OR 97232-2096 CARRIER ]AV: SEEPAGE1 EFFECTIVE DATE: SEE PAGE 1 ESPINESENMI Page 1 of 1 ACORD 101 (2008/01) - -- _ The ACORD name and logo are registered marks of ACORD P ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS POLICY TYPE: Excess Workers Compensation Limits Per Statute and Employers Liability Each accident: $1,000,000 CARRIER: Arch Insurance Company Disease — policy limit: $1,000,000 POLICY TERM: 12/01/2015 —12/01/2016 Disease — each employee: $1,000,000 POLICY NUMBER: 71WCX4953807 Information and Instructions Massachusetts General Laws. chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicantwho has not produced acceptable evidence of compliance with the insurance coverage required," Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority, Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should call the you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number, In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. "Nhere a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05