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HomeMy WebLinkAboutBest Buy 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:. BEST BUY - CORPORATION Whose place of business is: BEST BUY STORES, LP #1140 280 SCHOOL STREET PERSON(S) IN CHARGE: JONATHAN OLSON Permit Expires: December 31, 2016 License Number: S-28 Food Fee: $25.00 BOARD OF HEALTH MichaeCMcClean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-28 FOOD ESTABLISHMENT PERMIT APPLICATION - -- --- - -- ice ion mus�be subm�l ed d 6 -13 da s before Tff6 -Tanned o en►n date I- y- o -h p g 7 1) Establishment Name BEST BUY STORES, LP #1140 12) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) c/o KPMG LLP 2200 Cabot Dr. Suit 400 ' -Lisle, IL 60532 - 4) Establishment Telephone No (508) 261-2340 5) Applicant Name & Title: BEST BUY STORES, LP #1140 6) Applicant Address 7601 PENN AVENUE S, RICHFIELD, MN 55423 7) Applicant Telephone No.: (612) 264-4863 24 Hour Emergency No.: (508) 261-2340 (508) 283-0552 8) Owners Name & Title BEST BUY - CORPORATION j 9) Owner Address (If different from applicant) 7601 PENN AVENUE S, RICHFIELD, MN 55423 Owner's telephone number 5082830552 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association ! or partner. ��&f,-erlsea#ion Name Title Address ❑ An Individual k1 A Partnership ❑ Other legal Entity _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: JONATHAN OLSON Address: 280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No: 603-721-2066 24 Hour Emergency No: (508)261-2340(5001'283-0552 i FAX: E-mail: 1J­0--N--A-- THAN.OLSON(cpBESTBUY.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: !DAVE POULIN I Address: 11 WORCESTER ROAD, FRAMINGHAM, MA 01701 I Telephone No: 1(508) 875-1025 24 Hour Emergency No: DAVID.POULIN@BESTBUY.COM FAX: Food Establishment Information 14) WATER SOURCE: TOWN �15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 17) DAYS/HOURS: SUN 11 AM - 7 PM MON-SAT 10 AM - 9 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: Permanent Location I 22) Establishment Type ❑ Moblie Moblie Start Date: [X Retail (29,944Sq. Ft) Moblie End Date: [] Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: ❑ Food Service up to 101 -200 Q Annual or up to 25' PHF display $75.00 ❑ Seasonal ❑ Food Service up to 201 + or 25'+ PHF display $137.50 i Seasonal Dates: ❑ Temporary ❑ Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: TOWN ❑ Caterer $12.50 i ] Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 LI Manufacture Frozen Desserts/loe Cream $12.50/freezer _j Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 Retail Food $50.00 IVJ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 I Rain Date: 23) Food Operations I Definitions: PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time4emperature controls required) i(Check all that apply): I RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) i Sale of Commercially Pre -Packaged Non-PHFs 1 ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held __ __-------------___.--- • _ _-- _-- 1 __ _ ._ _ -_ _-----.-___--..-.._. _.: for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And . -. ._. _._1 - - Cold Holding For Single Meal Service (❑ PHF and RTE Foods Prepared For Highly i ❑ Delivery of Packaged PHFs _.__ —.._ .__ _._.__.._ ...-_._.I Susceptible Population Facility ----- - .- - --- ❑ Sale of Raw Animal Foods Intended _ ❑ Reheating of Commercially( to be Prepared by Consumer I ❑ Vacuum Packaging / Cook Chill i 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 Plan (including bare hand Perishable Foods Only Ice Manufactured and Packaged for contact alternative, time as a public health - - .� ------ --- - - ---- -- ❑ Preparation of Non-PHFs Retail Sale control) Other Food Operations I ❑ Juice Manufactured and Packaged for i ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date --_- - - - - -_- - - - - - - or Reconditioned Food I' To be completed by the Board of Health -- I Total Permit Fee: $12.50 Payment is due with application ❑ 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 copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: ( U) Pursuant to MGL Ch.62C, sec. 49A, I ce and paid state taxes required under law. under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 41-.1822872 26) Signature of Individual or Corporate Name: 2pe � �t certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. * Signature of Individual dr Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 41-1822872 ** 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 fumished 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 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: —r Address: ✓�(`�(�(� City/State/Zip:P_kQV&Ee_r(� tq + () y'— Phone #: LP r -j-,6q Are you an employer? Check the appropriate box: 1. I am a employer with 3 _ employees (fiill and/ or part-time),* 2. ❑ 1 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. [Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,0 Manufacturing 11.❑ 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 othor 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 Name: L INC. Insurer's Address: --Q %my\irw Avenut City/State/Zip: Y -A , CT 0 woo a Policy # or Self -ins. Lie, # SVDN35 _Y(0-0 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. I do hereby certify, under the pains andpenalties ofperjury that the information provide aho(`v is true and correct~ K Official use only. Do trot 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 IN lvkyjlw• The Commonwealth EPARIWW OF INDUSTRUL ACCIDENTS -1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our Wured employees under the above-mentioned chapter by fimaing with: XL Insurance America, Inc. NAME OF INSURANCE COMPANY 70 Seaview Avenue, Stamford, CT 06902 ADDRESS OF INSURANCE COMPANY RWD9435346-04 2/712096 - 2/112097 . POLICY rtLJMI3EK EFFEer VE DATES AQN Risk Services Central, Inc. 208 E Randolph Street, 13th Floor, Chicago, IL 60601 312-3614737 NAME OF INSURANCE AGENT ADDRESS PHONE # Best Buy Co., Inc. 280 School Street, Mansfield MA 02048 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE The above naloned insurer is requimd in cases of personal 1qur ios arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services m awrdance with the Provisions of the Wodwr% Compensation Act. A copy of the First Report of Injury must be given. to the injured employee. The employee may select his or her own physician.. The reasonable cost of the services Provided by the treating physician will be paid by the insim, if the treatment is necessary and reasonably connected to the work related mjury. In cases requiring hospital attention, employees are, hereby notified that the insurer has arranged for such attention at the t• OF HOSMAL , ADDRESS TO BE POSTED BY MP , .