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HomeMy WebLinkAboutWeight Watchers 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 SNACK 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:. JAMES CHAMBERS, PRESIDENT Whose place of business is: WEIGHT WATCHERS NORTH AMERICA, INC. 321 SCHOOL STREET, BLDG. A, STE. 150 PERSON(S) IN CHARGE: SUZANNE HURLEY Permit Expires: December 31, 2016 License Number: S-27 Food Fee: $12.50 BOARD OF HEALTH MichaecmcCtean, Chairman 7 . FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved -By: Permit # Issued S-27 FOOD ESTABLISHMENT PERMIT APPLICATION ...... . .... . -TApp _ric_a_Ftd_rimust 57e__S_Ubt77_/ffe VW7 1) Establishment Name WEIGHT WATCHERS NORTH AMERICA, INC. Establishment -.- ---Address ." 321 SCHOOL STREET, BLDG. A, STE. 150 * ------- ---- --- :3) Establishment Mailing Address (if different) 300 JERICHO QUADRANGLE, STE. 360 I : JERICHO, NY 11753. 4) Establishment Telephone No (508) 272-5197 5) Applicant Name& Title: MICHAEL INGRASSIA 6) Applicant Address 300 JERICHO QUADRANGLE, STE. 360, JERICHO, NY 11753 7) Applicant Telephone No.: (508) 390.1386 8) Owners Name & Title 0) Owner Address (if different from applicant) Owner's telephone number. 10) Establishment Owned By: 0 An Association W A Corporation 0 An Individual El A Partnership El Other legal Entity 12) Person Directly Responsit Name & Title'_16ifSTN� Address: Telephone No,, FAX: E-mail: 24 Hour Emergency No.: (505) Z72.5101 - CHRIS DIMINO WEIGHT WATCHERS NORTH AMERICA, INC, 5163901400 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address For Daily Operations (owner, person in charge, supervisor, manager etc.) . .... ....... 5O9, -a7,2 J 24 Hour Emergency No: Alt E -Mail: _]WIDURP EE(& -CO M CAST. NET 13) District Or Regional Supervisor (if applicable) Name & Title:- -[CHRISTINE HORAN, DISTRICT MANAGER Address; - — ------- Telephone No: (.508) 918-0235 Telep 24 Hour Emergency No: __' . . ............. . .... ........ ... . ..... _Mal L FAX: i It Food Establishment Information l15 SEWAGE DISPOSAL. TOWN 14) WATER SOURCE: TOWN I ) DEP Public Water Supply No; (if applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: VARIOUS 18) Name of Person In Charge Certified in Food Protection Management: 1 If more than 3 individuals are Certified, complete list Is on file. i 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: RJ Permanent Location 22) Establishment Type ❑ Caterer $12,50 �] Moblie Mobile Start Date: i [J Retail (IItE b 0Sq. Ft) ❑ Milk & Cream $5.00 1 Mobile land Date: ❑ Food Service up to 100 or I ❑ Mobile Food & Consesslon $37.50 up to 10' PHF display $62.50 Mobile Comments; ❑Manufacture Frozen Desserts/ice Cream Ik ........ -- $12.50/freezer 21) I-ength of Permit: ❑ Food service up to 101 -200 0 Annual or up to 25' PHF display $75.00 ❑ Pushcart $12.50 # of Pushcarts; ❑ Seasonal ~ ❑ Food Service up to 201 4, ❑ Residentla) Kitchen $50,00 or 25'+ PHF display $137.50 ❑ Retail Food $50.00 Seasonal Dates; ❑ Temporary ❑ Food Service - Institution © Retail Snack Foo 12.50 i Temporary Start pate: ( Meals/Day) E] Tobacco Products Temporary End Date: i Temporary Time; ._.._.---- j Rain Date: . Definitions: P14F - Potentially hazardous food (0-11emperature controls required) l 23) Food Operations Non-PHFs - non-potontially ha2ardous food(no tlme/temperefum controls required) !(Check all that apply}: RTt; - ready -to -eat foods (-X• sandwiches, salads. muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs 71 fiaiA of Cnmmerniaily Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Custotner, Self=Service of Non PHF and Non - Perishable Foods Only 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 ❑ Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers RTE PHF in Bulk Quantities ~[ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ❑ 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 ars a public health ❑ Offers Raw Or Undercooked Food Of — Animal Origin _ ___.. —_ —_ _•___ ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service 1 Ta be completed by rho Board of Neafth —I -- -- ---'" -- - --- I Total Permit Fee; $12.50 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 low. I have been instructed by the board of health on how to obtain copies of 105 CMRf590.000 and the federal Food Code. 24) Signature of Applicant:`, Pursuant to MGL Ch.62C, seo, 49A, I Certify under the penalties of perjury that I, to my best knowledge aild belief, have filed all state tax returns and paid state taxes required under law, 25) Social Security Number or Federal ID: 52-155(3141 26) Signature of Individual or Corporate Name: j 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. cam,* Signatule of Individual or Corporate Name (Mandatory) By: Corporate Offi6er (Mandatory, if applicable) x« 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 wi11 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 InVestigatmns kv 600 Washington Street Boston, MA 0211.1 fvww.fnassgov/dia . Workers' Compensation Insurance Affida-*it. General Businesses ApQlicant ]informat, tyl �'�eas� 'ria Legibly Business/Organization N Address: City/State/Zile: Are you employck? Check the appropriate box: I , 'lam a employer .with employees (fulI and/ or part-time).* 2, 0 1 ani a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.0 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. n We are anon -profit organization, staffed by volunteers, with no employees, [No workers'.comp. inmiranca req,] Phone #: Buer(required): A=il 5. 6. ❑ Restaurant/Bar/Eating Establishment 7, ❑ Office and/or Sales (incl. real estate, auto, etc,) 8. © Non-profit 9. Entertainment I0.0 Manufacturing 11.[] Hoa 1 e 12. OAny applicant that ohecks box #1 must also fill out the section below showing their workers' compensation policy infoltttatlon, 0*If the corporate officers have exempted themselves, but tho corporation has other employees, a workers' compensation policy is required and such atl organization should check box #1. I ain an employer that is providing workers' compensation Instfrance for iffy employees. Below is the policy infortnatiom Insurance Company Nam Insurer's Address: City/stgie/Zip: Policy # or Self -ins, Laic. #_\�_ko \"',' I~ailure to secure coverage as required under Section 25A of MGL 0, 152 esn lead to the imposition of criminal penalties of a fine up to $1,500,00 and/or arie-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 t4 the Office of Investigations of the DIA for insurance coverage verification, j I do hereby certify, un er the pains acid penalties of perjury that the hiformation provided above Is tate and correct Simiature: rl"JU ilix'k-x4bate: 0 �-1„ 1 1 Official u&e only. Do not write in this area, fo 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 Covilact Person; vhvrv.mass,gov/dia Phone ACCORD® ( ` ATE OF LIABILITY INSURANCE 9/29/2016 `.►, CERTIFICATE (Y DATE (MMIDDYYY) 9/28/2015 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 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 LOCKTON COMPANIES 500 West Monroe, Suite 3400 CHICAGO IL 60661 (312)669-6900 CONACT NAME: PHONE FAX C x A/C No): EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Lexington Insurance Company 19437 N INSURED Weight Watchers North America, Inc. 1357624 675 Avenue of the Americas, 6th Floor INSURER B: National Union Fire Ins Co Pitts. PA 19445 INSURER C: Insurance Company of the State of PA 19429 INSURER D: New Hampshire Insurance Company 23841 New York NY 10010 INSURER E : ACE American Insurance Company 22667 INSURER F: COVERAGES CERTIFICATE NUMBER: 12015154 REVISION NUMBER: XXXXXXX 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 MM/DD�YY MMIDDY� LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 51 OCCUR Y N 6796754 9/29/2015 9/29/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE T111 PREM SESOEa otccur .rice $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000000 PRODUCTS -COMP/OP AGG $ I OOO OOO POLICY ❑ JECT LOC $ OTHER: B AUTOMOBILE LIABILITY N N CA7469927 9/29/2015 9/29/2016 CND LIMIT $ 11000,000 BODILY INJURY (Per person) $ XXXXXXX ANY AUTO BODILY INJURY (Per accident) $ XXXXXXX ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS Ix AUTOS Ix PROPERTY DAMAGE $ XXXXXXX Per accident $XXXXXXX UMBRELLA LIAR OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XXXXXXX EXCESS LIAR HCLAIMS-MADE DED I I RETENTION $ $ XXXXXXX C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNEWEXECUTIVE Y / N OFFICERIM(Mandatory In H) EXCLUDED9 N[N--] (Mandatory in NH) N / A N WC067940179 (AO WI) WC067940179 AOSt) 9/29/2015 9129/2015 9/29/2016 9/2912016 H X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1000 000 E.L. DISEASE - POLICY LIMIT 1 $ 1 000 ,000 If yes, describe under DESCRIPTION OF OPERATIONS below E D D Property WC (CA) WC (FL) N N MAU D37412247 003 WC067940183 WC067940184 9/29/2015 9/29/2015 9/29/2015 9/29/2016 9/29/2016 9/29/2016 Replacement Cost- subject to terms and conditions of the policy. Plate Glass Included DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder and any applicable required parties are named as additional insured as respects to the General Liability in accordance with a written, signed and dated contract. The above referenced insurance is primary and non-contributory in accordance with a written, signed and dated contract. Waiver of subrogation applies in accordance with a written, signed and dated contract. C:tK I II-IL:A I It: HULUtK < F11Y liGL1 M I M• 12015154 Weight Watchers International SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Wei Jim Watchers Int natTax on Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. 300 Jericho Quadrangle, Suite 350 Jericho NY 11753— AUTHORIZED REPRESENTATIVE_——— ©1988-2M4 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD