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HomeMy WebLinkAboutBertucci'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: FOOD SERVICE 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:. BERTUCCI'S RESTAURANT, CORP. Whose place of business is: BERTUCCI'S ITALIAN RESTAURANT 280 SCHOOL STREET PERSON(S) IN CHARGE: SUZETTE LANDRY, DISTRICT MANAGER Permit Expires: December 31, 2016 License Number: FS -4 Food Fee: $137.50 Milk & Cream W BOARD OF HEALTH MichaeCvicCCean, Chairman Commonwealth 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: BERTUCCI'S RESTAURANT, CORP. having a place of business at. BERTUCCI'S ITALIAN RESTAURANT 280 SCHOOL 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 12/31/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -4 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -4 FOOD ESTABLISHMENT PERMIT APPLICATION (AppTcation nmust-be submitte�teas-t-3a-days�e-fore thepTannec-opening date] 1) Establishment Name BERTUCCI'S ITALIAN RESTAURANT 2 Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET 4) Establishment Telephone No MANSFIELD, MA 02048 (508) 261-2371 5) Applicant Name & Title: BERTUCCI'S RESTAURANT 6) Applicant Address 155 OTIS STREET, NORTHBOROUGH, MA 01532 7) Applicant Telephone No.: (508) 351-2500 24 Hour Emergency No.: (508) 272-2119 x 1 8) Owners Name & Title BERTUCCI'S RESTAURANT, CORP. 9) Owner Address (If different from applicant) 155 OTIS STREET, NORTHBOROUGH, MA 01532 M Owner's telephone number (508) 351-2500 10) Establishment Owned By: i 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ❑ A Corporation Name Title Address ❑ An Individualli ❑ A Partnership I ❑ Other legal Entity - -- -- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: SUZETTE LANDRY, G NE Ai MApAGER r Address: 9 CLINTON STREET, TAUNTON, MA 02780 Telephone No. (508) 261-2371 24 Hour Emergency No: (508) 272-2999 FAX: (508) 261-2375 E-mail. BERT129@BERTUCCIS.COM Alt E -Mail: - ILICENSING(aD_BERTUCCI'S.COM i 13) District Or Regional Supervisor (if applicable) - ' Z r`t r Name & Title: LC r- 1 Address: (155 OTIS STREET, NORTHBOROUGH, MA 01532 Telephone No: 24 Hour Emergency No: FAX: (508) 393-7657 m Food Establishment Information m ' 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 25+ 17) DAYS/HOURS: MON-THURS 11 AM -10 PM SAT & SUN 11 AM -11 PM 18) Name of Person In Charge Certified in Food Protection Management: SHARON L. LOGIUDICE 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 NANCI R. BRAMHALL certificate MICHAEL L'HEUREUX 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0 20) Location: Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑Retail ( Sq. Ft) Moblie End Date: ❑ = d SeYvice u `0 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: ❑ Food Service up to 101 -200 0 Annual or up to 25' PHF display $75.00 Food Service up to 201 + ❑ Seasonal ❑ Vacuum Packaging / Cook Chill or 25'+ PHF display $137.50 Seasonal Dates: ❑ Customer Self -Service ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations ;Check all that apply): ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 FV1 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 I i Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) L]Sale of Commercially Pre -Packaged Non-PHFs �/❑ PHFCooked To Order �� Hot PHF Cooked and Cooled or Hot Held - --- -- -Th S' I M I S ❑ Sale of Commercially Pre -Packaged PHFs ElDelivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours E] Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations - -- --- - ❑ Preparation of PHFs For Hot And for More an a mg a ea ervice --__- Cold Holding For Single Meal Service j ❑ PHF and RTE Foods Prepared For Highly --- - -- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility -_ 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 ❑ Ice Manufactured and Packaged for contact alternative, time as a public heap Retail Sale control) ❑ Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for —" — --"❑ ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ii I To be completed by the Board of Health - - Total Permit Fee: $137.50 Payment is due with application ❑ waived I, the undersigned, attest to the accur c of the information provided in this application and affirm that g p pp at the food establishment operation will comply th 105 CMR.=590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cop s f 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: U f Z Pursuant to MGL Ch.62C, sec. 49A, 1 ertify 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 I w. 25) Social Security Number or Federal ID: 04-2844750 26) Signature of Individual or Corporate Name: 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: BERTUCCI'S ITALIAN RESTAURANT ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 261-2371 FAX NUMBER: (508) 393-7657 OWNER OF BUSINESS: BERTUCCI'S RESTAURANT, CORP. TELEPHONE OF OWNER: (508) 351-2500 FEDERAL ID/SS NUMBER: 04-2844750 FEE: $5.00 PERMIT NUMBER: FS -4 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. R. * Signature of Individual or Corporate Name (Mandatory) By: Crpo to Officer (Aan satory, 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 suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth ofiVassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: __S Address:*' City/State/Zip; Are you an employer? Check a appropriate box: 1. am a employer with 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.] /acs ` a169 Phone #:F Business Type (required): 5. []Retail 6. Rcstaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1111 Health Care 12.❑ 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company NNa~me. `t t Insurer's Address:] Yi City/State/Zip; Policy # or Self -ins. Lie. # L Expiration 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 DLA for insurance coverage verification. Ido hereby certify, d the pains and penalties of perjury that the information provided above is true and correct Cirmafiira• Al }.'.. Trate., Official use City or Town: not write in this area, to be completed by city or town official 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,moss.gov/dia Phone Policy Number: Date Entered: /1k_ CERTIFICATE CSF LIABILI Y INSURANCE DA /DD/YYYY) 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. _7//161612015 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). PRODUCER FLINTRIDGE INSURANCE SERVICES 340 N. WESTLAKE BLVD. #150 WESTLAKE VILLAGE, CA_ 91362 CONTACT NAME: aH0 No.Ext• (805) 44_9-2800 j aAic ,1:(805)449-1765 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICm (805) 449-2800 INSURER A:N&VIGATORS INSURANCE COMPANY INSURED Bertucei ' s Corporation INSURER B ;TRAVELERS CASUALTY INSURANCE COMPANY 1417 69 PERSONAL &ADV INJURY j S1,000,000 INSURER C;LIBERTY MUTUAL INSURANCE COMPANY 23043 155 Otis Street Northborough, MA 01532INSURER INSURER D: CRUM & FORESTER'INSTJRANC;�OMPA2IY 31348 E; AFFILIATED FM INSURANCE COMPANY INSURER F: I $ 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. IN5'A�OLiS BRj LTV TYPE OF INSURANCE 1 INSD WVO? POLICY NUMBER POLY EFF ! POLIY P ' I MMlOICD MMlDCD(YEXI LIMITS A 1 COMMERCIAL GENERAL LIABILITY j 1 EACH OCCURRENCE ' $1,000,000 ICLAIMS-MADE I OCCUR ISI5CGL136117IC p/13/2015 7/13/2016 `DAMAGE TO RENTED i50 000 { i PREMISES Ea occurrence I $ , €MED EXP (Any one person) ! $ EXCLUDED PERSONAL &ADV INJURY j S1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I i GENERAL AGGREGATE I $ 2, 000, 000 gPRO POLICY i JECT ( LOC I PRODUCTS-COMP/OP AGG 1$1,000,000 j OT -H=R: I $ I AUTOMOBILE LIABILITY s COM8119ED SINGLE LIMIT 1$1,000,000 B ANYAUTO ! IBA -4D161942 -15 -SEL I. Y Ea accdan0 /9/2015 7/19/2016 BODILY INJURY (Per person) S I ALL OWNED SCHEDULED i� i € AUTOS I AUTOS I BODILY INJURY' Per accident c ( ( ) \/111 NON-OWNEDi HIRED AUTOS XI AUTOS i PROPERTY DAMAGE i Per accident ` $ Ll i$ (' jNi. UMBRELLA LIAB I OCCUR EACH OCCURRENCE 5 25, 000 r 000 i EXCESS LIAB ' TH7-611-256263-075 7/13/2D15 7i /13/2016cAIMS-MADE:AGGREGATE I s 25, 000, 000 I DED i RETENTION S 'WORKERS COMPENSATION j PER i i AND EMPLOYERS' LIABILITY Y N I S"ATU'TE ROTH DiOFFICERMEMBERANY IEXCLUDED??EGUTIVE ` ;]NIA. '406-724177-7 E.L. EACH ACCIDENT isi,000,000 (Mandatnryln NHI `—" E.L. DISEASE EM PLGYEE $ 1, 000, 000 'if yes, describe under -EA I _ ;DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT 1S1,000,000 A ILIQUOR LIABILITY ! IS15CGL1361171C 7/13/2015 7/13/2016 ipER OCCURRENCE 1, 00, 0000 AGGREGATE 2,000,000 E 'PROPERTY i ISY807 ?/13/2015 7/1312016 !LIMIT: 216, 840, B18 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 10i, Additional Remarks Schedule, maybe attached If more space is required) RE: Evidence of Insurance u�r-.r �rrt.t�ec nvt_lJr=te UANUELLATION BeYtucciIs Corporation 155 Otis Street Northborough, MA 01532-2414 USA 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD roduced using Forms Boss Plus software.. av .FormsBoss.cDnT, Impressive Pubrishing 800-203-1977 D Un I --- 1 it T , ft Whar -Alft 11ftift eMW 1WPAnfi1TdA Afifi&6 VOID VOInW vvnwil�lwi 1W101D VOID ID V_01D gaik "XVO I D V( 0 1 D VOID A aid% I ID °w �� I ��am�n Conien�*m���rm�m�n�� � ~� ~» ~*203*1St t-EctCertificate expires no an: 02/23/17 Congratulations! You have passed the National Certified Professional Food Manager examination. Your name has been added to the National database ofFood Managers. MICHAEL L'HEUREUX BERTUCCI`SCORPORATION 155OOS NORTHBOROUGH, MA 01532 Prometric n!You passed the Certified Professional Food Manager examinatI011, Your Score is as follows: Score Status Exam Date 83 PASS 02/23/2012 This is to cerlify that F,00 Prnozebdu 800.624.2736 l26OEnergy Lane '" a 70 c E u� c c o o ••a f Q LL o Z LU Q m_ N o W •7 //��� �((»Q p O a8 07 M N W ® X r p ~ X Q 'Er f- I -o Z a �C N W in m _a Q a ® LU u 6L" l V N a oO C Ouj D� 3 r r Q a o � �e ---Ionaffo Man werss odWh �OAPPALP�RDd??VV 0 �� - -J quirements.f6rceiTi am 140 Rq Certificate o: 1777571 Vrtifld46 expirii"o lafiir 09&i Congratulations! You have passed the National Certified Professional Food Manager examination. Yoorname has been added tnthe National database ofFood Managers, ^ RALPH PAPP4LARDD BERTUCC|`S CORPORATION 1SSOT>G NORTHBQROUQH'K0/\81O38 Proirfletric CoogrxkkVionx|YOU nxxxudthe CCnbh«| Professional Food Nfanager examination . Your Score ixnmfollows: Score� S ta t uu-, Li'�xuni Dat 86 09/2412013 Dlis is to eel-tifv that RALPH R W, iA ssary' q0 Dmmobic 800.624,2736 7941Corporate Drive Nottingham, NII) 21236 800&2,1.2736 0 N, Im u a v U �+ Vi Qu Q U M M W r` w v Ll Cy l� � � h H 4-j 0 O aJ N, Im u a v U �+ Vi Qu Q U M M W r` w v Ll N, Im ~° ~ p', Heart Lori Johnson lb a above individual ChOkesaVer and skills evaluations has 3/116/2016 Infaull CPR Written fe", cOmmanded 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 applicant -who 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 you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the 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 permiWicense 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. 'Where 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