Loading...
HomeMy WebLinkAboutWendy's 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establislimeni 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:. WENDY'S PROPERTIES LLC Whose place of business is: WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE PERSON(S) IN CHARGE: GHANDY RASSAS, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -70 Food Fee: $62.50 Milk & Cream 91 BOARD OF HEALTH AichaeCvicCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. WENDY'S PROPERTIES LLC having a place of business at. WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE Town of Mansfield 6 Park Row Mansfield, MA 02048 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 12131/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -70 Scott Leite, Heaah Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 License to Manufacture Frozen Desserts and/or Ice Cream Mix The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made hereunder, hereby issues WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This license expires December 31st of each year. License Number: FS -70 Freezers: 5 TOTAL: $62.50 MANSFIELD BOARD OF HEALTH Scott l Bite, Heaah .Agent FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued I � FS -70 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must esubmitte�aneast- 0Yays before the ap fine opening ) — - — ---- � 1) Establishment Name WENDY'S PROPERTIES LLC #166-2286 2) Establishment Address 64 COPELAND DRIVE 3) Establishment Mailing Address (if different) P.O. BOX 256 4288 W. DUBLIN-GRANVILLE ROAD, DUBLIN, OHI DUBLIN, OH 43017 4) Establishment Telephone No (508) 339-7284a " 5) Applicant Name & Title: WENDY'S PROPERTIES LLC #166-2286 6) Applicant Address 64 COPELAND DRIVE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (614) 764-3100 24 Hour Emergency No.: (508) 718-8414 8) Owners Name & Title WENDY'S PROPERTIES LLC 9) Owner Address (If different from applicant) 4288 W. DUBLIN-GRANVILLE ROAD, DUBLIN, OH 43017 Owner's telephone number (614) 764-3100 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name i ( Title,, Address ❑ An Individual Se,- El e ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: U-RASSAS, GENERAL MANAGER Address: 164 COPELAND DRIVE, MANSFIELD, MA 02048 iTelephone No 11(508) 339-7284 24 Hour Emergency No: (508) 718-8414 FAX: ;(508) 339-3607 (978) 392-121 E-mail ISTORE02286(&,WENDYSSTORE.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) i Name & Title: 1T4 Elft , DISTRICT MANAGER Address: 13 CARLISLE ROAD SUITE 250, WESTFORD, MA 01886 Telephone No: ( $4 Je4 Hour Emergency No { . A # E-mail: Tr►M- iA-L1N@VV"U rS-CCV FAX: (978) 392-1212 Food Establishment Information - -- - ---_-- 15) SEWAGE DISPOSAL TOWN 14) WATER SOURCE: TOWN --- - - - - DEP Public Water Supply No: (If applicable) i 16 No. of Food Employees 44 MON-SUN 10 AM -1 AM -- ---- 17) DAYS/HOURS: 18 Name of Person In Charge Certified in Food Protection Management: GHANDY N. RASSAS 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 CARMEN LOPES VARELA MICHAEL L GAGNE certificate - - 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): FSel_ - - - - ❑ Caterer $12.50 20) location: Permanent Location j 22) Establishment Type ❑J Milk & Cream $5.00 ❑ Mobile Mobile Start Date: Retail ( Sq. Ft) ❑ Mobile Food & Consession $37.50 Mobile End Date: [] Food Service up to 100 or up to 10'PHF U Manufacture Frozen Desserts/ice Cream i Pushcarts: ay Moblie Comments $12.50/freezer d j Food service up to 016 200 '' 21) Length of Permit: or up s rvi PHF display $75.00 ❑ Pushcart $12.50 # of P carts: Annual - ❑ Food service up to 201 + [❑� Residential Kitchen $50.00 ❑ Seasonal or 25'+ PHF display $137.50 Retail Food $50.00 Seasonal Dates: Food Service -Institution ❑ Retail Snack Food $12.50 ❑ ❑ Temporary Tobacco Products $12.50 Temporary Start Date: ( Meals/Day) ❑ Temporary End Date: Temporary Time: Rain Date: Definitions PHF - Potentially hazardous food (time/lemperature controls requ re 23) Food Operations Non-PHFs - non -potentially hazardous food(no time temperature controls required) '(Check RTE - ready -to -eat foods (Ex sandwiches, salads, muffins which need no further processing) all that apply): _ Hot PHF Cooked and Cooled or Hot Held I ---- ❑ Sale of Commercially Pre Packaged Non PHFs PHFCooked To Order for More Than a Single Meal Service --- --_ Preparation - y i I. j ❑ Sale of Commercially Pre -Packaged PHFs O Cold Holding ForiSingle rMeal Service ❑PHF and RTE Foods Pre aced For Highly p 9 Y - Susceptible Population Facilit ❑ Delivery of Packaged PHFs ! ❑Sale of Raw Animal Foods Intended _ - - - --- Vacuum Packaging / Cook Chill - to be Prepared by Consumer ❑ ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring A Variance -- - _ ❑Customer Self -Service and/or HACCP Plan (including bare hand , ❑ Customer Self -Service of Non PHF and Non- _ contact alternative, time as a public health perishable Foods Only [] Ice Manufacturetl and Packaged for control) Retail Sale - - [] Preparation of N s__-PHF-- — - - i El Juice Manufactured and Packaged for ❑Offers Raw Or Undercooked Food O Other Food Operations Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities _._ . ❑ Prepares Food/Single Meals for ❑ Catered Events or Institutional Food Service ❑Retail Sale of Salvage, Out -Of -Date - - — — - --- or Reconditioned Food To be completed by the Board of Health ----------— — _ _-' � Total Permit Fee: $62.60 !� Payment is due with application ❑ waived f!. e the undersigned, attest to the ply racy of the information provided in with 105 CMR 590 000 and all other applicableilaw. I have beenthat insttructed by the establishment operation will comply 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: 47-3661188 ' y L 26) Signature of Individual or Corporate Name: a �nar;fr; f`.` i .� Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: WENDY'S PROPERTIES LLC #166-2286 ADDRESS: 64 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-7284 FAX NUMBER: (508) 339-3607 OWNER OF BUSINESS: WENDY'S PROPERTIES LLC TELEPHONE OF OWNER: (614) 764-3100 FEDERAL ID/SS NUMBER: 47-3661188 FEE: $5.00 PERMIT NUMBER: FS -70 r °? x SIGNATURE: DATE:` : ` Town of Mansfield TO,, of Mansfield P Board of Health 6 Park Row Mansfield MA 02048 APP lication for License to Manufacture Frozen Desserts andlor Ice Cream Mix To the Board of Health at the 7'ovn of Mansfield: /n accordance with the provisions of section 65H of Chapter 9�J of the General Laws, (is most recently amended, and the regulations made thereunder, the tnndersigned hereby applies' for a license for a WH(7LGS,1 LEIRET�IIL manufacture of frozen desserts and ice cream +nix and submits the following informatiorn: 1. Full name of applicant: WENDY'S PROPERTIES LLC #166-2286 - ._.-- - 2. Business address P.O. BO__X 256 4288 W. DUBLIN-GRANVILLE ROAD, DUBLIN, OHIO 43017 DUBLIN, OH 43017 3. IJ'applicant is an individual: Ful) name: WENDY'S PROPERTIES LLC #166-2286 Residence: 64 COPELAND DRIVE, MANSFIELD, MA 02048 3a, if applicant is a partnership, full name and residence of all partners: 3h. /fapplicant is a corpo•atiora: State of incorporation: DE _ — --- -- -- Date of incorporation: 4/7/2015 -- - qf: Principal office: P.O. BOX 256 4288 W. DUBLIN-GRANVILLE ROAD, DUBLIN, OHIO 43017 Full name and address President SEE ATTACHED LIST __ _ _--- --_----------- -— Treasurer: Clerk: 4. Location o/'Plants: MASSACHUSETTS S. Nantes of brands and trade or corporation name, if cnrn, under which the products are to he sold: FROSTY Q 6. Number and capacity of freezers and fees: 5 Fee: ($12.50 per freezer) $ 62.5 7. is the mix purchased? Yes if so, front whom purchased.' 8. Is the mix pastetir ed of not? Yes 9. Number ofgallons cf frocen desserts and/or ice cream rnix to he sold in Massachuseits (hiring the licensing period 5 000_-_10,000___ 10. Number ofgallons gffrozen desserts and/or ice creast nux sold in Massachusens during the previous licensing period II, is the plant constructed and equipped as provided in the regulations' Yes 12. Is the water• supply public or not? Yes 13, Have you received a copy of the regtdations? Yes I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conditions. I attest that the information stated in this application is true and(curate under the pains and penalties of perjury. 1 d ---- - - °' --- - - - - f t ., (Company owner/officer's signature) � (DATE � f (Title) (City or Town) I certify under the penalties of perjury that 1, to my best knowledge ge andnder b lief, have filed ail State tax returns and paid all State o , 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 A lhcant Information Please Print Le�libly Business/Organization Name Address:_. City/State/Zip: `' Are you an employer? Check the appropriate box: �; employees and/ ( to LI I am a employer with P Y or part-time).* 2. ❑ I am a sole proprietor or partnership and have no i 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.] Phone #: s 1 S *Any applicant that checks box Ill 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. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: � � �'. Insurer's City/State/Zip: Policy ff or Self -ins. Lie. # Expiration Date: - - taration page (slioi ng=tha - 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 certify, under the pains and penalties of perjury that the information provided above is true and correct Lle Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # . k;' 01 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 #: wwwanass:gowata WENDCOM-01 DORFAA . m" CERTIFICATE OF LIABILITY INSURANCE.:, oATE(MhI,Do,rYvY, PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 12/29/2015 , THIS;, CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE:CERTIFICATE HOLDER: THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,' 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 polley(les) must be endorsed. if SUBROGATION IS WAIVEQ,,subjecf to '. the', terms and conditions of the policy, certain policies may require an endorsement. A statement onthls certificate does riot confer rights to the certificate holder In liau of such endorsement(s). PRODUCER - NAME: Wi1iiS Certificate Center Will[ Insurance Services of Georgia, Inc. c/o 26 Centurryy Blvd P.O. PHONE I FAx "- AIC Na Ext (877) 945 7378 k talc, No�(888) 467 2378 Box 305191 Nashville„TN 37230-5191 ADDRESS. COrtIflCate8 WilI1S Cont a k---• --- PERSONAL & ADV INJURY $ INSURERfS�AFFORDING COVERAGE j NAIC # I GENERAL AGGREGATE § (NSURERA ACE American Insurance Company. 22667 . INSUREDThe OTHER: Wendy's Company INSURERC One Dave Thomas Blvd INSURER D : �rt Dublin; OH 43017 ---- — - Ea sodden BODILY INJURY (Perparaon) INJURY msuREREc� ( INSURER F • _ THIS 1S 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 CERTIFICATE MAYBE. ISSUED OR MAY PERTAIN, THE, INSURANCE AFFORDED THIS' 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. ' IN POLICY NUMBER - 1 COMMERCIAL �, MPDY EFF MMNO. EXP p OMITS ly yyy1 - _ GENERAL LIABILITY - i EACH OCCURRENCE: § CLAIMS -MADE I OCCUR OA)iAGi TiiFrENTED PREMISES (Ea accurrertca $ MED EXP (Any one person) $ -- --- PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER. __ PRO. I GENERAL AGGREGATE § - POLICY 4 - LOC i ; PRODUCTS-COMPIOPAGG S OTHER: - $ AUTOMOBILE LIABILITY I _ _...� .a -MBINED SINGLE LIMIT 1 ANY AUTO I I I I Ea sodden BODILY INJURY (Perparaon) INJURY ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS__;AUTOS ( I S F BODILY INJURY (Per accident) S PROPERTYDAMAGE '-'-}”'"--'- LPer.Wd nhk S - .-- . UMBRELLA LIAB OCCUR J EACH OCCURRENCE § EXCESS LIARCLAIMS-MADE' .� � - AGGREGATE § DED ( RETENTION § i S WORKERS COMPENSATION � _ AND EMPLOYERS' LIABIUTY - H. ,. X. 1 STATUTE ER ', Y / N A ANY PROPRIETOR/PARTNER/EXECU FVE WLR C48597774 OFFICER/MEMBER EXCLUDED? t . N I A _ - 01101/2D161- 01/01/2017 E L EACH ACCIDENT S 1,000 (MandUes,doryInund If yos, describe under + ,000 E,L.DISEASE - EA EMPLOYE S 1,000,000 _ _ 4 DESCRIPTION OF OPERATIONS below I E L. DISEASE - POLICY LIMIT ! $ 1,000,000 A Workers CompensationCLIC CLIC 4W 8597737 01/01/2016 01/01/2017 See Attached DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddRlonal Remarks Schadula, may be attached It more space is required) The Wendy's Company One Dave Thomas Blvd 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 ©1988-2014 ACORD CORPORATION. All rights rPsRrvpri ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Wendy's Properties, LLC Name Title Address Telephone Brolick, Emil J. Manager One Dave Thomas Blvd., Dublin OH 43017 614.764.3100 Penegor, Tadd A. Manager One Dave Thomas Blvd., Dublin OH 43017 614-764-3100' Klein; Dana Manager One Dave Thomas Blvd., Dublin OH 43017 614-764-3100 Beausoleil, Ricardo Manager 1209 Orange St., Wilmington, DE 19801 302-777-0202 Schwartz, Jennifer A. Manager 1209 Orange St., Wilmington, DE 19801 302-777-0202 Brolick, Emil J. President and Chief Executive Officer One Dave Thomas Blvd., Dublin OH 43017 614-764.3100 Executive Vice President and Chief Financial Penegor, Todd A. Officer One Dave Thomas Blvd., Dublin OH 43017 614-764-3100 Senior Vice President - Chief Accounting & Kriss, Scott A. Tax Officer One Dave Thomas Blvd., Dublin OH 43017 614-764-3100 Executive Vice President and Chief Operating Wright, Robert D.' Officer One Dave Thomas Blvd., Dublin OH 43017 614.764-3100 Weisberg, Scott A. Chief People Officer One Dave Thomas Blvd., Dublin OH 43017 614-764.3100 Pringle, Abigail E. Chief Development Officer One Dave Thomas Blvd., Dublin OH 43017 614-764-3100 Kaffenbarger, Kris A. Vice President - Franchise Development One Dave Thomas Blvd., Dublin OH 43017 614-764.3100 Waugh, Gavin P. Vice President and Treasurer One Dave Thomas Blvd., Dublin OH 43017 614.764-3100 Karasarides, Shawn H. Vice President- Corporate Counsel One Dave Thomas Blvd., Dublin OH 43017 614-764-3100 Vice President - Compliance & Tax Potts, Kyndall J. Accounting One Dave Thomas Blvd., Dublin OH 43017 614-764.3100 Klein, Dana Assistant Secretary One Dave Thomas Blvd., Dublin OH 43017 614-764.3100 N o I� OZ O a X O Ow 0 r w F - Q O 0 a m 0 Ch m 0 0 0 Q c m 5 d _ 0 tFa Z c E C ,> x0 U amw C O_ �O C E d Lb U OC O a 2 U !1 a) O CD O m LL C � O o� m m 0 0 a Y LO N T � 41 o� 0 c m U 'C N m m m A� E U O U cn v - N o I� OZ O a X O Ow 0 r w F - Q O 0 a m 0 Ch m 0 0 0 Q c m 5 d _ 0 tFa Z c E C ,> x0 U amw