The URL can be used to link to this page

Home My WebLink AboutOmaha Steaks 12/31/2018Commonwealth 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: RETAIL FOOD 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:. OS SALESCO, INC. Whose place of business is: OMAHA STEAKS 280 SCHOOL STREET, #D150 PERSON(S) IN CHARGE: DAN OPPENHEIMER, STORE MANAGER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RF-14 BOARD OF HEALTH 'blichaet .McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued RF-14 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address OMAHA STEAKS 280 SCHOOL STREET, #D150 3) Establishment Mailing Address (if different) 11030 "O" STREET ATTENTION: COMPLIANCE DEPT. OMAHA, NE 68137 4) Establishment Telephone No (508) 261-8783 j 5) Applicant Name & Title: MARIE ASHBRIDGE, CORPORATE COMPLIANCE ANALYST 6) Applicant Address 11030 O" STREET, OMAHA, NE 68137 7) Applicant Telephone No.: (402) 597-8221 24 Hour Emergency No.: (401) 935-3009 8) Owners Name & Title OS SALESCO, INC. 9) Owner Address (If different from applicant) Owner's telephone number 11030 "O" STREET, OMAHA, NE 68137 4026978160 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers Ll An Association or partner. LI A Corporation Name Title Address ❑ An Individual ❑ A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title !DAN OPPENHEIMER, STORE MANAGER Address: Telephone No: FAX: E-mail: Alt E-Mail: SCHOOL STREET, #D150, MANSFIELD, MA 02048 261-8783 08)261-8785 24 Hour Emergency No: (401) 935-3009 13) District Or Regional Supervisor (if applicable) Name & Title: IBRIAN KALBERER Address: 111030 "O" STREET, OMAHA, NE 68137 Telephone No 24 Hour Emergency No: (609) 220-7964 -- _ g Y rE- il' BRIANK@omahasteaks.com -- '— - 11 FAX' '{781-)239 4902I Food Establishment Information 14) WATER SOURCE TOWN �15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: ,8- 17) DAYS/HOURS: MON-SAT 10 AM-8 PM SUN 10 AM-6 PM 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: [] Permanent Location [--I Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: (rii Annual ] Seasonal Seasonal Dates: ❑ Temporary -_-- --- Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type l.X Retail ( 923 Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $126.00 [_ ! 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) ❑ 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 ❑J Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (time/femperature controls required) Non PHFs non potentially hazardous food(no timeltemperature controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex sandwiches, salads, muffins which need no further processing) [] Sale of Commercially Pre Packaged Non-PHFs ] ] PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held --- ---- ----- ----- [] Sale of Commercially Pre -Packaged PHFs - ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service -� ---- ------------- Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly -- -- --_-- E J Sale of Raw Animal Foods Intended Susceptible Population Facility _] Reheating of Commercially to be Prepared by Consumer ❑Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours - -- -----_ ----, ---- [- Customer Self -Service of Non PHF and Non- ___ -- -- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ,J Ice Manufactured and Packaged for contact alternative, time as a public health ❑ Preparation of Non-PHFs Retail Sale _._ control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ 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 -Date I __ _ __ or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $100.00 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 dcopies of 105 CMR 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 filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 47-0805669 26) Signature of Individual or Corporate Name: 0'ate r , tr-c_ 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. -'� ��1r_<(c;r ?e-•tire_.. f. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *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:\HmIth\lane's Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of InduEtialAccidents I 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 Le> bly Business/Organization Name: Address: lit'33C "C ,4yee t City/State/Zip; C 1� r L N - G.f -t3 Phone #: Are you an employer? Check the appropriate box: Business Type (required): I. ® I am a employer with IE; employees (full and/ S. ❑ Retail or part-time).* 6. Restaurant/BadEatingEstablishment 2. E1 i am a sole proprietor or partnership and have no 7, Q Office and/or Sales (inel. 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 # I must also fill out the section below showing their workers' compensation policy information. °�If the eoryorate ofScers have exempted tknaulycs, but the corporation has other employees, a workers' compensation policy is required and such a a organization should check box M. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy informatioir. Insurance Company Name: i-.,bD,v 14 1�u4- —t 1n �, ,.k -,,- (. - Insurer's Address: t"IS C))Cr City/State/Zip: t''xu;-1r:� Policy # or Self -ins, Lic. #. - L'-i E 1 L4 t Sc= ( - (-'Z- t Expiration Date: '� I ` ` k 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, under the pains and penaties of perjury thatthe information provided above is true and correct. Signature: i -: lC�n..=i�F �(3�.�c}, <.� Date: lot 2✓-E- 7'i 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 #: www.rmasx.guvima WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Libe►•ty Mutual. NSURANCE INFORMATION PAGE 175 Berkeley Street Boston, MA 02116 Issued byl-iberty Mutual Fire Insurance Company(a stock company) 16586 Policy Number WA2-64D-444507-077 Issuing Office Lewiston, ME Renewal Of WA2-64D-444507-076 Issue Date 06/29/2017 Account Number 4-444507 1. Insured and Mailing Address Omaha Steaks International, Inc. 11030 O Street OMAHA NE 66137 Sub Account 0000 FEIN 44-0652560 NJ TIN 440652560000 Risk ID 917128308 MI Risk ID 0701300A Status Corporation Other workplaces not shown above:See Item 4. Premium - Extension of Information Page 2. Policy Period: The policy period is from 07/01/2017 to 07/01/2018`12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: AZ CA CO CT FL GA IL IN KS KY MD MA MI MN MS MO NE NV NJ NY NC OK PA RI TN TX VA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A and the States of: ND OH WA WY D. This policy includes these endorsements and schedules:See Item 3. Coverage D - Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans, All information required below is subject to verification and change by audit. Classifications Code Premium Basis Total Rate per $100 Estimated Annual Number Estimated Annual Remuneration of Remuneration Premium _ See Extension of Information Page Minimum Premium $1,500 (GA) _ Total Estimated Annual Premium $ 316,562 Premium will be billed Annual Deposit Premium $ 316,562 Deposit Tax/Surcharge/Assessment $ 5.857 Producer 0002 007662 ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC 10050 REGENCY CIR STE 300 OMAHA NE 681143721 Producer MATTHEWS 8926 Chicago, IL -Nat Countersigned by Authorized Rep. (FL) WC 00 00 01 A ®1967 National Council on Compensation Insurance, Inc. WC 0D 00 01 8 (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1