The URL can be used to link to this page

Home My WebLink AboutChipotle Mexican Grill 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:. CHIPOTLE MEXICAN GRILL OF COLORADO, LLC Whose place of business is: CHIPOTLE MEXICAN GRILL #1113 287 SCHOOL STREET, BUILDING B, SUITE 110 PERSON(S) IN CHARGE: STEVEN O'BRYAN - GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $126.00 License Number: FS-9 BOARD OF HEALTH Michae[McCean, 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: CHIPOTLE MEXICAN GRILL OF COLORADO, LLC having a place of business at CHIPOTLE MEXICAN GRILL #1113 287 SCHOOL STREET, BUILDING B, SUITE 110 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•9 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-9 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opei 1) Establishment Name CHIPOTLE MEXICAN GRILL #1113 2) Establishment Address Y87 SCHOOL STREET, BUILDING B, SUITE 110 date) 3) Establishment Mailing Address (if different) 1401 WYNKOOP STREET SUITE 500 °ATTENTION: -LICENSING DENVER, CO 80202 4) Establishment Telephone No (508) 339-2061 5) Applicant Name & Title:+-BAVt0-CD1:E-TZL AGENT 6) Applicant Address 1401 WYNKOOP STREET, SUITE 500, DENVER, CO 80202 17) Applicant Telephone No.: 24 Hour Emergency No.: (300)222-2524 30a)5�15'Z2 3 8) Owners Name & Title CHIPOTLE MEXICAN GRILL OF COLORADO, LLC 9) Owner Address (If different from applicant) 40 5th AVENUE, NEW YORK, NY 10011 Owner's telephone number (303) 222-2524 - 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1 [An Association or partner. I. 7 A Corporation i Name Title Address CJ An Individual A Partnership Other legal Entity_-- --_- -- - -_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: T RED-GU&I614•• GENERAL MANAGER C-I V M n i l r� p Address:nc zo 0^16&R��N nRn/o—AST IIA, FALLyRIIVVFR 4A V �6iJ�oeS�i�R�S{n S�• J Telephone No: I( 526 7063 4 _5� 3�J� 24 Hour Emergency No: (03) z 2- 5 4 ��a6� FAX: 1(508) 339-1687 - - --- - - -- -_I E-mail: lma.1113.mansfield(a)chipotle.com Alt E-Mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 21 --------------L------___. -_-- ------ 17) DAYS/HOURS: MON-SUN 10:45 AM - 10:00 PM 18) Name of Person In Charge Certified in Food Protection Management: JAftED-ebSfeK If more than 3 individuals are certified, complete list is on file. S MvM Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of I V �J certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): F/I 20) Location: FJJ Permanent Location 22) Establishment Type Mobile Moblie Start Date: ! ! Retail ( Sq. Ft) ! Mobile End Date v11 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 iV Annual or up to 25' PHF display $150.00 -�, Seasonal iJ Food Service up to 201 + -- or 25'+ PHF display $275.00 Seasonal Dates: 11 Temporary ;Food Service -Institution Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: ❑ Caterer $25.00 V Milk & Cream $10.00 ! 1 Mobile Food & Consession $75.00 -� Manufacture Frozen Desserts/Ice Cream $25.00/freezer [J Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $26.00 I Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (tim ltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) ,(Cheek all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ! J Sale of Commercially Pre -Packaged PHFs J Delivery of Packaged PHFs i 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 ❑ 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 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 ------ ---- -- ---i[- 1 I Customer Self -Service _J 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) -_.. F1 Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities 11 J Prepares Food/Single Meals for ! Catered Events or Institutional Food Service I J Retail Sale of Salvage Out -Of -Date - ____ ----- - ---- _-----_� or Reconditioned Food To be completed by the Board of Health 11 �- --- - --- -"----_--- Total Permit Fee: $125.00 Payment is due with application i i 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 copiesof105 CMR'�590.000 and the federal Food Code. 24) Signature of Applicant: t l)/Y � 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: 84-1485992 26) Signature of Individual or Corporate Name: V " Town of Town of Mansfield - Board of Health 6 Pak Rowansfield 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: CHIPOTLE MEXICAN GRILL #1113 ADDRESS: 287 SCHOOL STREET, BUILDING B, SUITE 110 TELEPHONE AT LOCATION: (508) 339-2061 FAX NUMBER: (508) 339-1687 OWNER OF BUSINESS: CHIPOTLE MEXICAN GRILL OF COLORADO, LLC TELEPHONE OF OWNER: (303) 222-2524 FEDERAL IDISS NUMBER: 84-1485992 FEE: $10.00 PERMIT NUMBER: FS-9 SIGNATURE: t DATE: t_�l `✓` Zv-1- — 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. ChU-HL W coin CIO Signature of Individual or Corporate Name 04— H-05T 2 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, i 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:\HnIthVands Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance. Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lepibly Business/Organization City/State/Zip: ,(" ^;', C IL) OU'�)0�4 Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. p I am a employer with employees (full and/ 5. ® Retail orpart-time).* 6. Restaurant/Bar/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 [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]* 11. ❑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 #1 must also fill out the section below showing the rworkers' compensation policy information. **if the corporate officers have exempted themselves, but the corporationhas other employees, a workers' compensation policy is required and such an organization should check box C. I am an employer that isproviding,workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: [ ';"U4 ` , (,", 11 / <. ;` i 1 (} r ;';.'{ r 1 ('' Insurer's Address: { s i LAC�Z- Rcacl t City/State/Zip: `} i � � � v� � S ;t,��/�k—�tJ f:vLFLf Policy# or self -ins. Li,. # L D`S D f 2- V+ Expiration Date: t 2 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 certf%y, under the pains and penalties ofperjury that the information provided above is true and correct Official use only. -Do not write in this area, to 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 S. Selectmen's Office 6.Other Contact Person: Phone A(C"Ra® CERTIFICATE OF LIABILITY INSURANCE V DATD/YYYY) 10/04/2017 /04/ 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, ANDTHE 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 endorsement(s). PRODUCER MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC, 5080 Spectrum Dr., Suite 900E CONTACT NAME: NCNNo Est), 469-232-2100 AIC No): _ E-MAIL ADDRESS: Addison, TX 75001 INSURERS AFFORDING COVERAGE NAIC N INSURER A:Safety National Casualty Corporation 15105 INSURED Chlpotle Mexican Grill, Inc.------ INSURER B :James River Insurance Company 12203 INSURER C : 1401 Wynkoop Street, Suite #500' " Denver, CO 80202 INSURER p INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:WSRU9H47 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 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 I O S B O POLICY NUMBER POLICY EFF MMIDDivvyY POLICY EXP MMIDD/YYl'Y LIMITS A X COMMERCIAL GENERAL LIABILITY GL4047266 10/01/2017 10/01/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR -DAMAGE K€NI EU PREMISES Ea occurtenwl $ 1,000,000 X MED EXP (Any one person) $ Liquor Llab $iM Each Occ/Aggregate PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000.000 POLICY PRO- n LOC JECT PRODUCTS-COMP/OPAGG $ 2.000,000 Policy Max General Agg: $ 25,000,000 OTHER: A AUTOMOBILE LIABILITY CAS4047262 10/01/2017 10/01/2018 OMBBINEDISINGLE LIMIT 1,000,000 BODILY INJURY (Par person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Paraccidenl $ HIRED NON -OWNED AUTOS ONLYHXAUTOS ONLY X $1,000 Comp $1.000 Call Ded Car! _ $ B UMBRELLA LIPS X OCCUR 000793740 10/01/2017 10/01/2018 EACH OCCURRENCE $ 5,000,000 $ 6,000,000 X EXCESS LIAB CLAIMSMADEAGGREGATE DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? F] (Mandatory inNH) NIA LDS4047264 (AOS) P54047265 I) SP4057707 (Excess OH) 10/01/2017 10/01/2018 - - X PER E OEH- E.L. EACH ACCIDENT -"'----'------'-'- E.L. DISEASE -EA EMPLOYEE — --- $ 1,000,000 $ 1,000,000 If yes, describe under DE SCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Information only AUTHORIZED REPRESENTATIVE Page 1 of 9)1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: ACC>I?ba ADDITIONAL REMARKS SCHEDULE Page 2 of 2 PRODUCER MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC. INSURED Chipotle Mexican Grill, Inc. POLICY NUMBER CARRIER NAIC CODE ISSUE DATE: 10/04/2017 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: Named Insureds: Chipotle Mexican Grill, Inc. Chipotle Mexican Grill U.S. Finance Co., LLC Chipotle Services, LLC Chipotle Mexican Grill of Colorado, LLC CMGGC, LLC ShopHouse, LLC PL Restaurant Holdings, LLC CMG Purchasing Co. LLC CMG Strategy Co., LLC CMG Pepper, LLC CMG Concessions, LLC (Below names not included on workers compensation) ShopHouse Maryland, LLC Ph Restaurant, LLC PLRH of Kansas, LLC NHNY, LLC NH Restaurant, LLC Nix Hedden Holding, LLC Chipotle Mexican Grill Texas Holdings LLC Chipotle Mexican Grill of Kansas, LLC Chipotle Mexican Grill of Berwyn Heights, LLC CMG of Prince Georges, LLC Chipotle Mexican Grill of Maryland, LLC Chipotle Texas, LLC EMEA Tortilla Limited CMG Purchasing Partners, LLP Chipotle Cultivate Foundation CMGSV, LLC TastyMade, LLC All riahts The ACORD name and logo are registered marks of ACORD CERTIFICATE NUMBER: WSRUgH47 9 I R Ias 6 � « W-� 0 W-4 � � Ed LJ Q� z � z � � W-4 z P4 . 4 i \ � ƒo \� � m \ x \ g \ / \ Q « } !e) ƒ \(a\ \ {\*J w .t2 m=«\ ( \§\\ \ \ \} \ f \ / *]) ) { (ƒƒ\ �% / \ � / \ \ ? \ n ■ #T � � � \ \ � ..� , y #7 \� � \ � 7a §� k3 v§�