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HomeMy WebLinkAboutBuffalo Wild Wings 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:. BLAZIN WINGS, INC. Whose place of business is: BUFFALO WILD WINGS 321 SCHOOL STREET, SUITE A110 PERSON(S) IN CHARGE: SHAWN FOURNIER, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $275.00 License Number: FS-5 BOARD OF HEALTH Michae(McCCean, Chairman Milk & Cream V 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: BLAZIN WINGS, INC. having a place of business at: BUFFALO WILD WINGS 321 SCHOOL STREET, SUITE A110 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-5 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-5 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name BUFFALO WILD WINGS 2) Establishment Address 321 SCHOOL STREET, SUITE All 10 DEC 13 201/ i 3) Establishment Mailing Address (if different) 5500 WAYZATA BOULEVARD, SUITE 1600 MINNEAPOLIS, MN 55416 4) Establishment Telephone No (952) 593-9943 5) Applicant Name & Title: BLAZIN WINGS, INC. 6) Applicant Address 7) Applicant Telephone No.: 5500 WAYZATA BOULEVARD, SUITE 1600, MINNEAPOLIS, MN 55416 (952) 593-9943 24 Hour Emergency No.: (952) 593-9943 8) Owners Name & Title BLAZIN WINGS, INC. 9) Owner Address (If different from applicant) 5500 WAYZATA BLVD., SUITE 1600, MINNEAPOLIS, MN Owner's telephone number (952) 593-9943 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 - -- — — — — -- -- — Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ',SHAWN FOURNIER, GENERAL MANAGER Address: :321 SCHOOL STREET, SUITE A110, MANSFIELD, MA 02048 Telephone No: ',(508) 339-4035 24 Hour Emergency No: (952) 593.9943 FAX: E-mail: (LICENSING(cDBUFFALOWILDWINGS COM j Alt E-Mail: 13) District Or Regional Supervisor (if applicable) r- - Name &Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE. TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) l 16) No. of Food Employees: 17) DAYS/HOURS: MON-SAT: 11:00 AM - 1:00 AM SUN: 11:00 AM - 12:00 AM 1 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. MICHELLE GOODWIN SHAWN FOURNIER Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of AMY LEPAGE certificate VADIME. MATVEEV _ARNOLD MENDE$_� 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): i 20) Location: [J Permanent Location 22) Establishment Type ❑ Caterer $25.00 _] Moblie Moblie Start Date: ❑; Retail ( Sq. Ft) Milk & Cream $10.00 Moblie End Date: [ i Food Service up to 100 or ❑Mobile Food & Consession $75.00 Moblie Comments up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream 21 Length of Permit: I El Food Service up to 101 -200 $25.00/freezer I ICI Annual i or up to 25' PHF display $150.00 1 -i Pushcart $25.00 # of Pushcarts: 0 Seasonal IJi Food Service up to 201 + -;' Residential Kitchen $100.00 Seasonal Dates: or 25'+ PHF display $275.00 - Retail Food $100.00 ,Temporary - - i._ Food Service -Institution j Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) i ] Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF - Potentially hazardous food dime/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) :'(Check all that apply): 1 RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ; I jSale of Commercially Pre -Packaged Non-PHFs -_1 Sale of Commercially Pre -Packaged PHFs j.1 Delivery of Packaged PHFs L--] Reheating of Commercially Processed Foods for Service Within 4 Hours _1 Customer Self -Service of Non PHF and Non Perishable Foods Only 171 Preparation of Non-PHFs ice! PHFCooked To Order j Hot PHF Cooked and Cooled or Hot Held ---__ —. r ;Preparation of PHFss For Hot Anndd -- for More Than a Single Meal Service i Cold Holding For Single Meal Service i 1 PHF and RTE Foods Prepared For Highly --- - I Susceptible Population Facility ❑ Sale of Raw Animal Foods intended i to be Prepared by Consumer D. Vacuum Packaging / Cook Chill Customer Self Service I i Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative time as a public health Retail Sale _ control) Other Food Operations f Juice Manufactured and Packaged for If JOffPre ayes Origin rs Raw Or Undercooked Meals for Of Retail Sale Animal On m Offers RTE PHF in Bulk Quantities I pFood/Single Catered Events or Institutional Food Service 1 Retail Sale of Salvage Out Of -Date I -- - -- - 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 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 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: 41-1957107 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Applieation 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: BUFFALO WILD WINGS ADDRESS: 321 SCHOOL STREET, SUITE Al10 TELEPHONE AT LOCATION: (952) 593-9943 FAX NUMBER: OWNER OF BUSINESS: (952)818-3674 BLAZIN WINGS, INC. TELEPHONE OF OWNER: (952) 593-9943 FEDERAL ID/SS NUMBER: 41-1957107 FEE: $10.00 PERMIT NUMBER: FS-5 SIGNATURE:/ " Ud DATE: TAX CERTIFICATION FORM 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. .1`7pkayn US Zy -, - P & Signature of Individual rate Name By: Corporate Officer (Mandatory, if Applicable) "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. R:\He IthVands Doc=wts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc LA The Commonwealth of Massachusetts Department oflndustialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMFFTING AUTHORITY. pplicant Information P1 Business/Organization N Address: M Are you an employer? Check the appropriate box: Business Type (required): IN I am a employer with �1_ employees (full and/ 5. ❑ Retail or part-time).* 614Restaurant/Bar/Eating Establishment 2.0 1 am a sole proprietor or partnership and have no ?, Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 9. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* I I. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. ❑ Other *Any applicant that checks box it most also fill out the section below showing their workers' compensation policy information. **If the corporate of5eers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State Policy # or Self -ins, Lie. #- k W 1 V R91 ` um Expiration Date: Q It 2_0 lib 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certil5i,)uibder the pgins and penalties of perjury that the information provided above is true and correct. Phone#• vn4__t:> Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone A� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOYIYY) 8/30/2017 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 Christensen Group Insurance 11100 Bran Road West CONTACT NAME; Nancy RasmUBsen PHONE (952)653-1000 FAX (952)663-1100 AIC, N4._Ext: _._ [(NC No): _ ADDRESS: nrasmussen@christensengroup. cost Minnetonka MN 55343 INSURER(5) AFFORDING COVERAGE NAIC # INSURERA:Hartford Fire Insurance Co 19682 INSURED BUFFALOWILD-WINGS, INC BLAZIN WINGS, INC. DBA: BUFFALO WILD WINGS 5500 Wayzata Blvd, Ste 1600 Minneapolis MN 55916 ._ INSURER a Trumbull Insurance Company_ _ _ 27120 INsuRERc INsuRERo INSURER E: _.. INSURER F: _ 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 IAODL SUaR -- --- LTR TYPE OF INSURANCE POLICY NUMBER I MMIDD/YYEYVY MM/DCfVEYYY LIMITS X COMMERCIAL GENERAL LIABILITY A CLAIMS MADE LX]OCCUR EACH OCCURRENCE _ DAMAGETORENTED $ 2,000,000 -- PREMISES (Ea occurrence $ 1,000,000 X Liqu Liability _ 41 CSE A94602 9/1/2017 9/1/2018 MED EXP(Any one person) $ Excluded -- -- PERSONAL B ADV INJURY $ 2,000,000 AGGREGATE LIMIT APPLIES PER: _ GENERAL AGGREGATE — i§ 15,000,000 GEN'L X _ _PRODUCTS -COMP/OP AGO _ $ 2, 000, 000 POLICY JECTPRO I� LOC OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A X ANVAUTO (En accident) BODILY INJURY (Per person) '-'- $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED 41 AB R94603 9/1/201] 9/1/201& BODILY INJURY (Per accident) PROPERTY -- $ _ HIREDAUTOS IAUTOS ! DAMAGE $ �(Peraccitlenll,_ $ I (UMBRELLA LIAR OCCUR EACH OCCURRENCE __$ IH EXCESS LIABLAIMS-MADE AGGREGATE § RETENTIONS O .AND EMPLOYERS' LIABILITY AND EMPS YERS' LI A (LIT PER OTH Y STATUTE OR �WORKERSCOMPENSATION V/N ANY O R/PARTNEREXECUTIVE OFFICERMEMBER EXCLUDED'+ �I NIA EL EACH ACCIDENT $ 1 0.00, 000_ B (Mandatory In NH) If yes, describe under 91 Pas R99600 9/1/2017 9/1/2018.: E.L. DISEASE- EA EMPLOYE _. $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Location: 321 School Street, Suite 110, Mansfield, MA 02048 Mansfield Health Department 6 Park Row Mansfield, MA 02048 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 Finley/NR�� © 1988.2014 ACORD CORPDRATInN ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) POLICY PROVISIONS. we no o0 o0 B INSURERHartford Accident and Indemnity Company Hartford Casualty Insurance Company Hartford Fre Insurance Company Hartford Underwriters Insurance Company Twin City Fire Insurance Company ADDRESS:HARTFORD, CT, 06155 NCCICOMPANYNO. INFORMATION PAGE NCCICOMPANYNO 10448 0 hlariford Insurance Company of Illinois C t Ie 14397 I{artfortl Insurance Company of the Midwest 20605 Besl L R R P 13269 Q Hartford Insurance Company of the suulheas'I 20621 Ind Co CF I 10456 ni 14974 ------- POLICY NO. 41 WN R94600 Previous Policy No. 41 WN R94600 Items 1. Named Insured and Mailing Address — (No., Street, Town, County, State) Individual Corporation x❑ Partnership Other------------- Other workplaces not shown above: 2. The Policy Period is from 09/01/2017 to 09/01/2018 Producer's Name Producer's Code NJ TIN: 311-455-915-000 BUFFALO WILD WINGS, INC. 5500 WAYZATA BLVD, SUITE 1600 MINNEAPOLIS, MN 55416 SUFFIX 171 enewal 07 IBC —To 6 12:01 A.M.,standard time at the insured's mailing address Issuing Regional Office 'CHRISTENSEN GROUP, INC. EDE 714969 THE HARTFORD 9855 WEST 78TH STREET ONE HARTFORD PLAZA EDEN PRAIRIE, MN 55344 HARTFORD, CT 06155 33.. A. Workers' Compensation Insurance:Part One of the Policy applies to the Workers' Compensation Law of the states listed here: AL, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, If,, IN, KS, KY, MA, MD, MN, MO, MS, NC, HE, NJ, NM, NV, NY, PA, RI, SC, IN, TX, UT, VA B. Employers' Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3A. The Limits of our Liability under Part Two are: Bodily Injury by Accident $1, 000, 000 Each accident Bodily Injury by Disease $1, 000, coo Policy Limit Bodily Injury by Disease $1, 000, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING AND ANY STATES DESIGNATED IN ITEM 3A OF THE INFORMATION PAGE D. This policy includes these endorsements and schedules: WC990005 AND SEE LISTING OF ENDTS 4. The premium for this policy will be determined by our manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis _ Rate Per Classifications Code Total Estimated $100 of Estimated Annual Number Annual Remuneration Remuneration'. Premium SEE SCHEDULE OF OPERATIONS _ $309„546 TERRORISM 9740 $22,619 CATASTROPHE 9741 $485 MINIMUM PREMIUM: $152,213. HIUIN:0007722362 RIUIN:0002354799 MN UIN: 7440920000 FEIN NO. 31-2455915 Interstate/Intrastate ID No. 918046895 NAILS: 722110 Total Estimated Annual Premium s;:1 s2, 65o Minimum Premium: $966 NJ Deposit Premium g332,650 Audit Period�X : 1Annual ��]Ouarte Seml-Annual dy Monthly n,,/o l/?n r Countelalyned by Form WC 00 00 01 A Punted in U S A Awhor,,,0 agnnr Ogle o9/olizor7 m m Mr w 0 W U w 1�1 V z 0-4 z rW V P4 W Z 2 O N •- N {� U N tl` N O O a o Z N u U o U o 0 Q o v Q 0 to tl w Enclosed please find the renewal appli t' nand/or invoice for Buffalo Wild Wings # If you have any questions or require additional information, please contact: Laura Carlson -Heideman, Sr. Licensing Specialist Phone: 952.516.8175 E-mail: lcarlson-heideman@buffalowildwings.com Please update our contact information/mailing address to: Buffalo Wild Wings Attn: Licensing Department 5500 Wayzata Blvd., Suite 1600 Minneapolis, MN 55416 Phone: 952.593.9943 E-mail: licensing@buffalowildwings.com Thank you for your assistance with this matter. 5500Wayzata Blvd, 161h Floor I Minneapolis, MN 55416 1 PHONE: 952-593-9943 1 FAX: 952-593-9787 1 BFFALOWILDWINCS.COM