HomeMy WebLinkAboutCapriotti's 12/31/2018 (2)Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: CATERING 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:.
SEAN OLSON, PRESIDENT
Whose place of business is:
OLSON RESTAURANT GROUP MANSFIELD DBA CAPRIOTTI'S
321A SCHOOL STREET #140
PERSON(S) IN CHARGE:
JOHN JULIO, MANAGER
Permit Expires: December 31, 2018
Food Fee: $25.00
License Number: C-1
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued C=1
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name OLSON RESTAURANT GROUP MANSFIELD DBA CAPRIOTTI'S'
2) Establishment Address 321A SCHOOL STREET #140
h�
3) Establishment Mailing Address (if different) 163-M,MN-STRCT-#2
M MA-02053-
4) Establishment Telephone No (508) 339-0522
5) Applicant Name & Title: SEAN OLSON, PRESIDENT
6) Applicant Address 6 GOLDENROD DRIVE, MEDWAY, MA 02053
-) _--_— 606 ----
7 Applicant Telephone No.: ( ) 533-3030 24 Hour Emergency No.: (781) 963-2687 SEAN
8) Owners Name & Title TSEAN OLSON, PRESIDENT
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
11 An Association or partner.
A Corporation Name Title Address
❑ An Individual < g
❑ A Partnership
��� nttio. io..�i G.,rir" t i t-. -:il._ CI_ i GCtt,i.l .t C <C: S 7
6 GOLDENROD DRIVE, MEDWAY, MA 02053
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title iMA�TT+fEW-GOUG14LiN; MANAGER
Address:
1163-MAIN-STRE-ET#2; MEDWI
Telephone Na(508)
533-3030
FAX:
(508) 533-3010
E-mail.
NICa4A@0tSONR6-C-OM-
Alt E-Mail:
JROBYNE(a)FIVEOLSONS.CON
13) District Or Regional Supervisor (if applicable)
Name & Title:
01
,_02053,- C, C Q �) 3
24 Hour Emergency No: (781) 953-2687 SEAN
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: MON-SUN 11:00 AM - 10:00 PM
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 10
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
�9) Person Trained in Anti -Choking Procedures (If 25 Seats or more)
20) Location: F/ Permanent Location 22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date:
Moblie Comments:
21) Length of Permit:
❑J Annual
LJ 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 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
❑ Food Service - Institution
( Meals/Day)
MAFT-HE*-GOUG t`W
LL Caterer $25.00
❑ Milk & Cream $10.00
❑ 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 (limeltemperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ Sale of Commercially Pr e-Packaged PHFs
❑ Delivery of Packaged PHFs
[J 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
F] PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
to be Prepared by Consumer
Customer Self -Service
Retail Sale
[_] 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
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale I Animal Origin
Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food ribbe completed by the Board of Health
Total Permit Fee: $25.00
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 of 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MOIL 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 stale taxes required under law.
25) Social Security Number or Federal ID: 46-1566737"
26) Signature of Individual or Corporate Name: -
The Commonwealth of Massachusetts
r' Department of Industrial Accidents
�R�-_�
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:
City/State/Zip`a `,t,,o�_� t
r
Are you an employer? Check the appropriate box:
Business Type (required):
I. ❑'l am a employer with _s= employees (full and/
5. ❑ Retail
or part-time).*
6. ❑-R stauranUBar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (me]. 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]*
I I.❑ Health Care
4. ❑ We area non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. [No workers' comp, insurance req.]
*Any applicant that checks box 91 must also fill 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 N.
l am an employer that is providing workers' compensation irtstu•ance for my employees. below is the policy information.
Insurance Company Name:
Insurer's Address: L-AJ
City/State/Zip: l - 1 (I_L_( —
c
Policy # or Self -ins. Lic. k Expiration Date: ➢ t t i -t 4, \
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.
1 do hereby certify, under the pains and penalties of perjury 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 5. Selectmen's Office
6. Other
Contact Person: Phone
w�vw.mass.gov/dia
CERTIFICATE OF LIABILir, INSURANCE 1 DA'S
11/zD/zo17
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CC NFERS 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 COh TRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder ITEM ADDITIONAL INSURED, the policy((es must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an andolseme It, A statement on this certificate does not confor rights to the
enrffffeab Hnlelm in H... of c..nl.....w..�.__..u..
PRODUCER
Eastern Insurance Group LLC
233 West Central St
(800)
Cora
Natick MA 01760 INSURJERAACadia Insurance Company 31325^
INSURED
INSURER B: Pechnol0 Insurance CO
Olson Restaurant Group Foxboro, LLC INSURER C:
840 Main Street INSURERD:
Suite 203
INSURER E :
Millis MA 02054 ............
UUVCKAl CFRTI9irATFMIIAAnCn•10.1R TA.M414a--. I — .......�__
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IE
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RED
9 GR.
SUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
JCED BY PAID CLAIMS.
PER
TYPEOFINSURANCE
A DLSUBR
POLICY IN ER
PO
ICY EFF
LADY EXP
LIMITS
A
R
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE ® OCCUR
EACH OURRENCE
CC
$ 2,000, 000
OAMAGET RENTEDnce
$ 300,000
MEDEXP(An onepsre0n)
$ 10,000
X
ADV3281986
31/
1/2017
11/21/2018
PERSONAL &ADV INJURY
$ 2,000,000
AGGREGATE LIMIT APPLIES PER
POLICY ❑ JECT ❑ LOC
GENERAL AGGREGATE
$ 4,000,000
GEML
X
PRODUCTS -COMPNP AGO
$ 4,000,000
OTHER:
Employee Senafils
$ 2,000,000
AUTOMOBILE
LUIBIUTY
COMIN
E aaltlx0it I
S
BODILY INJURY(Perpereon)
$
ANY AUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS(Peracccil
"'------
BODILY INJURY(Peracodatil
$
PROPERTY DAMAGE
E
X
UMBRELLAUAB
R
OCCUR
EACH OCCURRENCE
$ 5,000,000
A
EXCESS UAB
CLAIMS41ADE
AGGREGATE
$ 5,000,000
DED
RETENTIONS
$
CLW281967
11/
1/2017
11/21/2018
B
WORKERS COMPENSATION
ANDEMPLOYERS-IJABIUTY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUOEDI ®
(Mencarory In Nel
If yyes describe under
OMRIPTION OF OPERATIONS bel
NIA
TNO366135T
11/
9/201T
r11/19/2018.'EL.
y` STATUTE ER
E.L. EACH ACCIDENT
$ 500,000
DISEASE EMPLOYE
S 500,000
E.L DISEASE - POLICY LIMIT
$ 500 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sell may be an
Deli Restaurant
Chad If more apace is requima)
LOCATION: 321A SCHOOL STREET, MANSFIELD MA 02048
MANSFIELD COUNTRY SQUARE LLC ARE INCLUDED AS AN ADDITIONAL INSURED
WITH REGARDS TO GENERAL LIABILITY WHEN
REQUIRED BY WRITTEN CONTRACT OR AGREEMENT.
MANSFIELD COUNTRY SQUARE. LLC
C/O SAM PARK .AND COMPANY LLC
333 SCHOOL STREET #200
MANSFIELD, MA 02048
SHOULD #NY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EX ]RATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORD NCE WITH THE POLICY PROVISIONS.
DCOLLE f
91908-2014 ACORD CORPORATION. All
ACORD 25 (2014101) The ACORD name and logo are register 1 marks of ACORD
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ChokelSaavvee Participant
Has pleted a 0-e/save class for
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Beth D. Olesan
AHA Instructor Trainer 508.758-3188
American Sately Health Institute Iasi, bduleso508-7 ai-318 ill-�— I�
Issue Dat' a —�-Q—_
ExpnaUon Date