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HomeMy WebLinkAboutCosi 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:. COST, INC. Whose place of business is: COSI 280 SCHOOL STREET PERSON(S) IN CHARGE: MARCIA SIMMONS Permit Expires: December 31, 2018 Food Fee. $125.00 License Number: FS-14 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream ❑O 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: COST, INC. having a place of business at COST 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-14 Board of Health NichaeCNcCCean, 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-14 FOOD ESTABLISHMENT PERMIT APPLICATION -- - - -------------- (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address X*] 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 280 SCHOOL STREET I MANSFIELD, MA 02048 4) Establishment Telephone No (508) 261-.8740 5) Applicant Name & Title: VICKI BAUE, VICE PRESIDENT 6) Applicant Address 500 Rutherford, Suite 130, Charlestown, MA 02129 7) Applicant Telephone No.: (312)010-1336 24 Hour Emergency No.: NOV J 0 ZU)/ 1 1 8) Owners Name & Title COST, INC. 9) Owner Address (If different from applicant) 500 Rutherford, Suite 130, Charlestown, MA 02129 Owner's telephone number (857) 415-5000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers i An Association or partner. k A Corporation Name Title Address An Individual Vicki Baue, VP, 57 E. Delaware, Chicago, IL A Partnership David Polonitza, EVP, 500 Rutherford, Suite 130, Charlestown, MA _(i Other. legal Entity____-.-- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) I Name &Title: Marcia Simmons i i Address: 500 Rutherford, Suite 130, Charlestown, MA 02129 Telephone No: 617-719-9859 FAX: (847) 580-4964 E-mail: marcia.simmons@getcosi.com Alt E Mail: VBAUE(a)GETCOSI COM 13) District Or Regional Supervisor (if applicable) Name & Title 24 Hour Emergency No: 617-719-9859 Marcia Simmons Address: 500 Rutherford, Suite 130, Charlestown, MA 02129 Telephone No: 617-719-9859 24 Hour Emergency No: 617-719-9859 FAX: E-mail: i (847) 580-4964 marcia.simmons@getcosi.com 14) WATER SOURCE: TOWN Food Establishment Information DEP Public Water Supply No: (if applicable) 17) DAYS/HOURS: 7 AM-10 PM 7 DAYS 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 30 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 of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of I certificate . _... .___ _.. _.._. ._.,_ 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) I'1_' 20) Location: IV, Permanent Location Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: [Jj Annual !._ Seasonal Seasonal Dates: 22) Establishment Type Retell ( Sq. Ft) I Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275,00 Jaclyn Doucet �[] Caterer$25.00 (✓; Milk & Cream $10.00 Mobile Food & Consession $75.00 n Manufacture Frozen Dessertshos Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 I _ Residential Kitchen $100.00 I❑ Retail Food $100.00 �- Temporary Food Service iInstitution F-1 Retail Snack Food $25.00 Temporary Start Date: 1 ( MealsiDay) [j Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (tfmaitemperature controls required) Non-PHFs - non -potentially hazardous tood(no Ilme4emperefure connote required) ,(Check all that apply): RTE-ready-to-eatfoods(Ex. sandwiches, salads, muffins which noedno fudherprocessing) Cr Sale of Commercially Pre Packaged Non PHFs [di PHFCooked To Order .-_ ❑ Hot PHF Cooked and Cooled or Hot Held (-- -- -- - ---- --- -- - _ [ I Sale of Commercially Pre Packaged PHFs [d� Preparation of PHFs For Hot And ! �, - - - - -- - i Cold Holding For Single Meal Service for More Than a Single Meal Service El PHF and RTE Foods Prepared For Highly L_; Delivery of Packaged PHFs ;_f _ _ _ _ ___ --... -!Sale of Raw Animal Foods Intended r Susceptible Population Facility Reheating of Commercially; to be Prepared by Consumer rr Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ! I . --- ._.__. _ _--- ------ ---- I-- (J Use of Process Requiring A Variance j _ ! Customer Self -Service of Non PHF and Non ( Customer Self -Service and/or HACCP Plan (including bare hand - ----1 Perishable Foods Only j r-ufactured and - -Packaged for--] - _-, ce Man contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control El Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal Origin ' 'Offers RTE-PHF in Bulk Quantities 1-1 [ Prepares Food/Single Meals for _ Catered Events or Institutional Food Service [I Retail sale of Salvage, out -Of -Date or Reconditioned Food _ -- _ ______ _-_ To be completed by the Board of Health -—'------- - - — --- Total Permit Fee: $126.00 Payment is due with application L 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 obtaln,Wpies of 105 Cat 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 1, to my best knowledge and belief, have riled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 06-1393745 Cosi, Inc. 26) Signature of Individual or Corporate Name: 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: COST ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 261-8740 FAX NUMBER: (508) 261-8742 OWNER OF BUSINESS: COST, INC. TELEPHONE OF OWNER: (857) 415-5000 FEDERAL ID/SS NUMBER: 06-1393745 FEE: $10.00 PERMIT NUMBER: FS-14 SIGNATURE: ^� � �r{� &L — DATE: 11/20/17 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. Cosi, Inc. Signature of Individual or Corporate Name 06-1393745 "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. RAilWINJane's D,,=enfs\PERMIT APPLICATIONSUAX CERTIFICATION FORM -doe The Commonwealth of Massachusetts Department of AdustrilatAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit, General Businesses. TO BE FILED WrM TBE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: Cos!, Inc. Alt ro. 500 Rutherford, Suite 130 Charlestown, MA 02129 Phone #: 857-415-5000 Are you an employer? Check the appropriate box: 1. ® I am a employer with 1170 employees (full and/ or part-time),* 2: ❑ I 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. Business Type (required): 5. ❑Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) S. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing I I.❑ Health Care 12.❑ Other 'Any applicant that ebooh box #1 must also fill out tha section below showing their workers' oomponsation policy iofomtation. "If the eorponate officers have exempted themselves, but the corporation boa otheremployoes, a workers' compensation policy is required and such an orgmEzation should cbea box #I. am an employer that is providing workers' compensadan insurance for my employees. Below is the policy informadoir. Insurance Company Name: North River Insurance Company fnsurer's Address; c/o Hays Companies of New England, 133 Federal Street, 2nd floor City/Stale/zip., Boston, MA 02110 Policy # or Self -ins, Lic. # 408-731205-6 Expiration Date: 5/10/18 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 MOL c. 152 can lead to the imposition of criminal penalties of a tine 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 fmo 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. under thppains and penalties ofpeVury that the information provided above is true and correct, offoW use only. Do not write in this area, to be completed by city or town gfjYciaL City or Town: Permit/License # Issulog Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: AFRO® CERTIFICATE OF LIABILITY INSURANCE OAT/01/20/YYYV) la/Ol/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 1-617-723-7775 Hays Companies of New England CONTACT Moira Crosby PHONE FAX IAIC N Etel' ___IFAX 133 Federal Street E-MAIL mcroab ®ha seem aniea.com ADDRESS: Y Y P INSURERUAFFORDING COVERAGE NAICq 2nd Floor Beaton, MA 0211D INSURER A: LIBERTY INS CORP 42404 _ INSURED INSURER B: LIBERTY NUT FIRE INS CO 23035 INSURER C: NORTE___RIVER IN9 CO 21105 Cosi, Inc. INSURER D: 500 Rutherford Ave INSURER E: Suite 130 Charlestown, MA 02129 INSURER F: COVERAGES CERTIFICATE NUMBER: 51449348 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 R OF INSURANCE ADDLSUBRTYPE INSR Won POLICY NUMBER MMIPOL��NYYY MMIDDNYYY LIMITS A GENERAL LIABILITY TB5-Z71-B67G9H-027 02/01/17 02/01/18 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES We soon ence $ 500,000 CLAIMS -MADE IX-1OCCURMED EXP(Any one person) 10,000 PERSONAL 8 ADV INJURY -$ $ 1,000,000 ]AS2-Zll-B6709H-017 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AEG $2,000,000 $ X POLICY PRO- LOC H AUTOMOBILE LIABILITY 02/01/11 02/01/18 COMBINED tlEEDISINGLE LIMIT 1 000 000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS NON-OWNEO HIRED AUTOS AUTOS PROPERTY DAMAGE Par accident $ A UMBRELLA LIAB X OCCUR TH7-211-H67G9H-057 02/01/1 02/01/18 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE � 408-731205-6 05/10/1 05/10/18 X %GTATU- OTH- E.L. EACH ACCIDENT $ 1,000,000 OrFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA E.L. DISEASE EA EMPLOYE' $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL.DISEASE -POLICY LIMIT 8 1, 000 , 000 H Property YU2-Z71-H 67G9H-0 02 Ol 1 02/01/18 BPP 34,977,041 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is requlredl Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN Attn: Health Department ACCORDANCE WITH THE POLICY PROVISIONS, 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 �jJp�/ V/ `-^—� BSA V ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) MCrosby 51449348 The ACORD name and logo are registered marks of ACORD ACTOR&® CERTIFICATE OF LIABILITY INSURANCE DATE 12/0 /2017YY) 12/Ol/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(les) 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 1-617-723-7775 CONTACTNAMMoira Crosby Hays Companies of New England PHONE FAX n), LAL.09L E-MAo IL mcroab Ohs a acorn niee.com ADDRESS: Y Y P 133 Federal Street 2nd Floor Boston, MA 02110 INSURERS AFFORDING COVERAGE NAICIf INSURER A: LIBERTY INS CORP 42404 INSURED INSURER B: LIBERTY MOT FIRE INS CO 23035 Coat, Inc. INSURER C: NORTH RIVER INS CO 21105 INSURER D: 500 Rutherford Ave Suite 130 1. Charlestown, MA 02129 INSURER E: - INSURER F : COVERAGES CERTIFICATE NUMBER: 51449348 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. I�TR TYPE OF INSURANCE NEARSPOLICY D POLICY NUMBER MMIDNYYY MMID/YYYY LIMITS A GENERAL LIABILITY TB5-Zll-B6709H-027 02/01/17 02/01/18 EACHOCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES W. co u igo,n $ 500,000 _ CLAIMS -MADE u OCCUR MED EXP (Anyone Person) $ 10,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENT. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $2,000,000 _ X POLICY PRO LOG $ B AUTOMOBILE LIABILITY AS2-Z11-B67G9H-017 02/01/17 02/01/18 COMBINED SINGLE LIMIT 1,000,000 BODILY INJURY (Par person) $ X A1NY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPRTY pgpuEdiept) ACE _.-...._ $ HIRED AUTOS AUUTOSWNED A UMBRELLA LIAB X OCCUR TH7-Zll-B6709H-057 02/01/1 02/01/18 EACH OCCURRENCE $ 25, 000, 000 AGGREGATE $ 25, 000,000 EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ C WORKERS COMPENSATION 408-731205-6 05/10/1 05/10/18 X WCSTATU- OTH- TORYLIMIT ER AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARrNER/EXECUTIVE YIN E.L. EACH ACCIDENT --- $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N)A E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 11000,000 B Property YU2-Z 1-B6709H-0 02 01 5275171a BPP 3 4,977,0 1 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Health Department ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 USA V ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/06) MCrosby 51449348 The ACORD name and logo are registered marks of ACORD