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Home My WebLink AboutTGI Friday'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:. GC FRIDAY'S BOSTON LLC Whose place of business is: TGI FRIDAY'S #2750 280 SCHOOL STREET, SUITE A 100 PERSON(S) IN CHARGE: MARIO RODRIGUEZ, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -64 Food Fee: $137.50 Milk & Cream 0 BOARD OF HEALTH NichaeCvicCtean, 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: GC FRIDAY'S BOSTON LLC having a place of business at: TGI FRIDAY'S #2750 280 SCHOOL STREET, SUITE A 100 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 12/31/2016 unless previous to that time is suspended or revoked. Expires 12/31/2016 License No.: FS -64 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-64 FOOD ESTABLISHMENT PERMIT APPLICATION - -R )cation must be submitted at least 30 days amore the Alarmed peittg d — (pp 1) Establishment Name TGI FRIDAYS 2) Establishment Address 280 SCHOOL STREET, SUITE A 100 3) Establishment Mailing Address (if different) E CARROttTON., rX76007-1720 KJ� i [ K Z) 4) Establishment Telephone No (508) 261-4021 5) Applicant Name & Title: l ; 6) Applicant Address 420 , - 2)3q_ Ut 6, -) �bV(�671 bk'51 - - - 7) Applicant Telephone NO.; (972) 662.5725 24 Hour Emergency No.: (603) 651-0769 1 8) Owners Name & Title ��&t%i-CtGt 9) Owner Address (If different from applicant) 42-J �R U! - — Owner's telephone number -C 0 �S ! ' �� &6_ 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. CorporationName Title Address f, Nr J An Individual !-Ij'lI✓� �- + I ❑ A Partnership i �C�-1-----?FO- her legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc. Name & Title: MARIO RODRIGUEZ, GENERAL MANAGER Address: 280 SCHOOL STREET, STE A-100, MANSFIELD, MA 02048 Telephone No: 1(508) 261-4021 24 Hour Emergency No: (603) 851-0769 FAX: (508) 261-7017 -_ E-mail:— - --—ITSt�FR t't 4 ll(✓c VVIC¢ -�/%� Alt E-Mail: - 13) District Or Regional Supervisor (if applicable) Name & Title: , ---E A50- Address: FL -3 I Telephone No: '(9""6-2--754-3-- 24 Hour Emergency No: (603) 315.4522 FAX:I (604 E-mail: Food Establishment Information - - ----- --T 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN j DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 66 17) DAYS/HOURS: 7 DAYSIWEEK 11 AM -1 AM 18) Name of Person In Charge Certified in Food Protection Management: MARIO RODRIGUEZ If more than 3 individuals are certified, complete list is on file. r / Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SARAH J. TEDESCHI V certificate ERIC D SHUTE -_ - - _ 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: [v] Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: Mobile End Date: Moblie Comments: 21) Length of Permit: iV Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: I Temporary End Date: I Temporary Time: Rain Date: `❑ Caterer $12.50 ❑ Retail ( Sq. Ft) Milk & Cream $5.00 ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 up to 10' PHF 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 aq5b ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 11 of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 'i❑ Tobacco Products $12.50 23) Food Operations Definitions: PHF -Potentially hazardous food (lime/temperature controls required) Non-PHFs -non-potentially hazardous food(no timeltemperature controls required) '(Check all that apply): RTE -ready-to-eal foods (Ex. sandwiches, salads, muffins which need no further processing) [J] Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs ---------- Reheating Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only iJ Preparation of Non-PHFs - W 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 I 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 control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of j Retail Sale - Animal Origin Pre le Meals for Offers RTE PHF in Bulk Quantities F-]PreparesFood/Sin g I ( Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date _ _---. --- -- - I or Reconditioned Food To be completed by the Board of Health I 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 copie/of 105 CMR 5g0.00q and q federal Food Code. 24) Signature of Applicant: I' f h filed all state tax returns Pursuant to MGL Ch.62C, sec. 49A, I certify under the pen(ilties of perjury that I, to my best knowledge and be ie , ave and paid state taxes required under law. 25) Social Security Number or Federal ID: —T3-27777717 26) Signature of Individual or Corporate Name: Town ofMansfield Town "f 6��D� �/A' 8Park Row ^ ,"»''8-0Dmof'Health Application��r@��and Cream. Perinit , I hereby make application for a MILK AND CREAM PERMIT, which expires on June Ist of each year. NAME OF BUSINESS: TGI FRIDAYS #457 ADDRESS: 280 SCHOOL STREET, SUITE A 100 TELEPHONE AT LOCATION: (508) 261-4021 FAX NUMBER: (508) 261-7017 OWNER DFBUSINESS: TG|FR|DAYS. INC. TELEPHONE OFOWNER: (972) 662-5400 FEDERAL 0/SGNUKABGR��f�rT� FEE: $5,00 PERMIT NUMBER: FG -64 SIGNATURE: DATE: / Ly /kz' 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. G& [:V'I dam. * Signature of Indi idual or Corporate Name (Mandatory) By: Corporate fficer (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 Hassachusetfs Departinant of Industrial Accidents Office of Investigations — 600 f oshingion Street Boston, MA 02111 tvw►v.nurss.gov/dia Workers' Compensation Insurance Affidavit: Geneyal Businesses Applicant Znforruation Please Print Legibly Business/Organization Name; Address: G� L- City/Skate/Zip: e 17: Are you an employer? ChCck fut appropriate hos: Business Type (required). l . ED,] -am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, E] Office and/or Sales (incl, real estate, auto, etc,) employees working for me in any capacity. &. Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. Entertainment their right of exemption per e, 152, §1(4), and Nye have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]*' I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.0 Other with no employees. [No wor]<,ers', comp, insurance req.] 'Any applicant that checks 1)0-01 must also fill out the section below showing their workers' compcnsnlion policy inromation, a' It' (fit; corporate officers have exempted themselves, but the corporation has other employees, a tvorkcrs' compensntion policy is required and such an organization should check box ill. I ant an employer that is providing workers' coat r�elns tion insurance for tnp ertrployees, Beloit, is the policy infbi-oration. Insurance Company Name: C( C_� Insurer's Address: City/State/zip; Policy t( or Self -ins. Lic. # Expiration Date, Attach n copy of the workers' compensation policy declaration page (shoNying 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 certifyrider Lite paid rjd perr es of perjury that the brfornialion provided aboye is true acrd correct. Offleiat rise only, Do not write lit this area, to be completed by city or toren officiat. City or "FoNs'rt: Permit/License ft 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 11: \YlV \Y.IIItI]].�V TtV �n _ , ® ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 04/05/2016 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 MCGRIFF, SEIBELS & WILLIAMS OF GEORGIA, INC. 5605 Glenridge Drive - Suite 300 CONTACT NAME: �MExt): 404 497-7500 Fvc No E-MAIL ADDRESS: Atlanta, GA 30342 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Safety National Casualty Corporation 15105 09/29/2015 INSURED Gold Coast Fridays Boston, LLC INSURER B :Liberty Insurance Corporation 42404 133 Sevilla Avenue INSURER C: INSURER D Coral Gables, FL 33134 INSURER E: INSURER F: MED EXP (Any one person) $ 5,000 COVERAGES CERTIFICATE NUMBER:K9H29HSD 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 INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY GL4053854 09/29/2015 09129/2016 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR TED PREM SES E.DA A13E ccurrrence $ 1,000,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 X X GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY ❑ PRO-F—]LOC JECT $ OTHER: 1 A AUTOMOBILE LIABILITY CAF4053855 09/29/2015 09/29/2016 COMBINED SINGLE LIMIT 1,000,000 Ea accident BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X X HIRED AUTOS AUTOS I X X PROPERTY DAMAGE Per accident $ $ B X UMBRELLA LIAB OCCUR TH7651291646-015 09/29/2015 09/29/2016 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 EXCESS LIAB CLAIMS -MADE X X DED I X I RETENTIONS 10,000 Prods Comp Ops $ 25,000,000 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITYSTATUTE ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? F --1N (Mandatory in NH) / A X LDS4053852 09/29/2015 09/29/2016 X PER OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Liquor Liability GL4053854 09/29/2015 09/29/2016 Aggregate $ 2,000,000 Each common cause $ 1,000,000 X $ s is DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: North Attleboro, MA, Corp. Store #132, Franchise #2751. Manchester, NH, Corp. Store #175, Franchise # 2739. Framingham, MA. Corp. Store #188, Franchise # 2733. Seekonk, MA, Corp. Store #190, Franchise # 2753. Boston Danvers, MA, Corp. Store #203, Franchise # 2747. Everett, MA, Corp. Store #242, Franchise # 2740. Newington, NH, Corp. Store #311, Franchise # 2741. Methuen, MA, Corp. Store #319, Franchise # 2734. Millbury, MA, Corp. Store #350, Franchise # 2742. Braintree, MA, Corp. Store #408, Franchise # 2743. Waterbury, CT, Corp. Store #441, Franchise # 2731. Enfield, CT, Corp. Store #445, Franchise # 2732. Plymouth, MA, Corp. Store #446, Franchise # 2748. N. Dartmouth, MA, Corp. Store #451, Franchise # 2754. Mansfield, MA, Corp. Store #457, Franchise # 2750. Taunton, MA, Corp. Store #471, Franchise # 2755. Boston/Brigham Circle, MA, Corp. Store #477, Franchise # 2735. Milford, MA, Corp. Store #482, Franchise # 2736. Amherst, NH, Corp. Store #491 2744. Concord, NH, Corp. Store #494, Franchise # 2745. Leominster, MA, Corp. Store #510, Franchise # 2746. Stoughton, MA, Corp. Store #545, Franchise # 2749. Dedham, MA, Corp. Store #716, Franchise # 2737. Berlin/Marlborough, MA, Corp. Store #730, Franchise # 2738. Stoughton, MA Store #545. continued next page) rFRTIFICATE HOLDER CANCELLATION TGI Friday's Inc. C/O Insurance Tracking Services, Inc. (ITS) P.O. Box 21919 Long Beach, CA 90801 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't,Jj Page 1 of 5 (P) 1 UUU-204 AI:UKU L;UKYUKAI IUN. All rlgnis reserveu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Attn: Licenses and Permits I am enclosing the signed applications for TGI Fridays Restaurant. I apologize for the oversight. The SafeServe and Allergen Certificates are forthcoming. If you need fiarthe,. information or have any questions, please call me at 316/685-1622, X3155 Sincerely, ° 9W. Caman Terri M. Carman License Supervisor /enclosures InfoSync Service 1938 N. Woodlawn, Suite 110, Wichita, KS 67208 P:316-685-1622 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: MARIO RODRIGUEZ ,. Certificate Number: 2390936 Date of Completion: 6/22/2016 Date of Expiration://2212021 ?he above-named person is hereby issued this certg7cate for completing an allergen awareness trainingprogratn recognized by the Massarhusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). Deis reu7ificate will be valid fw five (5) years from date of completion. Issued By; NATIONAL d RESTAURANT _ _ —J/ ASSOCIATION, Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 VAw .restaurant.org Southborough, MA 01772 508-303-9905 www.rnarestaurantassoc.org