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HomeMy WebLinkAboutBuffalo Wild Wings 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 ESTABLISHMENT 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:. BLAZIN WINGS, INC. Whose place of business is: BUFFALO WILD WINGS 321 SCHOOL STREET, SUITE A110 PERSON(S) IN CHARGE: SHAWN FOURNIER, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -150 Food Fee: $137.50 Milk & Cream FVI BOARD OF HEALTH MichaeCMcCCean, 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: BLAZIN WINGS, INC. having a place of business at., BUFFALO WILD WINGS 321 SCHOOL STREET, SUITE A110 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 1213112016 unless previous to that time is suspended or revoked. Expires 12/3112016 License No.: FS -150 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 -150 FOOD ESTABLISHMENT PERMIT APPLICATION pp ica ion mus beLI m,1e 1 1 11 111::;'asdays before the planned opening date) 1) Establishment Name BUFFALO WILD WINGS 2) Establishment Address 321 SCHOOL STREET, SUITE A110 3) Establishment Mailing Address (if different) 5500 WAYZATA BOULEVARD, SUITE 1600 MINNEAPOLIS, MN 55416 4) Establishment Telephone No (952) 593-9943 5) Applicant Name & Title: BLAZIN WINGS, INC. 6) Applicant Address 5500 WAYZATA BOULEVARD, SUITE 1600, MINNEAPOLIS, MN 55416 7) Applicant Telephone No.: (952) 593-9943 24 Hour Emergency No.: (774) 644-7939 (952) 593-9943 8) Owners Name & Title BLAZIN WINGS, INC. 9) Owner Address (If different from applicant) 5500 WAYZATA BLVD., SUITE 1600, MINNEAPOLIS, MN Owner's telephone number (952) 593-9943 10) Establishment Owned By: ❑ 9n Association A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: , GENERAL MANAGER - k kk v C "k v- e,, - Address: Address: 321 SCHOOL STREET, SUITE A110, MANSFIELD, MA 02048 Telephone No: 7930- : , <-µ 24 Hour Emergency No: )-644-M9- (952) 593-9943 FAX: E-mail: LICENSING@BUFFALOWILDWINGS.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: FRANK GUIFFRIEDA Address: 842 MYRTLE AVENUE, WATERTOWN, NY 13601 Telephone No: (315) 767-5374 24 Hour Emergency No: FAX: E -mai l: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 75 DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SAT: 11:00 AM -1:00 AM SUN: 11:00 AM - 12:00 AM 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 10/112001 in accordance with 105 CMR 590.003(A) Please attach copy of DAMIAN S. RAMOS cerci#cate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): FIA 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) 0 Milk & Cream $5.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Mobile Comments: up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer 21) Length of Permit: W Annual or up to 25' PHF display $75.00 Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 E]Retail Food $50.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $12.50 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no limellemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non -PRFs FVJ 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 Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food 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 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,ofl105 CMR, 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify 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: 41-1957107 26) Signature of Individual or Corporate Name: tf ' ` & I wl c I hereby rr ' e applic 3 NAME O USINEB ADDRES 321 TELEPH AT L( FAX NU R: OWNER BUSIN FEE: $ PERMIT of Mansfield - Town of Mansfield and of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit a MILK AND CREAM PERMIT, which expires on June 1st of each year. BUFFALO WILD WINGS L STREET, SUITE A110 (952) 593-9943 (952)818-3674 BLAZIN WINGS, INC. (952) 593-9943 41-1957107 150 SIGNATURE: DATE: w", V i I E certify r the penalties of perjury that I, to my best knowledge and belief, ave fil State tax returns and paid all State taxes required under law. p E tbtx €V Signat f Individual or Corpo Name (Mandatory) y: Cate Officer ( slatory, if applicable) f -161 7 ** Soci urity dumber (Voluntary) or Fed dentification Number * This Ij se will not be issued unless the certification clause is signed by the ap t. ** Your al Security number will be furnished to the Massachusetts Depart of Revenue to determine whether you have met tax filing or tax payme ligations. Licensees who fail to correct their non -filing or delinquency will be ct to license suspension or revocation. This request is made under the aut of Mass. General Lavas, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: BLAZIN WINGS, INC. D/B/A BUFFALO WILD WINGS Address: 321 School Street, Suite 110 City/State/Zip: Mansfield, MA 02048 Are you an employer? Check the appropriate box: 1. I am a employer with 71 employees (full 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.] Phone #: 5083394035 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. ❑ Manufacturing 11. F] 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. Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: TRUMBALL INSURANCE CO Insurer's Address: C/O CHRISTENSEN GROUP INSURANCE, 1100 BREN ROAD WEST City/State/Zip: MINNETONKA, MN 55343 Policy # or Self -ins. Lic. # 41 WN R94600 Expiration Date: 9/1/2016 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. I do hereby certify,_under the pains and penalties of pef jury that the information provided above is true and correct. Phone #• (952) 593-9943 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: Phone #: www.mass.gov/dia 1 ® AC40 V CERTIFICATE OF LIABILITY INSURANCE6/2/2016 DATE (MMIDDIYYYY) 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 Christensen Group Insurance 11100 Bren Road West Minnetonka MN 55343 CONTACT NAME: Nancy Rasmussen PHONE (952)653-1000 FAX (952)653-1101 A/C No): ADDRESS:nrasmussen@christensengroup.com INSURERS AFFORDING COVERAGE NAIC # INSURER A:Hartford Fire Insurance Co 19682 INSURED BUFFALO WILD WINGS, INC. BLAZIN WINGS, INC. DBA:BUFFALO WILD WINGS 5500 Wayzata Blvd Ste 1600 Minneapolis MN 55416 INSURERB:Trumbull Insurance Company 27120 INSURER C: INSURER D: INSURER E: INSURER F: 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 ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ Excluded A I CLAIMS -MADE F_X] OCCUR 41 CSH R94602 9/1/2015 9/1/2016 PERSONAL &ADV INJURY $ 2,000,000 X Liquor Liability GENERAL AGGREGATE $ 15, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ aaccidentSINGLELIMiT E 1,000,000 X POLICY PRO- JECT_LOC AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ A X ANY AUTO ALL OWNED SCHEDULED 1 AB R94603 9/1/2015 9/1/2016 BODILY INJURY (Per accident) $ AUTOS AUTOSNON-OWN HIRED AUTOS AUTOS ED PROPERTY DAMAGE Per accident $ Underinsured motorist $ 1100 01000 UMBRELLA LIABOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR HCLAIMS-MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� (Mandatory In ER EXCLUDED? (Mandatory in NH) O $ Y WC STATU- R B NIA A 1 WN R94600 9/1/2015 9/1/2016 E.L. EACH ACCIDENT $ 11000,000 E.LDISEASE- EAEMPLOYE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below I _T DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Location; 321 School Street, Suite 110, Mansfield, MA 02048 ltla:i111liLow Mansfield Health Department 6 Park Row Mansfield, MA 02048 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 Christensen/NR'r `^ ACORD 25 (2010/05) W I V00'LV IV mllwmu �WI\rv11, I -- nn I Iy11�� INS025 (201005).01 The ACORD name and logo are registered marks of ACORD Blazin Wings, Inc. Corporate Officers Sally Jeanne Wold President % of Ownership = 0% 7001 Dublin Road Edina, MN 55439 952-903-9899 James Michael Schmidt Vice President % of Ownership = 0% 1732525 th Avenue N. Plymouth, MN 55447 952-593-9943 Emily Clark Decker Vice President % of Ownership = 0% 3155 Lafayette Ridge Road Wayzata, M N 55391 952-855-9615 Buffalo Wild Wings, Inc. Owner % of Ownership = 100% 5500 Wayzata Blvd. Suite 1600 Minneapolis, MN 55416 952-593-9943 FEIN# 41-1957107 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: DAMIAN RAMOS Certificate Number: 2347350 Date of Completion: 5/2611/16 Date of Expiration: 5/26/2021 The above-named person is hereby issued this cert�6cate for completing an allergen awareness training program recognized by the Massachusetts Department o f Public Health in accordance with 105 CMR 590.009(G)(3)(a). This cergcate will be valid forfive (5) years from date ofcompletion. Issued By: Massachusetts Restaurant Association 333 Turnpike Road, Suite 102 Southhorough,MA 01772 508-303-9905 wtvw, marestaurantas soc. org NATIONAL 6 RESTAURANT ASSOCIATION® 800,765.2122 lvww.restaurant.org ANSI ACCREUITIED PROGRAM cminME ISSUER 46655 National Restaurant Association 1*75 W. JzB<,on Blvd; Ime, 11700 1500 (Ihi-ago IL 60604-2814 800,76S,21;2 in Chicago area 312,715.'010 ReStouumt.org I ScrvSafe,corn This certificate is awarded to MICHELLE GOODWIN Congratulations! You have completed ServSafe- Food Handler Employee Food Safety Online Course and Exam 1765014 r)xo 01/21/2015 01(2102018-------.-.-...----.. Name of Recipient: KCHE'L! e Gnno,rrta Certificate; plumber: 2343111 Date of Completion: Date of Expzrratlon. 5i2 42f d a. Thi' aho e -nae# rl person rt hl nby user:d this c4rt)(icate f" r aornphtirag an al'ergl'ta a :zarenas trahiikk program ree&guiz, d by thy' Mastrrchn els Department of 'Athli Health iaa (aeeordanreuvith 105 CUR 590,009(G)P):(a), 7fiii rtrti�kate= lrvilll r* •tva/iii for.�trr� j.SJ_yerrrs %inrrr date o/`cnrnpletr`au. Issued 6y: ©© b n� NA'i`ibf�lAL RESTAURANT # « ASSt7Cy ATIOIN,, M;1$^=:t'}lu=Km Rtmiurant As ociatii CERTIFICATION AMY LEPAGE For successfully completing the standards set forth for the ServSofe® Food which is accredited by the American National Standards Institute (ANS 12/04/2 )ATE OF EXPIRA ecerti(ication requirements. CoNad us v al, que�ionr d 175 W kd.- M4 Ste 1600, Chicago, IL 60604 a S�Sgf 8«,wM�a.ap. CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: AMY LEPAGE Certificate Number: 1335114 Date of Completion: 03/0512014 Date of Expiration: 0310512019_ The above-named person is hereby issued this cert�6eate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in accordance with 105 CAIR 590.009(G)(3)(a). This rert�firate will be valid forfive (5) yearsfrom date ofrosnpletion. Issued By. Massachusetts Restaurant Association 333 Turnpike Road, Suite 102 Southbomugh,MA 01772 508-303-9905 Nvrvwtnarestaurantassoc.org NATIONAL RESTAURANT ASSOCIATION® 800.765.2122 vAv ..restaurantorg MARC COSTA for successfully completing the standards set forth for the ServSafe® Food Pro)aellon Nt4t e> fiertification Examination, which is accredited by the American National Standards Institute (ANSI}-Cgnfetgnre {mr"Food Protection (CFP). 11WINS] MBER EX 1/5/2 hilt, �'��'�''i 1/5/2021 DATE OF E DATE OF EXPIRA Local laws apply. ch envy for recer i(icotion requirements. ANS/ ACCPFomo In DOM Aniuzarz NaSuul Slsroul�YatNFe .:ae<comonewroanm r� ,, s: n13 c02p15IJorla,d Ego — kod.-& of rho tom. Conivc es v%lh "iia,s m 175 W Jo4— &d. Ste 1500, Chicago, L 60604 or S—So66re t wW.ag. CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: MARC COSTA Certificate Number: 2346024 Date of Completion: 5/2512016 Date of Expiration: 5/2512021 The above-named person is hereby issued this cert�ficate for completing an allege: awareness training program recognized by the Massacbusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). This certifrcate will be validfor-five (5) years front date ofcompletion. Issued By: Massachusetts Restaurant Association 333 Turnpike Road, Suite 102 Southhomugh,MA 01772 508-303-9905 www.marestaurantassoc.org I�l:�i C�7�• RESTAURANT ASSOCIATION, 800.765.2122 www.restaurant.org Certificate of Achievement ANSI ACCREDITED PROGRAM CERTIFICATE ISSUER #06$5 National Restaurant Association 175 W. Jackson Blvd, Ste.1500 Chicago, IL 60604-2814 800.765.2122 in Chicago area 312.715.1010 Restaurant.org I ServSafe.com This certificate is awarded to SHAWN FOURNIER Congratulations! You have completed ServSafeo Food Handler Employee Food Safety Online Course and Exam Certificate Number 1996732 Date 7/21/2015 Expiration Date 7/21 /2018 o�y IN CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: SHAWN FOURNIER Certificate Number: 2345989 Date of Completion: '5125/2018 Date of Expiration: 5125/2021 ?he above-named person is hereby issued this certificate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in accordance with 105 MMR 590.009(G)(3)(a). 7h is cert�6cate will be valid for five (5) years from date ofconrpletiou. Issued By- IV NATIONAL RESTAURANT Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 www.restaurant.org Southhomugh, MA 01772 508-303-9905 wwmniares taurantassoc. org r, BUFFALO ti WILD 1�I]NOS WINGS. BEER. SPORTS:" May 19, 2016 Town of Mansfield Board of Health 6 Park Row Mansfield, MA 02048 RE: Buffalo Wild Wings — 321 School Street Food Establishment Permit Application To Whom It May Concern, Enclosed please find the following items in regards to the above referenced Buffalo Wild Wings location: • Completed & Signed Food Establishment Permit Application • Worker's Compensation Insurance Affidavit & Proof of Worker's Compensation Insurance • Check payable to the Town of Mansfield for $137.50 If you have any questions or need any additional information please feel free to contact a Licensing Coordinator at licensing@buffalowildwings.com or at 952-593-9943. Sincerely, Kristin Westlund Licensing Coordinator Buffalo Wild Wings, Inc. 5500 Wayzata Blvd, 16th Floor I Minneapolis, MN 55416 1 PHONE: 952-593-9943 1 FAX: 952-593-9787 1 BUFFALOWILDWINGS.COM 1® A�0 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/ 8/31/201616 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 Christensen Group Insurance 11100 Bren Road West Minnetonka MN 55343 CONTACT Nanc Rasmussen NAME: y HCNNo Ext: (952) 653-1000 FAX No: (952)653-1100 E-MAIL ADDRESS: nrasmussen@christensengroup.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Hartford Fire Insurance Co 19682 INSURED BUFFALO WILD WINGS, INC. BLAZIN WINGS, INC. DBA: BUFFALO WILDWINGS 5500 Wayzata Blvd, "Ste 1600 Minneapolis MN 55416 INSURERB:Trumbull Insurance CompanV 27120 INSURERC: INSURER D: INSURER E: 1 INSURER F: rnVFRAr_Fc rFRTIPICATF NIIMRFR-9/1/16 Main 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. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMlDD/Yl'YYY MMFF /DDY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A CLAIMS -MADE ❑X OCCUR PREMISES (Ea occurDAMAGE TO rence) $ 1,000,000 MED EXP (Any one person) $ Excluded X Liquor Liability 41 CSE R94602 9/1/2016 9/1/2017 PERSONAL &ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 15,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY ❑ PE� ll LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 41 AB R94603 9/1/2016 9/1/2017 BODILY INJURY (Per person) $ BODILY INJURY (Per $ PROPERTY DAMAGE $ Per accident Underinsured motorist $ 1,000,000 UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N Y STATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - FA EMPLOYEE $ 1,000,000 B OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A 41 WN R94600 9/1/2016 9/1/2017 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Location: 321 School Street, Suite 110, Mansfield, ""MA"'02048 f`CDTICIr ATC unl nr-P CANCFI I ATIf7N © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mansfield Health Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Park Row ACCORDANCE WITH THE POLICY PROVISIONS. Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE G Bill Finley/NR © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) CHRISTENSEN GROUP INSURANCE 11100 BREN ROAD WEST MINNETONKA, MN 55343-6002 MANSFIELD HEALTH DEPARTMENT 6 PARK ROW MANSFIELD MA 02048-2433