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HomeMy WebLinkAboutBest Buy 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: RETAIL SNACK FOOD 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:. BEST BUY - CORPORATION Whose place of business is: BEST BUY STORES, LP #1140 280 SCHOOL STREET PERSON(S) IN CHARGE: JONATHAN OLSON Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: S-2 BOARD OF HEALTH Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued S-2 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name BEST BUY STORES, LP #1140 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) r1n I<prlr I I P Please Update Mailing Address to: -PO Box 4401 4) Establishment Telephone No (508) 261-2340 Lisle, I LK532-4401. 5) Applicant Name& Title: BEST BUY STORES, LP#1140 i 6) Applicant Address 7601 PENN AVENUE S, RICHFIELD, MN 65423 7) Applicant Telephone No.: (612) 291-4863 24 Hour Emergency No,: (508) 261-2340 (500) 283-0662 —J 8) Owners Name & Title BEST BUY - CORPORATION 9) Owner Address (If different from applicant) 7601 PENN AVENUE S, RICHFIELD, MN 55423 Owner's telephone number 5082830552 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address r-I An Individual FV1 A Partnership L0-Qth-Qr-1egaI Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title'. JONATHAN OLSON Address: I280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No: 1(603) 721-2066 24 Hour Emergency No: FAX: (508) 261-2340 (506) 283-0552 E-mail:---- -B-()SINESSLICENSE@BES.TB-LJY.COM Alt E-Mail:_ 13) District Or Regional Supervisor (if applicable) Name & Title: DAVE POULIN Address: 11 WORCESTER ROAD, FRAMINGHAM, MA 01701 Telephone No: (608) 875-1025 24 Hour Emergency No: 7 ------- FAX: I E-mail: XXXX9iMX09€KXXXWA ----BUS IN ESS LJCENSE,@BESTBUY, COM Food Establishment Information 14) WATER SOURCE. TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No (If applicable) 16) No of Food Employees: 17) DAYS/HOURS: SUN 11 AM - 7 PM MONSAT 10 AM - 9 PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as or 101112001 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) OF 20) Location: FYI Permanent Location 22) Establishment Type 1,L Mobile Mobile Start DateRetail (29 944sq. Ft) Mobile End Date: ] Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: [ Food Service up to 101 -200 W; Annual I or up to 25' PHF display $150.00 [Seasonal I !-.] Food Service up to 201 + or 25'+ PHF display $275.00 j Seasonal Dates: Temporary Li Food Service - Institution Temporary Start Date:, ( Meals/Day) Caterer $25.00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 r Manufacture Frozen Dessertslice Cream -- $25.00/freezer F1 Pushcart $25.00 # of Pushcarts: 0 [ I Residential Kitchen $100.00 Retail Food $100.00 IV Retail Snack Food $25.00 iL Tobacco Products $25.00 Temporary End Date: j Temporary Rain Date: e--_- --_ J------- I-- - 23) Food Operations Definitions.PHF - Potentially hazardous food thme/temperature controls required) Non-PHF's - non -potentially hazardous fsod(no timeAemperature controls required) i(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no funherprocessing) ye; Sale of Commercially Pre Packaged Non-PHFs 1 Sale of Commercially Pre Packaged PHFs ;Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations IJ PHFCooked To Order [] Hot PHF Cooked and Cooled or Hot Held [� Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service I] PHF and RTE Foods Prepared For Highly 1 ------- -- -- --- n Sale of Raw Animal Foods Intended to be Prepared by Consumer Susceptible Population Facility L_ --_____._. __ _. - - _ . n Vacuum Packaging / Cook Chill --- ------ ----- -- --- - --_-_' 1 i, Use of Process Requiring A Variance Customer Self -Service ..� and/or HACCP Plan (including bare hand 1. 1 Ice Manufactured and Packaged for F contact alternative, time as a public health Retail Sale control) _ Juice Manufactured and Packaged for �;_. ! Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _ ---" bu - — n Offers RTE PHF in Bulk Quantities ul Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date -_ __ _._.._—_..—_... or Reconditioned Food 1 o be completed by the Board of Health waived I, the undersigned, attest to tha acre; j`cy of the information provided in this application and affirm that the food establishment operation will y with 105 QQMR'90.000 and all other applicable law. I have been instructed by the board of health on how too 'n copiee,of 10$.(?tJfit 00 a1 Gtnadederal Food Code. 24) Signature of ApplicanUr Pursuant to MGL Ch.62C, sec, 49A, 1 certify under the penalties of perjury that I, to my best knowledge and belief, have filed all slate tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 41-1822872 26) Signature of Individual or Corporate Name: Robert Jamsa TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed ail state tax returns and paid all state taxes required under law. 1f .7 -b L41 S�- Signature of Individual or Corporate Name CyQi -MX—TrY% "Social Security No. (Voluntary) or Federal Identification Number Robert Jamsa By: Corporate Officer (Mandatory, if Applicable) *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. R inIthVa &s Documents\PERIvQT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street, Suite 100 Boston, MA 021I4-20I7 www.mass.gop/dia Workers' Compensation Insuran ce Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Best BUV #1140 .iDRUMMITino Mum- City/Stato/Zip: Are you an employer? Check the appropriate box: 1. ® I am a employer with, 75 employees (full and/ or part-time).* 211 1 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, ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp, insurance req,] Phone Business Type (required): S. ® Retail 6. []Restawant/Bar/SatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing I LF] Health Care 12,[-] Other °Any applicant that checks box #i must also fill out the suBon below showing dteir workers' compensation policy information. **If the corporafe of i.crs have cxemptcd themseNea, but the corporation has other employees, a workers' compensation policy is required and such an ' organization should check box #1. lam an employer that is providing workers' conipensadon insurance for my employees. Below is the policy irnforrnadoh. Insurance Company Name: XI Incliranre America Inc insurer's Address: 70 SeaVlew Avenue City/State/Zip: St Policy#or Self-ins,Lic.# RWD943534605 Expiration Date: 2/1/18 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 "c ist the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o�.tfi{r.cL�A for insurance coverage verification. I do hereby c' ,- under the thaf the information provided above is true and correct, Official use only. Do not write in this area, to be completed by city or (.own official, City or Town: 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 4� �® CERTIFICATE OF 'LIABILITY INSURANCE DATE inn) 2on 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 Marsh USA Inc. 333 South 71h Street, Suite 1400 CONTACT NAME: FAX PHONE_(AIC No Exg1 NC Not: Minneapolis, MN 55402-2400 E-MAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAICN INSURER A : Greenwich Insurance Company 22322 _024927-BB-GAWU-17-18 INSURED BEST BUY CO., Inc. INSURER e : XL Insurance America, Inc. 24554 ----- INSURER C: XL Specialty Insurance Company 37885 and its subsidiaries and affiliates 7601 Penn Avenue South Richfield, MN 55423-3645 INSURER D; INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: CHI-006854861-07 REVISION NUMBER:17 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 INSA ADDL I INSD SUER WVD POLICY NUMBER POLICYEFF I IMWDDfyyyy)MWDDIYYYY POLICYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY RGE943757205 02101/2017 02O112018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE E OCCUR DAMAGE TO RE TE PREMISES Eaoceumonce S 1,000,000 MED EXP (Any one person) 5 0 Sift applies per policy PERSONAL S ADV INJURY S 1,OOQWO terms & conditions AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 5,000,000 GEN'L POLICY n PRO ECT OC PRODUCTS-COMPIOPAGG S 2,000,000 X 5 OTHER: B AUTOMOBILE LIABILITY RAD943757405 02/01/2017 02/01/2018 COMBINED SINGLE LIMIT Ea accident_ S 3,000,000 X _ BODILY INJURY (Par person) S ANY AUTO ALLOWNED SCHEDULED AUTO S AUTOS BODILY INJURY (Perawidenl ) $ _ HIRED AUTOS X NON OWNED AUTOS X _ PROPERTY DAMAGE Per accident _ S $ C X UMBRELLA LIAB X OCCUR US00052668LI17A 02/01/2017 02101/2018 EACH OCCURRENCE S 10.000.000 S 10,000,000 EXCESS LIAB CLAIMSMADEAGGREGATE DEC X RETENTION S 10.000 _ S B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? NIA RWD943534605 (ADS [Excluding TX[ Stop Gap EL 10f ND WA WY PR) 0210112017 02/0112018/+- X I PER OTH- STATUTE ER EL, EACH ACCIDENT S L000,600 E.I. DISEASE -EA EMPLOYEE $ 1,000,000 (Mandatory in NH) C If yes, DESCRIPTION DESCRIPTION OF OPERATIONS below RWR943534705 AK,WI) ( 02AF12017 02/0112018 E.L. DISEASE - POLICY LIMIT 5 1,000,000 C Excess Workers' Comp/ RWE943534805 (NV, OH) 02/0112017 02/01/2018 Limit: Same as above Employers Liability SIR: 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached if mom space is required) The above policies contain broad named insured endorsements to include all subsidiary companies of Best Buy Co., Inc. and broad additional insured wording (except Workers CompensabonlEmployers Liability) to include all contractors, subcontractors, vendors, landlords, mortgagees, trustees, lessees and any other person a organization contractually required to be named as an additional insured. Such insurance extends automatically. Waiver of Subrogation applies to general liability and Workers' Compensation insurance as required by written contract. The insured is a workers' compensation non -subscriber in Texas. Best Buy Co., Inc. its subsidiaries and affiliates 7601 Penn Avenue South Richfield, MN 55423-3645 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 of Marsh USA Inc. Manashl Mukherjee-Mi " © 1988-2014 ACORD CORPORATION. All riahts ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD