HomeMy WebLinkAboutOmaha Steaks 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 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:.
OS SALESCO, INC.
Whose place of business is:
OMAHA STEAKS
280 SCHOOL STREET, #D150
PERSON(S) IN CHARGE:
DAN OPPENHEIMER, STORE MANAGER
Permit Expires: December 31, 2016
License Number: RF -111
Food Fee: $50.00
BOARD OF HEALTH
MichaeCMcCtean, Chairman
Date received:
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1) Establishment Name
FOR BOARD OF"'. ,F-ALTH USE ONLY
Date Inspected: Approved By: Permit # Issuec
RF -111
FOOD ESTABLISHMENT PERMIT APPLICATION
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OMAHA STEAKS
2) Establishment Address 280 SCHOOL STREET, #D150 MAY V`_l 24, 6
3) Establishment Mailing Address (if different) 11030 "0" STREET ATTENTION: COMPLIANCE DEPT.
OMAHA, NE 68137
4) Establishment Telephone No (508) 261-8783
5) Applicant Name & Title: MARIE ASHBRIDGE, CORP COMPLIANCE ANALYST
6) Applicant Address 11030 "0" STREET, OMAHA, NE 68137
7) Applicant Telephone No.: (402) 597-8221 24 Hour Emergency No.: (401) 935-3009
�8) Owners Name & Title OS SALESCO, INC.
9) Owner Address (If different from applicant) 11030 "0" STREET, OMAHA, NE 68137
Owner's telephone number 4025978150
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
1 ❑ An Association or partner.
W A Corporation Name Title Address
❑ An Individual
❑ A Partnership
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title. IDAN OPPENHEIMER, STORE MANAGER
- -j �- - ----------- ----- {,i
Address: 111030 "0"
STREET,- OMAHA, NE, 68137
Telephone No: (508) 261-8783 24 Hour Emergency No: (401) 935-3009
FAX' (508) 261-8785
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E-mail:
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title: DAVE HILLENBRAND, DISTRICT MANAGER
Address: 111030 "0" STREET, OMAHA, NE 68137
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Telephone No: (966)46943W 24 Hour Emergency No: (610) 969-8750
FAX: (516) 933-4623
E-mail: davehi@omahasteaks.com
Food Establish. 'dnt Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 16) No of Food Employees 5
17) DAYS/HOURS: MON-SAT 10 AM -8 PM SUN 10 AM -6 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: W Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
j W Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
22) Establishment Type
Retail ( 923 Sq. Ft)
❑ Food Service up to 100 or
up to 10' PFIF display $62.50
❑ Food Service up to 101 -200
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
❑ 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
❑d Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
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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)
0 Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
❑ 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
❑ PHFCooked To Order
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
❑ ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ 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
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
-- - F❑ 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 T be completed by the Board of Health
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- — Total Permit Fee: $50.00
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:
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: 47-0805669
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)
f A
By: Corporate Officer` / c y
(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: US ti—'e—
Address:
i--'e -Address: ki,o3o O` E+ "', -i
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City/State/Zip: ` , .. �A�_ C16k:6,1 Phone #: ('(09.) 5` 'i - 3
Are you an employer? Check the appropriate box:
I . FS I am a employer with l (P employees (full and/
or part-time).* trr V'°ltk
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. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
1 l . ❑ 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 #I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: C``CUAl 7Z -t W,�,t
Insurer's Address: ��� ��_S4-
City/State/Zip: c P'1l b 2--t t l� I
y Ver'F�c L -- C,' --[b - " ' 4 ` U``i cis t C —Expiration Date:—1
Polic # or Self -ins. Lic. #
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 violater. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct
Signature -1 Ci3 �t\F ,ta Date:
Phone #:4
Official use only. Do not write in this area, to he 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 #:
WORKERS CONDENSATION AN4EMPL�YERS LIABILITY
INSURANCE POLICY
INFORMATION PAGE
(a stock company) 16586
-016 Issuing Office
-015 Issue Date
Sub Account
Issued by Liberty Mutual Fire Insurance Co
Policy Number WA2-64D-
Renewal Of WA2-64D•
Account Number 4-444507
1. Insured and Mailing Address
Omaha Steaks International, Inc.
11030 0 Street
OMAHA NE 68137
Status Corporation
Other workplaces not shown above: See
2. Policy Period: The policy period is from
mailing address.
3. Coverage
A. Workers Compensation Insurance: I
states listed here: AZ CA CO CT
NV NJ NY NC
B. Employers Liability Insurance: Part
limits of our liability under Part Two
Bodily Injury t
Bodily Injury t
Bodily Injury t
C. Other States Insurance: Part Three
All States except those listed in Item
ND OH WA WY
D. This policy includes these endorse
Information Page
Liberty Mutual.
INSURANCE
175 Berkeley street Boston, MA 02116
Lewiston, ME
01/14/2016
0000
FEIN
44-0652560
NJ TIN
470805690000
Risk ID
917128308
MI Risk ID
0701300A
Item 4. Premium - Extension of Information Page
01/01/2016 to 01/01/2017 1-2:01 A.M. standard time at the Insured's
rt One of the policy applies to the Workers Compensation Law of the
L GA IL IN KS KY MD MA MI MN MS MO NE
KPARITNTXVA
of the policy applies to work in each state listed in Item 3.A. The
Accident $ 1,000,000 each accident
Disease $ 1,000,000 policy limit
Disease $ 1,000,000 each employee
the policy applies to the states, if any, listed here:
.A and the States of.
and schedules: See Item 3. Coverage D - Extension of
4. Premium: The premium for this policy w II be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required blow is subject to ver cation and change by audit.
Classifications Code I Premium Basis Total Rate per $100 Estimated Annual
See
Minimum Premium $1,500 (GA)
Premium will be billed Annual
Producer 0002 007662
ARTHUR J GALLAGHER RISK MANAG
SERVICES INC
10050 REGENCY CIR STE 300
OMAHA NE 681143721
Producer SMITH 8936
Overland Park,
WC 00 00 01 A ®1987
Ed. 07/01/2011
Total Estimated Annual Premium $ 319,394
Deposit Premium $ 319,394
Deposit Tax/Surcharge/Assessment $ 6,039
Countersigned by Authorized Rep. (AZ)
:NT
t'
Council on Compensation Insurance, Inc. WC 00 00 01 B (CA)
All Rights Reserved Page 1 of 1
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
applicantwho 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 cavy 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 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 (Le, 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