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HomeMy WebLinkAboutBertucci's 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD SERVICE 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:. BERTUCCI'S RESTAURANT, CORP. Whose place of business is: BERTUCCI'S ITALIAN RESTAURANT 280 SCHOOL STREET PERSON(S) IN CHARGE: SUZETTE LANDRY, DISTRICT MANAGER Permit Expires: December 31, 2018 Food Fee: $275.00 License Number: FS-3 BOARD OF HEALTH MichaeCMCCCean, Chairman Milk & Cream W 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: BERTUCCI'S RESTAURANT, CORP. having a place of business at: BERTUCCI'S ITALIAN RESTAURANT 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-3 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-3 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name BERTUCCPS ITALIAN RESTAURANT 2) Establishment Address Y80 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET, OCT0017 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 261-2371 t "v 5) Applicant Name & Title: BERTUCCI'S RESTAURANT 6) Applicant Address 155 OTIS STREET, NORTHBOROUGH, MA 01532 7) Applicant Telephone No.: (508) 351-2500 24 Hour Emergency No.: (508) 272-2119 (774) 888-7237 8) Owners Name & Title BERTUCCI'S RESTAURANT, CORP 9) Owner Address (If different from applicant) 155 OTIS STREET, NORTHBOROUGH, MA 01532 Owner's telephone number (508) 351-2500 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. V, A Corporation Name Title Address An Individual A Partnership 87C tv -5 c_ r� - - - -- Other legal Entity -- - - - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (SUZETTE LANDRY, DISTRICT MANAGER Address: 19 CLINTON STREET, TAUNTON, MA 02780 Telephone No: i(508) 261-2371 24 Hour Emergency No: FAX: (508)261-2375 I E-mail: iBERT129@BERTUCCIS.COM Alt E-Mail: LICENSING[WBERTUCCI'S.COM 13) District Or Regional Supervisor (if applicable) Name & Title: :SUZETTE LANDRY, DISTRICT MANAGER Address: ---- - 155 OTIS STREET, NORTHBOROUGH, MA 01532 (508) 272.2119 (774) 888.7237 Telephone No: 11(774) 888-7237 24 Hour Emergency No: (774) 888.7237 FAX: (508) 393-7657 E-mail: SLANDRY@BERTUcciS.cOM 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) - �_-- 16) No. of Food Employees 25+ 17) DAYS/HOURS: MON-THURS 11 AM-10 PM SAT &SUN 11 AM-11 PM 18) Name of Person In Charge Certified in Food Protection Management: SUZETTE LANDRY SHARON If more than 3 individuals are certified, complete list is on file. LOGIUDICE Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of LORI JOHNSON certificate MICHAEL L'HEUREUX 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): IYI 20) Location: ill Permanent Location 22) Establishment Type Moblie Moblie Start Date: Retail ( Sq. Ft) Moblie End Date: !, [ Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: [_J Food Service up to 101 -200 !/I Annual or up to 25' PHF display $150.00 is1 Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: !, Temporary Time: 1j Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) Caterer $25.00 !� Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 --i Manufacture Frozen Desserts/Ice Cream `-� $25.00/freezer .F Pushcart $25.00 # of Pushcarts: 0 i ,� Residential Kitchen $100.00 ❑ Retail Food $100.00 I --I Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food thme/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) -', Sale of Commercially Pre -Packaged Non-PHFs ! Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Vi 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 J PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held ------- - - --- --- for More Than a Single Meal Service Pre aration of PHFs For Hot And P Cold Holding For Single Meal Service j Sale of Raw Animal Foods Intended to be Prepared by Consumer ----------- PHF and RTE Foods Prepared For Susceptible Population Facility Vacuum Packaging / Cook Chill ❑ Customer Self -Service l__7 Aso ui riuwas ncywnny n vauaucc and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative time as a public health Retail Sale _-- control) Juice Manufactured and Packaged for L� Offers Raw Or Undercooked Food Of Retail Sale Animal Origin r Offers RTE PHFin Bulk Quantities i 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: $275.00 Payment Is due with application waived. -.. -.. I, the undersigned, attest to the accuracy of the inform Ei444n provided in this application and affirm that the food establishment operation will comply with 105 CMR 5 .00p and all other applicab aw. I have been instructed by the board of health on how to obtain copies of 105 CM 90.1fh00 and the federal od Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify and t e penaltie f 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: 04-28Q 7, _ 26) Signature of Individual or Corporate Name: L' ` / �' ` % 67c 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 December 31st of each year. NAME OF BUSINESS: BERTUCCI'S ITALIAN RESTAURANT ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 261-2371 FAX NUMBER: (508) 393-7657 OWNER OF BUSINESS: BERTUCCI'S RESTAURANT, CORP. TELEPHONE OF OWNER: (508) 351-2500 FEDERAL ID/SS NUMBER: 04-2844750 FEE: $10.00 PERMIT NUMBER: FS-3 SIGNATURE: DATE: TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. .a Signature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMTTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: dC 3 f �d Ct d s'�2 Address: Cd 5 cr�lC-�C City/State/Zip: Phone #: — f . ;3 `2! Are you an employer? Check the appropriate box: Business Type (required): 1. �4 I am a employer with employees (full and/ 5. ❑ Retail or part-time). * 6. RestaurantBar/EatingEstablishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit 3. ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 1 10. ❑ Manufacturing no employees. [No workers' romp. insurance required]* 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. ❑ Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box 41 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 M. I am an employer that is providing workers' compensation insurance for my employees./ Below is thepolicy information. Insurance Company Name: (. kc.t-41 F f'�/��,5'fe1� �/l�ok'_ '�j /G!✓Pfc'-• Insurer's Address: ( rLP— 6crC ccii S-tr c{-C6 2 City/State/Zip: f. 40` /i1 ti (�} ooaq o S Policy # or Self -ins. Lic. # 7 %t0 q o s O) Expiration Date: o 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*­DlA for insurance coverage verification. I do hereby cef r, under the pains aryd penalties ofperjury that the information provided above is true and correct. Signature: :r s ,/,/ Date: Ate' z- J4i -7 Official City or Town: not write in this area, to be completed by city or town offtciaL Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6.Other Contact Phone 0 www.mass.gov/dia RERTUCC-01 CERTIFICATE OF LIABILITY INSURANCE DATE 1 1/31/20117 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 have ADDITIONAL INSURED provisions or 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 endorsements . PRODUCER c0 TEA, CT Willis Towers Watson Certificate Center Willis of Massachusetts, Inc. c/o 26 Centurryy Blvd P.O. Box 305191 Nashville, TN 37230-5191 lac°,,"N , E#: (877) 945-7378 jAAic, Nei:(888) 467-2378 E pARIL . certificates@willis.com INSURERS AFFORDING COVERAGE NAIC # INSURERA: Starr Surplus Lines Insurance Company 13604 INSURED INSURER B: Trumbull Insurance Company 27120 INSURERC:GreatAmerican Insurance Company 16691 Bertucci's Corporation INSURER D: North River Insurance Company 21105 155 Otis Street Northborough, MA 01532 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 TYPE OF INSURANCE ADDLTR INSD "DSUBS POLICY NUMBER PMIDDDYEFF POIIDYE%P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR 1000306089171 01/31/2017 01/31/2018 EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED (Ea e $ 50,00PREMISS 0 MED EXP (Any one rson $ 51,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY JECT X LOG OTHER: GENERAL AGGREGATE $ 2,060,000 PRODUCTS - COMPIOP AGO 2,000,000 8 $ B AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY AUTOS ONLY IOUENHV7159 01/31/2017 01/31/2018 COMBINEDcdd,hSINGLE LIMIT $ 1,000,000 X BODILY INJURY Per P.M.0 $ BODILYBODILY INJURY Per accident $ Pe�aceRdenDAMAGE S $ C X UMBRELI.ALIAS EXCESS LIAR X OCCUR CLAIMS -MADE UMB1800395 01/31/2017 01/31/2018 EACH OCCURRENCE $ 25,000,000 AGGREGATE S 26,000,000 DED I X I RETENTION$ 10,000 S D WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY OFFICERMIEMSEER EXCLUDED9 ECUTIVE YIN (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 406.7264052 01/31/2017 01/31/2018 X PER OTH- E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE 1,000,000 $ E.L. DISEASE - POLICY LIMIT 1,000,000 $ q Liquor Liability 1000305089171 1113112017 01/31/2018 �$11,000,000 Occ/ Agg: 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) RE: Evidence of Insurance Bertucci's Corporation 156 Otis Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. f lil"ULVCN3— ACORD 25 (2016/03) 9)1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ko 41 . /« x ) \ / © . �10 � �^\ \ � � o Q \ % \ k \ Q § . .# )\\« \ ,zs # 7=fa ® o \«;gam ) } w lr? ,`l. ;`.J'.`:`ni�;. �:T%:}`.Q.; %�%).Ar.A./. !. �:[ 7,2J>^{�%\., ./ .i✓,.. "./ :} ! / '.:/.'� T i r>' J ,� � . r rffw tir ✓ � S' j '' r/ i � <' rr' ! f '`'. �'jr: / ✓ /" %r .�. 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M '? a4;1`I A40V Confexera-, lr�oSf(Protect�n _ -40itft ti fi ,�: s '! � Corti icate, No 1830970 �s�� f .-`'✓ � �' �f� � sf � �3Cdiit Dale .11f04�� 3 �— r V es1 C''adt3'`" 620304241 f r r> i YWVMcYhlltit,t 01e0f( uvre„ y`v[anrgol" i -. ' ,•, �. t '" g, CeAid& expires no lafer than; 11/041�0 •vl ', "Cut Here" Congratulationsl You have passed the National Prometric Certified Professional Food Manager examination. Score Report Your name has been added to the National database of Food Managers. Copgratulaticirisi You passed the Certified Professional Food Manager examination. x CAROL A SECKY BERTUCCI'S CORPORATION 166 OTIS NORTHBOROUGH, MA 01632 Your Score is as follows: Score smullus Exam Date 80 41/04/2014 PASS This is to cergy that f f 0 ` 00LA$PCE,Y ' O- this Af0 the rlcccs;sary t`i>gu fenli.li Food Manager Certification. Reca0l ed %nf renoxpr Fw lt'0-% 0.4106 x iDatc f Promethic 800.024.2736 7941 Corporate Drive NoltinghamrA,it) 21236 800,624.2736 2 � bio ® % Q 2 0 CA cq 0 ® % / d. ) � � \ 48 / 0 o e \ � / 6 7 ± \ \ / «> N\. \ ƒ\\ \ ! & r lrlrJf _ __ s.y "9- TIFICATION SHARON LOGIUDICE for successfully completing the standards set forth for the SemSafeo Food Protedipn Manager C4ificafion Examination, which is accredited 6y the American National Standards Institute fANSIKonferenco for road Protedion (CFP). BER EXA DATE OF E DATE OF EXPIRA Loral laws apply. Ch ency for re flllmtion mquiromenls. Camau�xbA grim,W 175W lu WA.S I5Ca Chk,, L&WMa 3m�ap. /cq / q cq m d \ { IV PA \ � / � / / $ \ ° ° a \ 4W� Q / ■ \ \ ) ) { � \ ,t% \ / av % k�/ \ « ƒ\ 3\ R \§)\ \ \/%\ « \ƒ\\ \ / rvSafe CERTIFICATION 01WO19:4 A_lMOM for wacessfally campleling the standards set forth for the SewSa%® Food Pr9tecTian hlmsager Certification Examinalian, which is accredited by The American National Standards Institute (ANSIf-Confaretice for Food Protection (CFP). 10/1 )ATE OF EXPIRP ecerlificalion regairemenh. GVMmwM gxaim�d I75Wbran B SM ISW,Gki ,L 60604x3- edehu , : � m \ \ 0 \ \ H. ƒ H H ( / 0 / _ & � / / © = a \ k / G : ) f \ ) \ ) $ƒ\\ ƒ \ | ] ) w r (\\6 \ƒ\) \ ${)¥ k 7 � / Exhibit A Bertucci's Restaurant Corp. (fka Bertucci's, Inc.) - Officers & Directors (Liquor License holder for Bertucci's Corporation) State of Incorporation - MA Current CEO, Director CFO, Treasurer, Secretary Brian K. Wright Brian Connell rian K. Wright Black Rock Drive Ingham, MA 02043 rian P. Connell Patriot Lane MA 02382-2379 A.Moscaritolo 70 LaGrange St Assistant Secretary Christine A. Moscaritolo West Roxbury, MA 02132 HE.ARTSAVER CPR AIED I HeartSaver® American CPR AED Heart Associakionm. William :Herren Choke Saver The above IodlNdaal hea mdoe5slully complefediho o6)ecpves and skillseValuaifong in accordance wNh the daiAcumm at the AHA Headsaver CPRAEU Proglam. Optimew campleiee modulesere ihu9a NOT m5rk0d ouft 2/1/2611(r1PRAEO 1dledt CPR 'Eitam i ll 21201.9 Inv. Date — 3ecammande0: Ren6Wa)pate HEARTSAVER CPR. A E D Heartsaver� American Heart CPR AED A$eoDiationd Sharon Logiudics. Choke Saver The above lndNidat)Ias sumesStully comPlatedtfie obtecbves and skills eV,§IdaHdlld+ of the AHA Head,tver CPHAEO Program' OPOdpel in accordance with thd;butdculum wnpialed modules ai&IDose NOT:markad out^ lid CPR AEO lRant CPR 2/11261.7 —^ ,2��.a19 Reaommande leave Col. 'I,