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Home My WebLink AboutKohl's 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 °ermit to Operate a Food Service Establishmen Type: RETAIL SNACK 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:. GEORGE WILSON Whose place of business is: KOHL'S DEPARTMENT STORES, INC. #767 280 K SCHOOL STREET PERSON(S) IN CHARGE NANCY SUAVE, STORE MANAGER Permit Expires: December 31, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: $12.50 License Number: S-16 BOARD OF HEALTH MichaeCMcCCean, Chairman Eo i CSL C `1 FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATIONI. Applicationmust besubmrtteo af7eas30 days beihe p nnai�eroperirng daf�j 1) Establishment Name 2) Establishment Address ° _. 3) Establishment Mailing Address (ifdifferent) 4) Establishment Telephone No 5) Applicant Name & Title: fl� 6) Applicant Address ` i �� `, , t -I)c 7 Applicant Telephone No.: R 24 Hour Emergency 9...ncy No.: c�lul a 8) Owners Name & Title El' 9) Owner Address (If different from applicant) ` Owner's telephone number CC 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers I—] An Association or partner. A corporation Name Title Address [7] An Individual . l- A Partnership E-11 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc,) Name & Title: e �- Address: Telephone.No: 24 Hour Emergency No.- FAX.- E-mail: o:FAX:E-mail: at¢ Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (tf applicable) 16) No. of Food Employees:` E 17) DAYS/HOURS: i> 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) P/ease attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more); ['] 20) Location: _ O ermanent Location 1 22) Establishment Type-, [,J Moblie Mobile Start Date:Retail ( Sq. Ft) Mobile End Date, . � [A Food Service up to 100 or Mobile Comments: 21) Length of Permit: Annual aj Seasonal Seasonal Dates Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: up to 10' PHF display $62 50 i ] Food Service up to 101 -200 or up to 25' PFIF display $75.00 [ Food Service up to 201 + or 25'+ PHF display $137.50 f 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 s Residential Kitchen $50,00 ><Retail Snack Food $12 50 [ Tobacco Products $12.50 _ 23) Food Operations Definitions. PHF - Potentially hazardous food (11me4emperature controls required) Non -PRFs - non -potentially hazardous food(no timehemperature controls required) Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) >KSale of Commercially Pre -Packaged Nort-PHFs [ Sale of Commercially Pre -Packaged PHFs Lj PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service [;] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service L] PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs - ( Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer (,° Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours -- - - Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- [ Customer Self -Service and/or HACCP Pian (including bare hand Perishable Foods Onlylee Manufactured and Packaged for contact alternative, time as a public health (a Preparation of Non-PHFs Retail Sale control) [) Juice Manufactured and Packaged for F;Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal Origin -&-i] Offers RTE PHF in Bulk Quantities �a Prepares Food/Single Meads for Catered Events or Institutional Food Service [$ }j Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ' To be completed by the Board of Health i Total Permit Fee: j 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 590.00 and the federal Food Code. 24) Signature of Applican _ Pursuant to MGL Ch.62C, sec, 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have riled all state tax returns and paid state taxes required under law, r 25) Social Security Number or Federal ID:� 26 Si4 of Individual or Corporate Name « I certify under the penalties of perjury that I, to myt to tknowledge es requiredednd belief, have filed all state tax returns and pard all s under law. d _ 1W ar Signature of Individual or Corporate Name By: Corporate Officer (Mandato"I, if Applicable) — '_ 2-: -– **Social Security No. (Voluntanl) nr Federal Identification Number *This license will not be issued unless this certification clause is signed ** 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 theirrevocation.filing r delinquency will be subject to license suspension o request is made under the authority of Massachusetts General Lav Chapter 62C, section 49A. C:�Lisersisleit�;ADesktop�Seott'a iJocum.msAFood I-stobiishnwlils- icmp`•.FAX C1-R11PICATION FORNI.doc The C'olrarnon)vealtlr of 1'Vlcrssachusetts Department of Industrial Accidents Office of Investigations a 600 Washin.toll Street Boston, j M 02111 ` s+ jow.rrlass.movIdia Workers' Compensation Insurance Affidavit: General Businesses Please Print Le6i1?h A licant.Information Business/Organization Name: 1 LA - �( Af Bone#: City/State/Zip; Fi . " �+` U -' Ss T pe (required): Are Y'u an employer? Check taleappropriate bas:5 emprl\loyee (full and/ p TRetail am a employer with _ 6 D Restaurant/Bar/Eating Establishment or part-time). 1 and have no �, C)ffice and,/or Sales (incl, real estate, auto, etc.) 2, ❑ I am a sole proprietor or partnership employees working for me in any capacity. 8. ❑ Non-profit. [No workers' comp. insurance required] its officers have exercised 9 Entertainment 3, ❑ Weare a corporation and their right of exemption per e. 152, §l(4), and we have 10 Manufacturing no employees. [No workers' comp. insurance required]* I 1 Fj Health Care 4,E] We are a non-profit organization, staffed by volunteers, insurance req.] 12 Other no employees. [No workers' comp. *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. has otlier emplovees. to workers' compensation Policy's required and such an *4,lY the corporate officers have exempted themselves, but the corporation it lar ran etatploj,er t(icrt is prot,iding wot-hers' compensation insAirance fur ntv entploi�ees. Be otv's t insurance Company Name: �� _ �,/ C , { � 10 insurer's Address —_-- e,policy ill f01` 11011ot?. Ci '/State/zi 1 t (� 0Expiration Date; �y � 4 Policy # or Self -ins. Lia n' 4 Attach a copy of the svorl:ers' compensation policy declaration page (showing the policy number end prpenalties�of a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition fine up to $1,500.00 and/or one-year imprisonment; as that a co civil of penalties es in tient maybe forwarded�o the Odie om of a f d a fine of up to $250.00 a day against the violator. Be advised copy Investigations of the DIA for insurance coverage verification. C do hereby certifj,, ynder the pail's marc penalties of petjuly that the infortnatiolt prided above is true and correct. �z )Ile nffreirrt �tse utrlt�. Do lot ierite in this area, to he completed by city of town r0leial, Permit/License #. City or Town: ---- Issuing Authority (circle one): tx�ent 3. City/Tosvn Clerk 4, Licensing Board 5. Selectmen's Cjf ice j. Board of Health 2, Building Depart 6. Other --- ---- Phone Contact Person: Gativay.mass.g<�v/dig DATE(MN1/DD/YYYY) -4 CERTIFICATE OF LIABILITY INSURANCE °2/°9/2°16 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). CONTACT PRODUCER NAME: Aon Risk Services Central, Inc. PHONE(866) 283-7122 FAX 800-363-0105 (A/C. No. Ext): A1C. No.): Minneapolis MN office EMAIL 5600 West 83rd street ADDRESS: 8200 Tower, suite 1100 Minneapolis MN 55437 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: New Hampshire ins co 23841 INSURED Kohl's corporation INSURER B: The Insurance co of the State of PA 1942 Steve Thomas, senior Vice President INSURER C: chief Risk and Compliance officer N56 W17000 Ridgewood Drive INSURER D: Menomonee Falls WI 53051 USA INSURER E: INSURER F: DVERAGES CERTIFICATE NUMBER: 570061161010 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 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 requestE SR ADD S BR POLICYNUMBER MM[ODNYYYPOLICY EF MMIDD EXP LIMITS TR TYPE OF INSURANCE IN WVD EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY A AGE TO RENTED CLAIMS -MADE F] OCCUR PREMISES Ea occurrence MED EXP (An one person) GEMLAGGREGATE LIMIT APPLIES PER: POLICY ❑PRO- El LOG — JECT OTHER: AUTOMOBILE LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE A WORKERS COMPENSATION AND wwl»iv— --• - EMPLOYERS'LIABILITY YIN All other States ANY PROPRIETOR/PARTNER/EXECUTIVE NIA Wc015519099 01/31/2016 A OFFICERWEMBER EXCLUDED? CA (Mandatory In NH) If yes, describe under nESCRIPTION OF OPERATIONS below Y PERSONAL& ADV INJURY GENERALAGGREGATE PRODUCTS-COMP/OPAGG COMBINED SINGLE LIMIT BODILY INJURY ( Per person) BODILY INJURY (Per accident) EACH OCCURRENCE AGGREGATE 'X I PER STATUTE I JOT Rt E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Evidence of workers compensation Insurance for the State of Minnesota (Policy No. WC015519096). $1,000,000 $1,000,000 $1,000,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Kohl's Corporation AUTHORIZED REPRESENTATIVE N56 w17000 Ridgewood Drive Menomonee Falls wI 53051 USA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD OFFICERS KOHL'S CORPORATION / KOHL'S DEPARTMENT STORES, INC N A UP AND TITLE, HOME ADDRESS Kevin Mansell 5370 North Lake Drive Chairman, Chief Executive Officer, & President Whitefish Bay, WI 53217 Michelle Gass 4138 West Beach Road Chief Merchandising and Customer Officer Oconomowoc, WI 53066 Richard D. Schepp 15285 Casey Circle Chief Administrative Officer Brookfield, WI 53005 Sona Chawla 524 Hawthorn Lane Chief Operating Officer JWLinnetka, IL 60093 Wesley McDonald 18336 North Greenvale Road Chief Financial Officer Fox Point, WI 53217 AGENCY CUSTOMER ID: 210000001618 LOC #: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY Aon Risk services Central, Inc. NAMED INSURED Kohl's corporation POLICY NUMBER see certificate Number: 570061161010 CARRIER 77CODE1 see certificate Number: 570061161010 POLICY NUMBER EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE I NAIC # I INSURER I INSURER IINSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL IVSD SUBR wVD POLICY NUMBER POLICY EFFECTIVE DATE (AIATIDD/YYYY) POLICY EXPIRATION DATE (NL I/DDM'YY) LIMITS WORKERS COMPENSATION A N/A WC015519100 FL 01/31/2016 01/31/2017 A N/A WC015519101 IL, KY, NC, NH, UT, VT 01/31/2016 01/31/2017 A N/A wc015519103 NJ, PA 01/31/2016 01/31/2017 A N/A WCOIS519098 AK, AZ, GA, VA 01/31/2016 01/31/2017 B N/A wc015519102 MA 01/31/2016 01/31/2017 A N/A wc015519104 ND, WI, WY 01/31/2016 01/31/2017 A N/A wco15519097 ME 01/31/2016 01/31/2017 ACORD 101 (2008101) - © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD