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Home My WebLink AboutQdoba Restaurant 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:. QDOBA RESTAURANT CORPORATION Whose place of business is: QDOBA MEXICAN EATS #2365 280 SCHOOL STREET PERSON(S) IN CHARGE: JASON FURTADO, MANAGER Permit Expires: December 31, 2016 License Number: FS -86 Food Fee: $62.50 Milk & Cream FVI BOARD OF HEALTH MichaeCMcCtean, 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: QDOBA RESTAURANT CORPORATION having a place of business at: QDOBA MEXICAN EATS #2365 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 1213112016 unless previous to that time is suspended or revoked. Expires 12/31/2016 License No.: FS -86 Scott Leite, 9--1'eaah ,gent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Town of Mansfield 6 Park Row Town of Mansfield -Board of Health Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1 st of each year. NAME OF BUSINESS: QDOBA MEXICAN CRIrLi #2365 ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 337-2400 FAX NUMBER: (508) 337-2477 OWNER OF BUSINESS: ZRG-OPERAT-Ms-c- OI171PAI TELEPHONE OF OWNER: FEDERAL IDISS NUMBER: 84-1480725 FEE: $5.00 PERMIT NUMBER: FS -86 SIGNATURE: DATE: _ t i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ALL 02111 www.mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses Please Print Lesibly Applicant Information G Business/Organization Name:` Address: 1 R `5- ,� ;� r-- �l ��- Are you an employer? Check the appropriate box: 1. 1 am a employer with p i <' 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, E] We are a non-profit organization, staffed by volunteers, 1 ees [No workers' comp. insurance req.] Phone #: i Business Type (required): 5. ❑ Retail 6. Q4estaurant/Bar/Eating Establishment 7, ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment 10.❑ Manufacturing I LEJ Health Care 12.❑ Other with no en oy *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. Belo►v is the policy information Insurance Company Name; ` . L- :. Insurer's Address; City/State/Zip: c-' `4 Expiration Date d Policy # or Self -ins. Lia # - . 1 � 1 �' ` 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. Ido hereby certify, under the pains acrd penalties of perjury that the information provided above is true and correct Phone It: IFOfficial 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): t. Board of Health 2. Building Department 3. city/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.moss.gov/dia Page 2 of 2 ADDITIONAL REMARKS SCHEDULE BLAMED NAMED INSURED mED w;" - 'If� jACA N TI-IE enx tt�o E W-Y rTMER RGM, Marsh & McLennan Agency LLC AT-f�ILESLEPWITTMERNSKk lklT ILE 93T LBO .43 BA! BOA AVENLE POLICY NIMBER 'AN DEG 0, OA 92liD MAIC COM CARRIER EFFECTIVE DATE! 1� �'(r11 P�' n � tl Ft i a5 r 4 �2t Jf �sftY'� 6i tt az � ra P r A7w,r,1 A,4ii tl'144 tf-deA Iq xr nr. pi','x PA 10(AIR Sid(1f�tJV�f F(. irijE:P�. isA.-wV7IVifsirp ."z::r r,{arr�iit t1�,��nxs.ei3y lt_ t� � �,s �wA3a E.4 iixx lk:R 3,§H IW! tin (Nipni#- RRIA7 mrrtrn - ------ - - _. _ . ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE (MMI0;;WYYI 08/25/2015 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 COVPRAGE 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 a�pppp## I NAMEaCT Marsh & McLennan Insurance Agency LLC CA Lic #01-I18131 PpI 0{{ NE PAX (AJC, No, EX8ji -- E-MAIL i ADDRESS^ certe lrta-west.com P.O. Box 85638 San Diego, CA 92186 _ i SURE Sj AFFORDtNO COVERAGE NAI INN P INSURERA:ACE American Insurance Company _ 22667 INSURED Jack in the Box Inc INSURER XL Specialty Insurance Company 37885 _ — {sUREgc; Indemnity Insurance Company of 43575 Et Al (see attached] INSURER D XL insurance America, Inc. -- 24554 9330 Balboa Ave San Diego, OA 92123 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 WI ITCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE IERNS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR LTR __. _ -_ - ADDL TYPE OF INSURANCE IND. GENERALLIABIUTY SUSR gyve_ .. -. POLICY NUMBER PgqLICy E�F {MR�loDtYYY E— P�OLFCYEYE— {rdlODlYYVYi LIMITS _- EACH OCCURRENCE 11,000,000 A HDOG27398765 9/01/2015 09/01/2016 1{ COfA7AERCiAL GENERAL LIABILITY IAAOF TO E 4tsrS fl a occ Treece 11,000x000 _ MED LXP (Any one Gerson) 0 CLAIiAS MADE i � t OCCUR '; PERSONAL &ADV INJURY $1,OOO,QOQ Xi Owner's &Contractor III GENP.RAL AGGREGATE 52,000 Protection CAI..408827527 OMPIOP AG,000,000 PROqun` wCC? :3 GEN'L AGGRFGATE LIMIT APPLIES PER: NOLIOY3 ESDI 1+LLO, A AUTOMOBILE LIABILITY _ { -_- 9101/2015 0910112016,lcOFAtitN-il51N(iLELIIAIT �'1'00a'01D0 ANY AUTO I BODILY INJURY (Par patsa r)I $ 1 BODILY INJURY (Por accident¢ 5 ALL OWNED SCHEDULED AUTOS AUTOS NON OWNED HIRED AUTOS AUTOS -- PROPERTY DAMAGE — --_-. Per scddent)S S B X UMBRELtALIAB OCCUR US00072527LI15A — 9101/2015 0910112016 LACHOCCURRENOC 81.000, 00 AGGREGATE S1,000,000 EXCESS UAB I i CLAVAS -GRADE UE.0 RETENTION $ - �. _.. A C WORKLRSCOMPENSATION AND EMPLOYERS' LIAaIIrrY YIN ANY PROPRIETORtPARTNERtExrcUTivE Ol"NCERJMEMBER EXCLUDED'? N I A WLRC48591619 WLRC48591607 9/0112015 9101/2015 09/01/201 09/01/2016 WG $TA IU- OTH- if �Tczr�YSLo�s FR i— _....__ E L EACH ACCIDENT S1,000,000 (MNndalory in NH) E.L. DISEASE. EA EMPLOYEE $1,000,01)0 L: DISEASE Pt`1Ltb.Y LIMO t 51,0000 Use describe urder DC-5CRIPTION OF OPERATIONS bnloty „_ _;_E D Property US00057839PRISA5115/2015 05/15/201 ' Agreed Amount Real Personal 100% Replacement Cost Property Deductible $1,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS 1 VEHICLES (Attach ACORD 901, Additional Remarks Schedule, if more space Is requirach RE: Proof of Insurance, Jack In The Box, Inc, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BEFORE CANCELLED BEFOR THE. EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVER- IN 9330 Balboa Avenue ACCORDANCE WITH THE POLICY PROVISIONS. San Diego, CA 92123-1516 __- AUTHORIZED REPRESENTATIVE 0 1988-2018 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered matics of ACORD #S487205IM487199 WHIC ACCWOO L--- ADDITIONAL REMARKS SCHEDULE AGENCY Marsh & McLennan Agency LLC NAMEDWSURED JACK IN TWE BOX INC. iATTN. LF,LE WR7TWER, RISK W'Mr -94 -() FIA1,140A AVEtIlUE POLICY NUMBERK f:j "AN DIEGO, CA 92123 CARMER NAIC CODE EFFETnV-. DAM THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, -FORM NUMBER., 25 FORM TITLE: Certificate Of Liability Insurance Additional Named Insured lack in the Box Eastern Division LP Qdoba Restaurant Corporation ZRC Operations Company, Inc. (D 2008 ACORD rhe ACORD name and logo are registered marks of ACORD reserved. FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -86 FOOD ESTABLISHMENT PERMI I AFF'LIUA I IUN (Ap__p_W`caT1dn 17MLL #2366 1) Establishment Name QDOBA MEXICAN 0 c 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 9330 BALBOA AVENUE SAN DIEGO, CA 92123 M 4) Establishment Telephone No (508) 337-2400 Address: 5) Applicant Name & Title: AIWANDA-MCCARRON, ACCOUNTING SPECIALIST 6) Applicant Address 9330 BALBOA AVENUE, SAN DIEGO, CA 92123 7) Applicant Telephone No.: (1B"Y"1--244s_ 24 Hour Emergency No.: (774) 219.8923 (774) 249-8833 k r ou, -1 24 Hour Emergency No: -W440-8,923- 8) Owners Name & Title ZRC-OPERATIONS-COMPANY V' 9) Owner Address (if different from applicant) 7244V-.B0NF1L"-AN",AKEWOOD-,C"0226 Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. R] A Corporation Name Title Address El An Individual V LrOl < I I L, 1, �/ � , (,4" 1 "A' El A Partnership El Other legal Entity 47\ o ^n nirmnti%i i4ocnnneinip rnr i miiv ( inFirRTInns, i ownHi - uuisui i III ul icit uu. outivi v owl, 11 at —m— r�— 13) District Or Reqional Supervisor (if applicable) Name & Title: MAA-IRIL'10-DE-13MT-A-Ri,-itMONAL--MANAGER Name & Title: C-HRISTGPHER-STRONG, MANAGER Telephone No: (6474-766-017-6--`o; � P 24 Hour Emergency No: FAX: Address: REST, ATTLEBOR ",A -02-70-a nA Telephone No: (774) 249-8833 k r ou, -1 24 Hour Emergency No: -W440-8,923- FAX: E-mail: QMG365@_QDOBA.COM Alt E -Mail: 13) District Or Reqional Supervisor (if applicable) Name & Title: MAA-IRIL'10-DE-13MT-A-Ri,-itMONAL--MANAGER Address: 604-V1lLLAGER0AD-,NGRWO6@;M"2062 Telephone No: (6474-766-017-6--`o; � P 24 Hour Emergency No: FAX: E-mail: Food Establishment.lnformation r, 14) WATER SOURCE: TOWN �-15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 'll4g 17) DAYS/HOURS: MON-SAT: 11 AM -10 PM SUN: 11:30 AM - 9:36.101M 18) Name of Person In Charge Certified in Food Protection Ma6gement: - R . TRONa If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2009 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti-Chok(ng Procedures (If 25 Seats or more): 0 20) Location: ❑ Permanent Location 22) Establishment Type F_; ❑ Caterer $12.50 ❑ Mobile Mobile Start Date: ❑ Retail ( SgJFt) Milk & Cream $5.00 Mobile End Date: � ❑�/ Food Service up to 106 or E] Mobile Food & Consession $37.50 { Moblie Comments: up to 10' PHF display $62,50 " F1 Food service up to 101 ' -zoo ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer 21) Length of Permit; Annual or up to 25' PHF display $75.00 ❑ Food Service up to 26114 ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Seasonal i i Seasonal Dates: or 25'+ PHF display $137.50 ❑ Retail Food $50.00 ❑ Food Service - Instituiti5n ❑ 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 Definitions. PHF - Potentially hazardous food (timeAemperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) RTE -ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Heid 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 ❑ Delivery of Packaged PHFs ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility E] Sale of Raw Animal Foods Intended El Reheating of Commercially ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours to be Prepared by Consumer ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance Perishable Foods Only and/or HACCP Pian (including bare hand ❑ Ice Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) ❑ Preparation of Non-PHFs___ Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Prepares Food/Single Meals for E] Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date To be completed by the Board ofHealth or Reconditioned Food Total Permit Fee: $62.50 Payment is due with application ❑ waived i, the unaersignea, 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 59(1:000 and the federal Food Code. d e , 24) Signature of Applicant:* Y 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: 84-1480725 26) Signature of Individual or Corporate Name: i, # N ? `'