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HomeMy WebLinkAboutCapriotti'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 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:. SEAN OLSON, PRESIDENT Whose place of business is: OLSON RESTAURANT GROUP MANSFIELD,LLC DBA CAPRIOTTI'S 321A SCHOOL STREET, SUITE 140 PERSON(S) IN CHARGE NICHOLAS ARONE Permit Expires: December 31, 2016 License Number: FS -27 Food Fee: $75.00 BOARD OF HEALTH NichaecNcCtean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -27 I FOOD ESTABLISHMENT PERMIT APPLICATION ionmmtaes Te orfi fre planneaopen►ng dater umied 1) Establishment Name OLSON RESTAURANT GROUP MANSFIELD,LLC DBA CAPRIOTTI'S 2) Establishment Address 321A SCHOOL STREET, SUITE 140 3) Establishment Mailing Address (if different) 163 MAIN STREET #2 MEDWAY, MA 02053 4) Establishment Telephone No (508) 339-0522 5) Applicant Name & Title: SEAN OLSON, PRESIDENT 6) Applicant Address 163 MAIN STREET #2, MEDWAY, MA 02053 7) Applicant Telephone No.: (508) 533-3030 24 Hour Emergency No.: (617) 592-9852 (781) 953-2687 8) Owners Name & Title SEAN OLSON, PRESIDENT 9) Owner Address (If different from applicant) Owner's telephone number 5085333030 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ❑ A Corporation Name Title Address ❑ An Individual _- " £ ---------- --- - - - - ❑ APartnership s { - -J V Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc ) Name & Title: ]NICHOLAS ARONE Address: 163 MAIN STREET #2, MEDWAY, MA 02053 Telephone No: (508) 533-3030 24 Hour Emergency No: (617) 562-6652 (ass) 953-2687 FAX: 1(508) 533-3010 E-mail: NICKA(cD-OLSONRG.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: i-- FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 12 17) DAYS/HOURS: MON-SUN 11:00 AM - 10:00 PM 118) Name of Person In Charge Certified in Food Protection Management: NICHOLAS ARONE 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: W Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: Eve] 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 Annual or up to 25' PHF display $75.00 ❑ Seasonal Seasonal Dates: ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Caterer $12.50 ❑ 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 ❑ Temporary ---I❑ Food Service - Institution F1Retail Snack Food $12.50 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: -- - 23) Food Operations Definitions: PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs W PHFCooked To Order T❑ Hot PHF Cooked and Cooled or Hot Held -- - -- - -- for More Than a Single Meal Service ❑ Sale of Commercially Pre -Package( ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the acc establishment operation will comply board of health on how to obtain cot 24) Signature of Applicant: Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ manufactured and Packaged for �❑ Offers Raw Or Undercooked Food Of Retail Sale j Offers RTE PHF m Bulk Quantities ❑ Prepares Food/Single Meals for J ❑ _ Catered EventsorInstitutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health ------ -- _- ---- Total Permit Fee: $62.50 Payment is due with application ❑ waived I information provided in this application and affirm that the food MR 590.000 and all other applicable law. I have been instructed by the CMR 590.000 and the federal Food Code. 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. 11-1117 25) Social Security Number or Federal ID: 46-1566737 26) Signature of Individual or Corporate Name: « " " 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. Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, 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 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: CA Address.[ t , F 4 City/State/Zip: 4\_�,\, e �t"j ,kx) c, C: ",,r Phone #: i .,i Are you an employer? Check the appropriate box: 1. I am a employer with 1 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. ❑ Retail 6. �]I 7. Oftaurant/BarBating Establishment ice and/or Sales (incl, real estate, auto, etc.) 8. [] Non-profit 9. ❑ Entertainment 10.❑ Manufacturing H, . ❑ 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 Name:_ L,2 L L -L M" r ,.m Insurer's Address: P01 City/State/Zip:& tJ� t " Policy # or Self -ins. Lic. # V ` / Expiration Date: i Z 6 �i 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif er the pains and penalties of perjury that the information provided above is true and correct Phone #• ;;12L �_ 3 : -`3,L,`3'0 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 ------ 1� ® LAG CERTIFICATE OF LIABILITY INSURANCE 8002 DATE (MM/DD/YYYY) 11/9/2015 THIS CERTIFICATES 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 SUBROGATIONIS 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 PAYCHEX INSURANCE AGENCY INC 210705 P: F: (888) 443-6112 PO BOX 33015 SAN ANTONIO TX 78265 CONTACT NAME: �aC"N,Ext): (a,No): (888) 443-6112 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Sentinel Ins Co LTD 11000 INSURED OLSON RESTAURANT GROUP FOXBORO LLC DBA CAPRIOTTIS SANDWICH SHOP 321 SCHOOL ST STE 140A MANSFIELD MA 02048 INSURER B: Hartford Ins Co of the Midwest 37478 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. IN.SR nTEOFINSURANCE ADDL .S'UBR POLICYNUAIBER POLICYEFF MAUDD/r ,n POLIC)'E%P LLIIITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g1, 000, 000 CLAIMS -MADE OCCUR FRI DAMAGE TO RENTED_7 PREMISES (Ea occurrence) $1,000, 000 X MED EXP (Any one person) $10, 000 A X General Liab 76 SBW PF4214 11/21/2015 11/21/2016 PERSONAL & ADV INJURY $1, 000, 000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2, 000, 000 POLICY [::] PRO- FX—] LOC JECT PRODUCTS - COMP/OP AGG s2,000, 000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOSAUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) HIRED AUTOS NON -OWNED AUTOS 9 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE s5,000,000 A EXCESS LIAB 1-1 CLAIMS -MADE 76 SBW PF4214 11/21/2015 11/21/2016 AGGREGATE s5,000,000 DED X RETENTIONS 10, 000 $ WOR%ERY COdIPENNATION ANDEMPLO)ERTLIABILIn' ANY PROPRIETOR/PARTNER/EXECUTIVE YIN x PER OTH- STATUTE ER E.L. EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NA WA 76 WEG EV2349 11/19/2015 11/14/201& E.L.L.DISEASE-EAEMPLOYEE 500 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1,500,000 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate Holder is an Additional Insured per the Business Liability Coverage Form SS0008 attached to this policy. CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED MANSFIELD COUNTRY SQUARE LLC BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C/O SAM PARK AND COMPANY LLC 812 CONSTITUTION AVE�� LITTLETON, MA, 01460 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD c .4 c r, o u_ � V c c o o .�`o u 0 V L m c u - c P o 0 a N u_ Q Lc � a L �O V) —0 cc O Z -70 O C U 6 -C -4-= Q N E UO 1- d � u v os 3 rn 14 w Z: Lu I 0 H Q . O Z a) C,4 ;-, N a e cle) N X lJ T— w O N , ` " N O.0 r- h Q N ~ N p Y w 0 rn 14 W �. m I H O V U- 0 0 C,4 ;-, N w cle) N p lJ 2S rn 14 U W-0 (W� z z W W 0"1 W 0 d Z 0 Qo H t A N O 2 0-0 O N 0 N U_00C Z N a N cid a ou 4 14 o U (4-4 w 0 z u Q Q fA 0 d Qo H t A ,N � o y �+ O N fA 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 apphcantwho 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 pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05