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HomeMy WebLinkAboutTGI Friday's 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:. GC FRIDAY'S BOSTON LLC Whose place of business is: TGI FRIDAY'S 280 SCHOOL STREET, SUITE A 100 PERSON(S) IN CHARGE: MARIO RODRIGUEZ, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $275.00 License Number: FS-88 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream W Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: GC FRIDAY'S BOSTON LLC having a place of business at. TGI FRIDAY'S 280 SCHOOL STREET, SUITE A 100 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-88 MichaeCMCCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred <:I L A lct FOR BOARD OF HEALTH USE ONLY Permit # Issued FS 88 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) SUITE A 100 !OX 781898 ITA, KS 67278— - m-- 2614021 nb^ , LC :ORAL GABLES, FL. 33134 24. Hour Emergency No.. IDAY'S BOSTON LLC EVILLA AVENUE, CORAL GABLES, FL. 33134 7 3582 or partnership give name, title, and home address of officers Title Address g y _._. _i — 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc,) 1) Establishment Name TGI FRIDAY'S 2) Establishment Address 280 SCHOOL STREET, 3) Establishment Mailing Address (if different) P.O. I WICH 4) Establishment Telephone No (508) 5) Applicant Name & Title: GC FRIDAY'S BOSTON 6) Applicant Address 133 SEVILLA AVENUE, 7) Applicant Telephone No.: (305) 5673s52 8) Owners Name & Title GC FIR 9) Owner Address (If different from applicant) 133 S Owner's telephone number 305-56 10) Establishment Owned By: 11) If a corporation C.1 An Association or partner. ❑ A Corporation Name C1 An Individual A Partnership �i Other le al Entit Name & Title iMARIO RODRIGUEZ, GENERAL MANAGER ✓ Address: 280 SCHOOL STREET, STE A-100, MANSFIELD, MA 02048 Telephone No: (608) 261-4021 24 Hour Emergency No: (774) 240-5513 FAX: ,(508) 261-7017 E-mail: 2750@FRI DAYS.COM Alt E-Mail: TERRI.CARMANPISSVC.COM 13) District Or Regional Supervisor (if applicable) Name & Title: PAUL TORNABENE Address: 133 SEVILLA AVENUE, CORAL GABLES, FL. 33134 Telephone No: — -------- ! 24 Hour Emergency No: (sat) 827-8720 1 E-mail: PTORNABENE@GCHRESTAURANTS.COM FAX: (972) 212-5803 Food Establishment Information 14) WATER SOURCE: TOWN r 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) ! 16) No. of Food Employees: 66 17) DAYS/HOURS: 7 DAYSIWEEK 11 AM-1 AM 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 certificate C9) Person Trained in Anti -Choking Procedures (If 25 Seals or more): tJ 20) Location: ;Vi Permanent Location 122) Establishment Type [_ Mobile Mobile Start Date: ! Retail ( Sq. Ft) Mobile End Dale: I..-; Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: j Food Service up to 101 -200 [V! Annual or up to 25' PHF display $150.00 [_..i Seasonal Seasonal Dates: I_] Temporary Temporary Start Date: Temporary End Date: Temporary Time: ,A Food Service up to 201 + or 25'+ PHF display $276.00 j.,] Food Service - Institution ( Meals/Day) n.nn. ven.r n MARIO L RODRIGUEZ rsrn�rm�vc. HtGA1DNNA- ❑ Caterer $25.00 [V� Milk & Cream $10.00 El Mobile Food & Consession $75.00 [-� Manufacture Frozen Dessertstice Cream $25.00/freezer Pushcart $26.00 # of Pushcarts: 0 Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Ram Date: j 23)Food Operations Definitions:PHF- Potentially hazardous food(timeBemperalure controls required) Non-PHFs - non-potentlally hazardous food(no timeAemperature controls required) (Check all that apply): RTE- ready-to-eal foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs [JI, Sale of Commercially Pre -Packaged PHFs V1 Delivery of Packaged PHFs [Vj Reheating of Commercially Processed Foods for Service Within 4 Hours r] Customer Self -Service of Non PHF and Non - Perishable Foods Only [I 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 Ice Manufactured and Packaged for Retail Sale Juice Manufactured and Packaged I Retail Sale j_ Offers RTE PHF in Bulk Quantities -! Retail Sale of Salvage. Out -of -Dab or Reconditioned Food 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 Packacinq / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service I I To be completed by the Board of Health I 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 I OA( CMR 590,000 aryl thjq federAood Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties and paid state taxes required under law. 25) Social Security Number or Federal 10: 47-41670785 26) Signature of Individual or Corporate that I, to my best knowledge and belief, have fled all stale tax returns 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: TGI FRIDAY'S ADDRESS: 280 SCHOOL STREET, SUITE A 100 TELEPHONE AT LOCATION: (508) 261-4021 FAX NUMBER: (508) 261-7017 OWNER OF BUSINESS: GC FRIDAY'S BOSTON LLC TELEPHONE OF OWNER: 305-567-3582 FEDERAL IDISS NUMBER: 47-4670785 FEE: $10.00 PERMIT NUMBER: FS-88 SIGNATURE: DATE: / (���� �t 0/�--- 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. GC FRIDAYS BOSTON, LLC Signature of Individual or Corporate Name 47-4670785 "Social Security No. (Voluntary) or Federal Identification Number C:1-'Cis I ° 1 0a"yo- CQr1 By: Corporate Officer (Allandatory, 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,\He UhVanes 1)Qc=ea(s\PERMrr APPLICATIONS\TAX CERTIFICATION FORM.doe The Commonwealth ofMassachusetis Department oflndustrialAccidents I Congress Street, Suite 100 o 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 Leaibly Business/Organization Name: GC FRIDAYS BOSTON, LLC 280 SCHOOL ST SUITE Al00 City/State/Zip: MANSFIELD, MA 02048 Are you an employer? Check the appropriate box; L [3 I am a employer with 65 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.l 'Any applicant that checks box 91 must Phone #: 508/261-4021 Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other compensation noliev "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 a I. lam an employer tliat is providing ivoi,kers' compensation insurance for my employees, Below is the policy information. Insurance Company Name: SAFETY NATIONAL CASUALTY CORP Insurer's City/State/Zip: 1832 SCHUETZ ROAD ST. LOUIS, MO 63146 Policy # or Self -ins. Lic. # LDS4053852 Expiration Date: 4/1/2018 Attach a copy of the workers' compensation policy declaration page (shoving 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. the pains and penaltfete ofperjuiy that the information provided above ins true alid correct. Phone #: 316/685-1622 X3155 ` Official rise only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle ore): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone ACORO® CERTIFICATE OF LIABILITY INSURANCE lk . DATE (MMIDD YYYY) 11/20/2017 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, ANDTHE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL 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 endorsement(s). PRODUCER MCGRIFF, SEIBELS 8 WILLIAMS OF GEORGIA, INC. 5605 Glenridge Drive - Suite 300 NAME: PHONE € FAX _W N_s..:JL404 497-7500 ac No: Atlanta, GA 30342 E-MAIL ADDRESS: INSURER(SI AFFORDING COVERAGE NAIC#_ _ ______ _ INSURER A:Safe!y National Casualty Corporation __ _ 15105 INSURED RMET Holdings, Inc. INSURER B : DBA Gold Coast Holdings INSURER C : Go GC Fridays Boston, LLC 133 Sevilla Avenue INSURER D INSURER E: Coral Gables, FL 33134 INSURER F : COVERAGES CERTIFICATE NUMBER:54UG2QKL 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. LTR TYPE OF INSURANCE AINSD OD n POLICY NUMBER MMIDDY� MMIDDIYYXYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ❑ OCCUR AMACLAIMS-MADE PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ GEN'L POLICY JECPR6T ❑ LOC PRODUCTS - COMP/OP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Par person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per eccideng $ PROPERTY DAMAGE Per acddnnt $ H UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE —TOED RETENTION$ $ I A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPMETORIPARTNERIEXECUTIVE YIN OFFICEMMEMBER EXCLUDED? (Mandatory In NH) NIA LDS4053852 04/01/2017 04/01/2018 X PER STATU OETE H- E.L. EACH ACCIDENT $ 1,000,000 ' E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 Use. describe under DESCRIPTION OF OPERATIONS belae A Liquor Liability GL4053854 04/01/2017 04/01/2018 Aggregate 2,000,000 Each common cause $ 1,000,000 $ $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: TGIF#2750, GC Fridays Boston, LLC, 280 School Street, Suite Al00, Mansfield, MA 02048 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE W ITH THE POLICY PROVISIONS. Town of Mansfield AUTHORIZED REPRESENTATIVE /p 6 Park Row Mansfield, MA 02048 Page 1 of 1 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD \12 � � \ES J 2«a � {\{ � )} [ §(k§ §#2§ so 0 ! ,E \ �CL � \§| ) « } k � k r®e waHaaw 6A40