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HomeMy WebLinkAboutMichael's 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 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:. MICHAELS STORES, INC. Whose place of business is: MICHAELS @ MANSFIELD CROSSING MALL #7737 280 SCHOOL STREET, SUITE 220 PERSON(S) IN CHARGE: BRIAN AHERN Permit Expires: December 31, 2016 License Number: S-32 Food Fee: $12.50 BOARD OF HEALTH 3v1ichaeCNcCCean, Chairman 25-Apr-2016 14:29 Spa�'„jSP Fax Header 5083396946 p.3 FOR BOARD OF HEALTH USE ONLY 641,Ay 1F roved By: Permit* I�SV4 Date received: Date Inspected: APP S-32 FOOD ESTABLISHMENT PERMIT APPLICATION - - - (App attbn musT-be submitted at leae-30 days before the planned opening elate) 1) Establishment Name MICHAELS @ MANSFIELD CROSSING MALL #7737 ✓ _i 2) Establishment Address 280 SCHOOL STREET, SUITE 220 I 3) Establishment Mailing Address (if different) P.O. BOX 619566 ATTENTION: BARBARA SALTER DALLAS, TX 75261-9566 4) Establishment Telephone No (508) 339-6239 5 Applicant Name & Title: n I 6) Applicant Address 8000 BENT BRANCH DRIVE, 1RVING, TX 75063 _... ........ ..._.... _ _ ..._-..._....._ ... _ ..-- 7) Applicant Telephone No.: (972) 409-1300 (972) 831-4149 24 Hour Emergency No.: (774) 265-2633 '; 8) Owners Name & Title MICHAELS STORES, INC. 9) Owner Address (If different from applicant) Owner's telephone number - 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association 1 or partner. W1A Corporation Name J Title Address 0 An Individual j ❑ A Partnership El Other legal Entity ---._...._..- ..... _... - -- 12) Person Directly Responsible For Daily Operations (oyvner, person in charge, supervisor, manager etc,) Name & Title: Bff1 P N" u t Address: Telephone No: 24 Hour Emergency No; (774) 265.2633 i FAX: E-mail: Alt E-Mail: _......._.I 13) District Or Regional Supervisor (if applicable) Name & Title: i.BARBARA SALTER, BUSINESS LICENSE ANALYST Address: P.O. BOX 619566, DALLAS, TEXAS 75261-9566 Telephone No: '(972) 831-4149 24 Hour Emergency No: FAX: (972) 831-4196 E-mail: salterb@michaels.com Michaels Stores. RECEIVED: 2016-04.25 10:31:47 (GMT -06:00) 25 -Apr -2016 14:30 Spu(DSP Fax Header 5083396946 p•4 r - Food Establishment Information 14) WATER SOURCE: TOWN i 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable)16) NO. of Food Employees: 17) DAYS/HOURS: MON - SAT 9 AM - 9 PM SUN 10 AM - 7 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 atfach copy of certificate _..... _.... .. .. _........ . 19) Person Trained in Anti -Choking Procedures (if 25 Seats or more): 20) Location [./j Permanent Location I 22) Establishment Type [ [ Caterer $12.50 i Mobile Mobile Start Date: n Retail ( 17,502 Sq. Ft) [__] Milk & Cream $5.00 Mobile End Date: O Food Service up to 100 or 1F.1 Mobile Food & Consession $37.50 up to 10' PHF display $62.50 --� Manufacture Frozen Desserts/Ice Cream Mobile Comments. [ _......__....._.._ . � —' $12.50/freezer ' 21) Length of Permit: [] Food Service up to 101 -200 _ or up to 25' PHF display $75.00 [� Pushcart $12.50 # of Pushcarts: Annual 17 Food Service up to 201 + [ ]Residential Kitchen 50. 00 i I. Seasonal I or 25'+ PHF display $137.50 -•- Retail Food $50.00 ; Seasonal Dates: -- - - ' Food Service - Institution (J� Retail Snack Food $12.50 Temporary J Temporary ( Meals/Day) [� Tobacco Products $12.50 Temporary Start Date: I Temporary End Date: i Temporary Time: Retail Sale _. Rain Date: [ ] Juice Manufactured and Packaged for i 23) Food Operations I Definitions: PHF - Potentially hazardous tood (time/temperature controls required) Non-PHF's - non -potentially hazardous tood(no timehemperature controls required) Check all that apply)' RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no (urther processing) Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food (�] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [ ..J PHF and RTE Foods Prepared For Highly Susceptible Population Facility [_] Vacuum Packaging / Cook Chill t] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for I Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: $12.50 Payment is due with application r__, waived 1, 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 copips�of�,05 CMR 590.000 and the federal Food Code, 24) Signature of Applicant: a Pursuant to MGL Ch,62C, sec. 49A, 1 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: 75-1943604 t E 26) Signature of Individual or Corporate Name: t y € Michaels Stores. RECEIVED: 2016.04.25 10:32:17 (GMT -06:00) Sale of Commercially Pre -Packaged Non-PHFs ] PHFCooked To Order ...... ... .. . [] Sale of Commercially Pre -Packaged PHFs 1 [_ Preparation of PHFs For Hot And Cold Holding For Single Meal Service [� Delivery of Packaged PHFs- .... - - ..._... I. . -..''I.— [l Sale of Raw Animal Foods Intended [_J Reheating of Commercially I to be Prepared by Consumer Processed Foods for Service Within 4 Hours _..__ . . El Customer Self -Service of Non PHF and Non- r_] Customer Self -Service — I Perishable Foods Only Ice Manufactured and Packaged for f ❑ Preparation of Non-PHFs Retail Sale _. [ ] Juice Manufactured and Packaged for Other Food Operations Retail Sale Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food (�] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [ ..J PHF and RTE Foods Prepared For Highly Susceptible Population Facility [_] Vacuum Packaging / Cook Chill t] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for I Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: $12.50 Payment is due with application r__, waived 1, 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 copips�of�,05 CMR 590.000 and the federal Food Code, 24) Signature of Applicant: a Pursuant to MGL Ch,62C, sec. 49A, 1 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: 75-1943604 t E 26) Signature of Individual or Corporate Name: t y € Michaels Stores. RECEIVED: 2016.04.25 10:32:17 (GMT -06:00) 25 -Apr -2016 14:30 Sp-IDSP Fax Header 5083396946 P•5 I certify under the penales of erjury that State tax returns and pad all (State tabxestrequibelief, red under llaw. have filed all *Signature of Individual or Corporate Name (Mandatory) j i By: Carp to Offider I (Mandatory, if applicable) i ** 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 Mass General Laws, Chapterension or revocation. Section request9AIs made under the authority o Michaels Stores. RECEIVED: 2016.04.25 10:32:56 (GMT -06:00) ZS -Apr -2016 14:37 SpahDSP -Fax Header 5083396946 PA The Commonwealth of Massach usetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lvlvw.rnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ), ,`/ /.-_D f lw rW'' Address: City Phone 4: `4 Are yap employer? Cheek h ' ppropriata box: Business Type (required): 1.► 'J 1 am a employer with employees (full and/ 5. ❑Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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. g. Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1('1), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* • IL ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 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. ~ ! am an employer that is provktng workers' com ensction Ion /or my emplc(yees. Belw is the policy information, Insurance Company Name: �� �^ Insurer's Addrf City/State/Zip:r—. policy # or Self -ins. Lic. if ( Expiration Date A t G{lt� z g e °PY.,nf.,theti wop}kers' pp?Age3uSsklit► l p?tttG dealat ttolnnpir f{�li�`v ttth"Wicj!;.rt�llti�hgr ane} exp ration 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 DTA for insurance coverage verification, t do hereby certify, under the pains and penalties Qfperjury that the itlfnrmation provided above is true and correct. 11V11G R. Offleial 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 Cleric 4. Licensing Board 5. Selectmen's Office Phone #: www,mass.govldia Michaels Stores. RECEIVED: 2016.04.25 10:39:33 (GMT -06:00) OF LIABILITY INSURANCE 011/2n16 DIYYYY) TE(MMIDCERTIFICATE F�A27/20 15 THIS CERTIFICATE IS ISSUEL'mS 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(los) must be ondorsed. 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 Lockt n Companies 1-14 W. 47th Street, Suite 900 Kansas City IVIG 64112-1906 (816)960-9000 CONTACT NAME: FAX PHONE NC No IAic..No Entl: Ly _I_ e -MAIL ADDRESS: _ INSURER(S) AFFORDING COVERAGE NAIC it INSURER A: Sa Ilety National Casualty Corporation 15105 6/1/2015 INSURED NlICHAFLS STORFIS, INC. 12311 8000 EENT BRANCH DR. INSURER B: A Z.OUS Cl .R. IEE SE' A TTA CI ,D INSURERC: XL INSURANCE AMERICA INC. A XV INSURER D: I RV IN6 '1-X 75063 INSURER E : PERSONAL & ADV INJURY $ 1,000,000 INSURER F: AGGREGATE LIMIT APPLIES PER: POLICY 1:]PRO- (� LOC JECT l OTHER: rnvcoAncc nnu'!-!AO2 CFRTIFICATF NUMBER- 10R797`6 REVISION NUMBER: XXXXx;CX 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. IN SR LTR TYPE OF INSURANCE ADDL I SD SUBR D POLICY NUMBER POLICY EFF IM POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE LX]OCCUR N N GL 4044104 6/1/2015 6/1/2016 EACH RE C 1,000,000 DAMAGE TO RETED PREMISES (Ea ocNcunence) $ 1 000,000 -- -G_EN'L X MED EXP (Any oneperson) $ XXXXXXX PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY 1:]PRO- (� LOC JECT l OTHER: GENERAL AGGREGATE $ 10.000.000 PRODUCTS - COMP/OP AGO $ 2,000,000 A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED X PI-IYS DAM X $1000 COMP N CO N L DID CAF 4044106. 6/1/2015 6/1/2016 COMBINED SINGLE LigrT (Ea accident) $ 1.000.000 BODILY INJURY (Per person) S XX XX 'X_ BODILY INJURY Per accident $ XXXXXXX PROPERTY DAMAGE S XXXXXXX (Per accident) $ XXXXXXX C X UMBRELLA LIAB EXCESS LIAB )( OCCUR CLAIMS -MADE N N US00058061­115A 6/1/2015 6/1/2016 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,001000 000 DED RETENTION $ $ xxxxxxx A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A N LDS 4044102 (AOS) PS 4044105(W I) 6/1/2015 6/1/2015 6/1/2016 6/1/2016 - X STATUTE ER E.L. EACH ACCIDENT $ 1 000.000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 B PROPERTY - ALL RISK N N VARIOUS SEE ATTACHED 6/1/2015 6/1/2016 '6!0,000,000 LMT PER OCC. BUSINESS INTERRUPTION INCL 'T'ENANT'S PERSONAL PROP DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is require BLANKET ADDITIONAL INSURED APPLIES PER WRITTEN CONTRACT. SUBROGATION WAIVED PER WRITTEN CONTRACT. (C=DTICICATR HOLDER CANCELLATION See Attachment 2987926 SPECIMEN COPY FOR PROOV OF INSURANCE ONLY 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 REPRESENTATtE /p/ 4�,z ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I M- 0.045 Where Creativity Happens - To Whom It May Concern: If you have any questions about the enclosed documents, please call me at 972-831-4149. Sincerely, Barbara Salter Business License Analyst Michaels Stores, Inc. Office Location: 8000 Bent Branch Drive Irving, TX 75063 Mailing Address: PO Box 619566 DFW, TX 75261-9566 972/831-4149 FAX 972/831-4196 V Where Creativity Happens- (3ar6ara Safter—(Business LicenseAnafyst To Whom It May Concern: To ensure Michaels Stores Inc. payments for your Business Licenses, Permits, Device Registrations, etc. be received by your specified due dates, PLEASE mail your renewals and correspondence to the below address. Michaels Stores Inc. (store # if applicable) ATTN: BARBARA SALTER P.O. Box 619566 DFW, TX 75261-9566 Should you use the physical address of 8000 Bent Branch Dr., Irving, TX 75063, PLEASE add the attention line — Attn: Barbara Salter. Do not send correspondence to the store location as it only delays payment or return correspondence. Our stores cannot complete the transaction. All payments come from our Corporate office. Our Corporate facilities consist of several buildings located in multiple DFW areas. If your correspondence is not addressed correctly, it can "float" for some time before reaching the correct destination. PLEASE MAIL ALL LICENSES/PERMITS TO THE ABOVE CORPORATE ADDRESS FOR PROPER DISTRIBUTION TO OUR STORES. THIS WILL NOT ONLY INSURE DELIVERY TO THE STORE, BUT ALSO ALLOW US TO MATCH THE PERMIT/LICENSE TO OUR PAID RECORDS. Your cooperation in these matters will be greatly appreciated. Thank you, J Barbara Salter Business License Analyst Michaels Stores Inc. Office Location: 8000 Bent Branch Drive, Irving, TX 75063 Mailing Address: PO Box 619566 DFW, TX 75261-9566 Ph: 972.831.4149 Fax: 972.831.4196 MICHAELS STORES, INC. OFFICER LIST Officers Position Held Charles M. Sonsteby Chief Admin. Officer 8000 Bent Branch Dr. & Chief Financial Officer Irving, TX 75063 Michael J. Veitenheimer SVP General Counsel 8000 Bent Branch Dr. & Secretary Irving, TX 75063 Jennifer Robinson Vice President 8000 Bent Branch Dr. Business Planning & Irving, TX 75063 Analysis Rebecca Shaffer Vice President Tax 8000 Bent Branch Dr. Irving, TX 75063