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HomeMy WebLinkAboutPapa Gino'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:. PAPA GINO'S, INC. Whose place of business is: PAPA GINO'S 280 SCHOOL STREET, BUILDING J-UNIT 335 PERSON(S) IN CHARGE: CYNTHIA COSTA/DAVIS, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-75 BOARD OF HEALTH .MichaeC.MCCCean, Chairman Milk & Cream fJ Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: PAPA GINO'S, INC. having a place of business at: PAPA GINO'S 280 SCHOOL STREET, BUILDING J-UNIT 335 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-75 Board of Health MichaeCblcCCean, 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 FSFS75 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name PAPA GINO'S 2) Establishment Address Y80 SCHOOL STREET, BUILDING J-UNIT 335 3) Establishment Mailing Address (if different) 600 PROVIDENCE HIGHWAY' rt NUV 07 2017 DEDHAM, MA 02026Hi 4) Establishment Telephone No 261-2330 , 5) Applicant Name & Title: KOTUS BROWN, A/P ASSOCIATE 6) Applicant Address 600 PROVIDENCE HIGHWAY, DEDHAM, MA 02026 7) Applicant Telephone No.: (781) 467-1609 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: r 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ��� A ��A . P Wei A Corporation e / / Addre s 7/� ❑ An Individual PA (�y N b S A Partnership / 1� 1\ !F'OVI -iA .. r � A- 24 Hour Emergency No,: (781) 686-4029 (781) 461.1200 4 PAPA GINO'S, INC. 600 PROVIDENCE HIGHWAY, DEDHAM, MA 02026 (781) 461-1200 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CYNTHIA COSTAIDAVIS, GENERAL MANAGER Address: 1280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No (508) 261 2330 24 Hour Emergency No: (781) 686-4029 (781) 461-1200 FAX: i(781) 752 2210 E-mail: KKBROWN@PAPAGINOS.COM Alt E-Mail: GQ t Q %'lu7P✓k/�_•" ({�l— - - _ -- 13) District Or Regional Supervisor (if applicable) Name & Title (TERRY SCHULTZ - DM Address: 1600 PROVIDENCE HIGHWAY, DEDHAM, MA 02026 I - - Telephone No: ',(781) 461-1200 24 Hour Emergency No: (781) 686-4028 FAX: 1 (781) 752-2210 —LE-mail: TS H U LTZ@ PAPAG I N OS. C O M 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) -.`- 16) No. of Food Employees: 20 17) DAYS/HOURS: SUN -SAT 10 AM - 10 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: L Permanent Location Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: FV1 Annual ❑ Seasonal Seasonal Dates: [; Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type ❑ Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $125.00 [ l 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) CYNTHIA L. DAVIS ❑ 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 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs non -potentially hazardous food(no timeRemperature controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) [I Sale of Commercially Pre -Packaged Non-PHFs [J_] PHFCooked To Order [Ji Hot PHF Cooked and Cooled or Hot Held - - - ----re-P-- --- ---- ❑ P Sale of Commercially ackaged 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 -- - ------ ------------ __- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility [Jj Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _....._ ------------ -- ------ V1 Customer Self Service of Non PHF and Non- ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand -._ --- Ill Customer Self -Service Perishable Foods Only -- ---- ------—� Ice Manufactured and Packaged for contact alternative time as a public health ❑ Preparation of Non-PHFs Retail Sale control) Other Food Operations El Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin [�J Offers RTE PHF in Bulk Quantities �Pl Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ 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 ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will compI with 105 CMR 590,000 and all other applicable law. I have been instructed by the board of health on how to gbtai72pies of 105 CMR 590.000 and the federal Food Code, 24) Signature of Applicant: / '%V ti I ) f W 12 Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, and paid state taxes required under law. 25) Social Security Number or Federal ID: 33-0491264 26) Signature of Individual or Corporate Name: -1 all state 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: PAPA GINO'S ADDRESS: 280 SCHOOL STREET, BUILDING J-UNIT 335 TELEPHONE AT LOCATION: (508) 261-2330 FAX NUMBER: (781) 752-2210 OWNER OF BUSINESS: PAPA GINO'S, INC. TELEPHONE OF OWNER: (781) 461-1200 FEDERAL ID/SS NUMBER: 33-0491264 FEE: $10.00 PERMIT NUMBER: FS-75 SIGNATURE: 2✓"� DATE: C r-6 _Ac _..3 u, 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. Signature of Individual or Corporate Name 33 - 0 4 !?- /��, **Social Seen* No. (Voluntary) r Federal Identification Number By: ate 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. W: 11 alWane's Doc=mts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 V 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. APPUcant Information A Pl Business /Organizaa on me:� V 0 Address: . 7— 7/ `% r1 �—' ��t!r� v Are you an employer? heck the appropriate box: 1. & am a employ _�h)_ employees (full and/ 2: Dorpart-tithe).*2totrpastrita-ship I am a sole proand 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 j Phone #: Business Type (required): 5. ❑ Retail 6. Restaurant(Bar/FatingEstablishment 7, ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment loll Manufacturing I I.F1 Health Care 12.❑ Other *Any applicant Nat checks box #1 must also fill out the section below showing their Workers' compensation policy information. **If the corporate of eers have cxemptcd themselves, but the corporation has other employees, a workcrs' compensation pobey is required and such an organization should check box 41. I am an employer that is provi. mg�rvcrkers' come ati, n insur ncefor my employees. Below is t pokey informadoh. Insurance Company Name: M;;eeAq f� J'1111-"J v ravL.' .�',l✓=yT"yyL°I�" "- insurer's Address: /--� .S-/ A UV KAk �1 (�'- f�� �n..e� y-�( City/State/Zip: `& (,j / Yo �/ % / / / O b I / Policy # or Self -ins. Lic. # �/ �✓ Q '` < F� i ` 7" Expiration Date: 1U b %/i�Ik Attach a copy of the workers' compensation policy declaration pade (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 c fy, under the pains and penalties of perjury that the information provided above' true// nd correct11 Phone #• L g/- 4 4 /- f W 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 3 6. Other Contact Person Permit/License City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone SPECBRA-01 MERMY1 .vlKu CERTIFICATE OF LIABILITY INSURANCE DATE YY) 061271'201 O6127/2017 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 pollcy(ies) 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 C TACT Kreuter &Company 1350 Avenue of the Americas PHONE FA INC. No, Ext): 1 (212) 696.3400 jNc, Np):1 (212) 596-3460 18th Floor New York, NY 10019 EDDgIE INSURERS AFFORDING COVERAGE NAICN INSURER A:United States Fire Insurance ComDanV 21113 INSURED INSURER B:PII rim Insurance Company INSURERC:XL Catlin Specialty Brands Holdings, LLC 600 Providence Highway Dedham, MA 02026 INSURER D INSURER E: INSURER F COVERAGES CERT!nrnrc unaec co. - '-""""^"' ^"^""- KCVLTIVN NUMtlER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 TR A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILI Y CLAIMS -MADE ❑X DCCUR ADDL IN SUBR D POLICY NUMBER 543-217454-1 POLICY EFF 06/`3012017 POi IpY E%P 06/30/2018 LIMITS EACH OCCURRENCE s 1,000,000 DAMAGETO apNTIEO se s 1,000,000 MED EXP An one arson s PERSONALBADV INJURY $ 1,000,000 GENERAL AGGREGATE s 10,000,010 GEN'L AGGREGATE LqIMIT APPLIES PER: X POLICY ❑ JEOT LOC PRODUCTS-COMP/OP AGO S 2,000,000 COMBINED SINGLE LIMIT a title s Included S 1,000,000 s B OTHER: AUTOMOBILE LIABILITY ANY AUTO AWNEDVXAUODUUL X OTD ONLY X SOSWNDp CSC-00001002881 06/30/2017 06130/2018 BODILY INJURY Per rcon SMOS aBODILYINUAacGtlenl Per PcEdRtleYm�AGE S EACHOCCURRENCE s S 25,000,000 C A q A X UMORELLA UAB X OCCUR EXCESS LIAB CLAIMS -MADE N/A US00079103LI17A 408-731603.4 543-217454-1 543.217454-1 06/30/2017 06/3012017 06/30/2017 06/30/2017 06/30/2018 O6/30/2018 " O6/30/2098 06/30/2018 AGGREGATE S 26,000,000 DED X RETENTIONS 10,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE YIN WFatla oFndeeMI NH) EXCLUDED? ❑N Ifgs, describe under DESCRIPTION OF OPERATIONS below Liquor Aggregate Liquor Liability X PER a ELITE ETH- S - E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE -EA EMPLOYE S 1,000,000 E.L.DISEASE-POLICY LIMIT Aggregate Common Cause s 1,000,000 2,000,000 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may bo adachod if more space Is required) 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. ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORO AGENCY CUSTOMER ID: SPECBRA•01 MERMYI LOC #: 1 ACORO° L ../ ADDITIONAL REMARKS SCHEDULE Paste 1 of 1 NAMED INSURED 600Providence s Holdins, LLC hway Dedham, MA 0202aNAIC ffAGENCY CODE SEEP 1 EPPEcnvE DATE; SEE PAGE 1 4 nDITIn NInI ocnnn ovc THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liahlllty Insurance The following are included as Additional Named Insured: Specialty Brands Holdings, LLC PGHC Holdings, Inc. Papa Gino's Holdings Corp. Papa Gino's, Inc. Papa Gino's Franchising Corporation Delops, Inc. D'Angelo Sandwich Shops, Inc. Progressive Food, Inc. D'Angelo Franchising Corporation South Point Hospitality, Inc. Project Grill Project Grill II Pap Gino's/D'Angelo Card Services, Inc. D'Angelo Sandwich Shops Advertising Fund, Inc. 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD gRiGGgO 6AHUWItlHES C01"ANIMS PGHC HOLDINGS INC PAPA. GINO'S HOLDINGS CORP PAPA GINO'S INC PAPA GINO'S FRANCM)m CORD D'ANGELO'S SANDWICH SHOPS INC DELOPS INC PROGRESSIVE FOOD INC ANT QFF=gS MARK,DEBLOIS 184.FOREST STREET SHER80RN, MA 01770 PRESIDENT, CHIEF OPERATING OFFICER CORKY WENDLAND 41 FIELDSTONELANE FALMOTTM; ME 04105 CHIEF FINANCIAL OFFICER Papa Gino's Inc. z c- Q O X � w O H Q Y C X X ._ W p� W OC 0.1 w 8 Q ( ) ) 2 /E § ) ) k E ¥ ! /) cel � \ � \ . � o \ �/ § %� �� �ƒ k� )] 4� o Z \ f 2/ $ \j ) E / 0 ; $ ± 2 § 2 3 / § 2 i V z �W* z w w 3q s Qw ^ N E N d W N � r � w eN- R L R V CL W " 0 � Q U � o o W `aA� W V k�yh ti h N lz v M o� O ? W V