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Home My WebLink AboutLLBean 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:. L.L. BEAN Whose place of business is: L.L. BEAN, INC 280 SCHOOL STREET PERSON(S) IN CHARGE: PETER FISH, MANAGER Permit Expires: December 31, 2016 License Number: RF -99 Food Fee: $50.00 BOARD OF HEALTH 'VlichaeCwicCCean, Chairman (�— FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued l -RF-99 J FOOD ESTABLISHMENT PERMIT APPLICATION `"-----"------""--"----"A-lication must -be sutimitfer3 at least`30 da s before fhe Tanned -o enin d 1) Establishment Name L.L. BEAN, INC �� 2) Establishment Address 280 SCHOOL STREET' 3) Establishment Mailing Address (if different) 280 SCHOOL STREET— ' MANSFIELD, MA 02048 4) Establishment Telephone No 5) Applicant Name & Title: Phyllis Cyr, Sr Manager Cash & Risk 16) Applicant Address 15CASCO STREET, FREEPORT, ME 04033 7) Applicant Telephone No.: (207)552 4167 24 Hour Emergency No.: (207)552-3317 8) Owners Name & Title L.L. BEAN 9) Owner Address (If different from applicant) 15 CASCO STREET, FREEPORT, ME 04033 Owner's telephone number 2075522000 ------------ 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. f O A Corporation Name Title Address +' El An Individual O A Partnership ❑ Other legal Entity ----------------------------------- -----------_-------------- 12) Person Directiv Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: PETER FISH, MANAGER Address: 280 SCHOOL STREET, MANSFIELD, MA 02.048 Telephone No: FAX_ --_(207) E-mail: x(888) 552-5547 24 Hour Emergency No: (207) 552-3317 552-3317 -- IPFISH .)LLBEAN.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Kim Devanny, District Manager — Address: 15 CASCO STREET, FREEPORT, ME 04033 Telephone No: (603) 361-7696 24 Hour Emergency No: FAX: E-mail: kdevanny@llbean.com Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 17) DAYWHOURS: MON-SAT 8:00 AM -10:00' PM SUN 8:00 AM-$ 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 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 1-1 Caterer Caterer $25.00 Milk & Cream $10.00 Q Mobile Food t£ Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $100.00 Q Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF - Potentially hazardous load (fime4emperature controls required) - Non-PHFs - non-potentlelly hazardous food(no tima4emperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [l Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held - --- .-._ - - - -- ---- -- ----- --- - -- - ----- -- --- ----- - -- for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And -- ----- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs - -.-- - Susceptible Population Facility ----- - -- __.-...__..-._._:-----•.,--•___-- ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging I Cook Chill Processed Foods for. Service Within 4 Hours _-.-__.___.-__ _---.-• _.._--_.___- _.._._... on P ..— _..---_--•.. - -- ❑ Use of Process Requiring A Variance ❑ Customer Self-Seryice of Non PHF and Non Customer Self-service and/or HACCP Plan (including bare hand Perishable Foods Only (� Ice Manufactured and Packaged for contact alternative, time as a public health __._____..-------------•_.�.------_.._..__ control) ❑ Preparation of Non•PHFS _ _ _ Retail Sale—_ -_—.- -Other Food Operations - ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale _Animal Origin ❑ Offars RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for _ ___-_ of S_ Catered Events or Institutional Food Service) Q Retail Sale alvage, Out -Of -Date or Reconditioned Food r % be completed by the Board of Health --'---- --" Total Permit Fee: - $100.00 Payment is due with application ❑ waived 1, the undersigned, attest to the acc racy of the information provided in this application and affirm that the food establishment operation will compI , th 10"MR 590.000 an SII other applicable law. I have been Instructed by the board of health on how to obtain c Ei �f 1 CMR 000 nd the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 4 A, I certiy under the penalties of perjury that I, 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 01-0026590 26) Signature of Individual or Corporate Name; �- • �- d (1, It) 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location _ Permanent Location'v 22) Establishment Type Q Mobile Mobile Start Date: ' M Retail ( Sq. Ft) Mobile End Date: ❑ Food Service up to 100 or Mobile Comments: i up to 10' PHF display $125.00. ---- -- --------;--'--------.----------.- C21) Length of Permit: ❑ Food Service up to 101 -200 I--- Q Annual or up to 25' PHF display $150.00 ❑ Seasonal ❑ Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: E] Temporary --- -- - --- ------ Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date:-.._. -- . -_..,--------- 1-1 Caterer Caterer $25.00 Milk & Cream $10.00 Q Mobile Food t£ Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $100.00 Q Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF - Potentially hazardous load (fime4emperature controls required) - Non-PHFs - non-potentlelly hazardous food(no tima4emperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [l Sale of Commercially Pre -Packaged Non -PRFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held - --- .-._ - - - -- ---- -- ----- --- - -- - ----- -- --- ----- - -- for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And -- ----- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs - -.-- - Susceptible Population Facility ----- - -- __.-...__..-._._:-----•.,--•___-- ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging I Cook Chill Processed Foods for. Service Within 4 Hours _-.-__.___.-__ _---.-• _.._--_.___- _.._._... on P ..— _..---_--•.. - -- ❑ Use of Process Requiring A Variance ❑ Customer Self-Seryice of Non PHF and Non Customer Self-service and/or HACCP Plan (including bare hand Perishable Foods Only (� Ice Manufactured and Packaged for contact alternative, time as a public health __._____..-------------•_.�.------_.._..__ control) ❑ Preparation of Non•PHFS _ _ _ Retail Sale—_ -_—.- -Other Food Operations - ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale _Animal Origin ❑ Offars RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for _ ___-_ of S_ Catered Events or Institutional Food Service) Q Retail Sale alvage, Out -Of -Date or Reconditioned Food r % be completed by the Board of Health --'---- --" Total Permit Fee: - $100.00 Payment is due with application ❑ waived 1, the undersigned, attest to the acc racy of the information provided in this application and affirm that the food establishment operation will compI , th 10"MR 590.000 an SII other applicable law. I have been Instructed by the board of health on how to obtain c Ei �f 1 CMR 000 nd the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 4 A, I certiy under the penalties of perjury that I, 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 01-0026590 26) Signature of Individual or Corporate Name; �- • �- d (1, It) 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. vlcQ 4)Z4 a'", L.-, L.. � nL. * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Volunta ) 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 3 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le ibly Business/Organization Name: L 1piran . I n e . Address: City/State/Zip: rldn_5,Q- (d M(- °ac`gPhone #: Are you an employer? Check the appropriate box: LS I am a employer with I -a!5 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. ;R Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing II.❑ Health Care 12. ❑ Other *Any applicant that checks box #I 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 # 1. 1 am an employer that Is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: M t= m / e -- Insurer's Insurer's Address: 17 'S Q C—%rn • , 7—C 50 eD City/State/Zip: Y17A n(`ho-s epi N N 03 w4= Policy # or Self -ins. Lic. # 3 d Z 4SD (_ 3 t7 a Expiration 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 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. 1 do hereby c f ` lnenalties of perjury that the information provided above is true and correct tt t , t Signature:# `' f ` Dat k PhnnP f#' J.tom Z/ 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: www.mass.gov/dia Phone #: 315012 �— , ® ACC?RE0 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 3/11/2016 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 Commercial Lines - (617) 330-1005 Wells Fargo Insurance Services USA, Inc. 200 Berkeley Street, 23rd Floor Boston, MA 02116 CONTACT NAME: Russell Beliveau PHCN o Ext , 617-330-1005 AIC No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Maine Employers' Mutual Ins Co 11149 INSURED L.L. Bean, Inc. 15 Casco Street Freeport ME 04033 INSURER B : INSURER C'. INSURER D; INSURER E; INSURER F: CnVERAGPS CFRTIFICATF NUMBER: 1U241293 REVISION NUMBER: See below 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. INSR LTR TYPE OF INSURANCE INSD SUER POLICY NUMBER MMIDDfYYYY MMIDC mYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $ DAMAGE T PREM SES Ea occur ante $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICYF—] JECTPRO ❑ LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNEDSCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED =RETENTION $$ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 5101800821 (ME) 3102801302 AOS ( ) 03/01/2016 03/01/2016 03/0112017: 03/01/2017 X STATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 E.L" DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) RE: Evidence of Workmans Comp Evidence of Coverage eGRTIFfreTF HOI DEP CANCELLATION Evidence Covereage 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 The ACORD name and logo are registered marks of ACORD U IUUB-ZU14 AOUKU UUKVUKA I IUw. An rignrs reserves. ACORD 25 (2014/01)