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Home My WebLink AboutCorporate Chefs @ Smith/Nephew 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:. CORPORATE CHEFS Whose place of business is: CORPORATE CHEFS @ SMITH & NEPHEW 130 FORBES ROAD PERSON(S) IN CHARGE: ANN MARIE HATHAWAY Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-13 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: CORPORATE CHEFS having a place of business at: CORPORATE CHEFS @ SMITH & NEPHEW MTIYX*7;T-.T:T.Ce_BE 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-13 Board of Health Michae(McCCean, 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-13 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name CORPORATE CHEFS @ SMITH & NEPHEW 2) Establishment Address 130 FORBES ROAD F-7 41 NOV 5 zu,I 3) Establishment Mailing Address (if different) 22 PARKRIDGE ROAD l' HAVERHILL, MA 01835 4) Establishment Telephone No (508) 261-3710 5) Applicant Name & Title: KELLY KIJANKA, LICENSE ADMIN. 6) Applicant Address 22 PARKRIDGE ROAD, HAVERHILL, MA 01835 7) Applicant Telephone No.: (978) 372-7400 24 Hour Emergency No.: (978) 372-7400 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corl An Association or partner. Vi A Corporation Name 'An Individual . _.__._.... .. . A Partnership CORPORATE CHEFS 22 PARKRIDGE ROAD, HAVERHILL, MA 01835 (978) 372-7400 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: A-nn Mare, 4&4_� �, oaLt Address Telephone No. 24 Hour Emergency No: (978) 372-7400 FAX: i(978) 372-0150 E-mail: I KKIJANKA(a)CORPORATEC H EFS.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title. SUE PELOQUIN, DISTRICT MANAGER Address: 162 BLACKSTONE STREET, BLACKSTONE, MA 01504 Telephone No: '(508) 254-0398 24 Hour Emergency No: (978) 372.7400 FAX: % (978) 372-0150 E-mail: SPELQUIN@CORPORATECHEFS.COM -_. -. __ - _-. I. --_---- --------------------------.._ -- --... Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 3 117)DAYS/HOURS: M-F6:30AM-3PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. I Required as of 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): Ili 120) Location: V] Permanent Location 22) Establishment Type I [] Mobile Mobile Start Dale:,' Retail ( Sq. Ft) j Moblie End Date: [�� Food Service up to 100 or Mobile Comments up to 10' PHF display $125.00 L. 21) Length of Permit: ❑ Food Service up to 101 -200 ICI Annual or up to 25' PHF display $150.00 [] Seasonal Seasonal Dates: [_, Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): [ ] Food Service up to 201 + or 25'+ PHF display $275.00 [ ] Food Service - Institution ( Meals/Day) ►-h-u-N F- a t ie ❑ Caterer $25.00 [] Milk & Cream $10.00 I I Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer [] Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (tlmeAemperature controls required) Non-PHFs - non -potentially hazardous food(no timeAemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) V 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 I Preparation of Non-PHFs Other Food Operations Imo] 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 IJI Customer Self -Service [� Ice Manufactured and Packaged for Retail Sale [.] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health J Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of 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 -Dale _ ___ _ pb or Reconditioned Food � To be completed by the Board of Health - --- µ Total Permit Fee: $125.00 Payment is due with application rL_ 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 copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Pursuant to MGL Ch.62C, sec. 49A, I ceA 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: 04-2981626 26) Signature of Individual or Corporate Name: rnoY—Llsl' l' h ��.5 n l:, 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: CORPORATE CHEFS @ SMITH & NEPHEW ADDRESS: 130 FORBES ROAD TELEPHONE AT LOCATION: (508) 261-3710 FAX NUMBER: OWNER OF BUSINESS: (978)372-0150 CORPORATE CHEFS TELEPHONE OF OWNER: (978) 372-7400 FEDERAL ID/SS NUMBER: 04-2981626 FEE: $10.00 PERMIT NUMBER: FS-13 SIGNATURE: XI DATE: I/� _ 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. (Oqcnaxk M S ine, Signature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number 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:\HmIthVane's DocumentsWERMIT APPLICATIONSUAX CERTIFICATION FORM.doc aN The Commonwealth of Massachusetts U1VDepartment 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 PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Address: \ a_- _f 1 C�q e City/State/Zip: C 35 Phone #: 9'i8 - 3 Are yoy-an employer? Check the appropriate box: Business Type (required): L ❑Q 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 [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 I 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 #] must also III 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 #l. I am an employer that is Insurance Company Nan Insurer's City/State/Zip: workers' compensation insurancefor my employees. Below is the policy information. Policy # or Self -ins. Lic. # ?0 - ) $� YO — G Expiration Date: ghha 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 the DIA for insurance coverage verification. I do hereby certify, y.3der the pains and penalties of perjury that the information provided above is true and correct. 9> is 3'> a , � 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 Person Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone CERTIFICATE OF LIABILITYINSURANCE DATEYYYY) 9/1/9/1/2018 8/23/203/2017 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 CO TRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ,�..n,..,e,; n u1e cerancare nomer is an AUDITIONAL INSURED, the policy(les 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 ended sement(s). PRODUCER Lockton Companies I CONNAME: TACT 3280 Peachtree Road NE, Suite #250 PHONE FAX Atlanta GA 30305 E-MAIL A/c N.), (404) 460-3600 ADDRESS . .�..uu4 G00V INSURED Corporate Chefs, Inc. INSURER B : SentC Insurance a Mutual Com an 24988 1426071 Elite Vending, Inc. R ABD Catering, LLC suRERc: Ontjnental Casual[ Com an 20443 22 Parkridge Road INSURER D: Haverhill MA 01835-7278 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER- 14 THIS INDICATED. CERTIFICATE EXCLUSIONS LTR ILTH B IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY AND CONDITIONS OF SUCH TYPE OF INSURANCEim X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR UI PERTAIN, POLICIESN—SR. ADOL N INSURANCE SUER An N 916630 LISTED BELOW HAVE BEEN TERM A CONDITION OF ANY THE INSURANCE AFFORDED BY LIMITS SHOWN MAY HAVE BEEN POLICYNUMBER 90-18840-06 I TH RE P IM 9/ SUED TO ONTRACT POLICIES UCED BY LICY EFF /OD/yyYY /2017 THE INSURED OR OTHER DESCRIBED PAID CLAIMS. POLICY EXP MM/DD VVV 9/I/2018 REVISION NUMBER: NAMED ABOVE FOR THE DOCUMENT WITH RESPECT HEREIN IS SUBJECT TO LIMITS EACH OCCURRENCE XXXXXXX POLICY PERIOD TO WHICH THIS ALL THE TERMS, $ 1,000,000 P0 GE REMISES ER ED occurrence $ 1,000.000 MED EXP Any ona parson) Is 5000 PERSONAL$ ADV INJURY $ 1 000 000 B C N N N N 90-18840-04((AOS) 90-18840-05(MA) 6012283531 9/ 9/ 9/ /2017 /2017 12017 9/1/2018 9/1/2018 9/1/2018 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY jEC 0LOC OTHER: AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED To HIRED S ONLY NON OWNED AUTOS ONLY AUTOS ONLY X Drive Other. X UMBRELLA LIAB X OCCUR EXCESS LIAS CLAIMS -MADE GENERALAGGREGATE It 2000000 PRODUCTS-COMP/OP AGG $ 2 OOO OOO COMB NED SI GLE LIMIT Ee.c.1dent $ 2 OOO QQO BODILY INJURY (Per person) $ XXXXXXX BODILY INJURY (Per accident) $XXXXXXX PeOPccida^DAMAGE al $XXXXXXX EACH OCCURRENCE $ XXXXXXX $ 25,000,000 AGGREGATE $ 25,000,000 B A B DED RETENTION$ EMPLOYERS' WORCOMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y/N OFFICEA/MEMBER EXCLUDED? (Mandatory scribe under DESCRIPTION OF OPERATIONS below Liquor Liability N/A N N N 90-18840-01 90-18840-02 (Retro) 90-18840-06 9/ 9/ 9/ /2017 /2017 /2017 9/1/2018 9/1/2018` 9/1/2018 X STATUTE EHH $ XXXXXXX E.L. EACH ACCIDENT $ 1000000 E.L. DISEASE - EA EMPLOYEE $ 1 000000 E.L. DISEASE - POLICY LIMIT Each Claim:$1,000,000 $ 1,000,000 Aggregate: $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additlonel Remarks Schedule, may be as ched if more space is required) rlannnnnre un, n n,va.c� Fl nvly 14916638 Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZE REPRE$ENTg/T,3�IVE� ,^ 91988-201 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD