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Home My WebLink AboutQdoba Restaurant 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:. QDOBA RESTAURANT CORPORATION Whose place of business is: QDOBA MEXICAN EATS #2365 280 SCHOOL STREET PERSON(S) IN CHARGE: AUSTIN SCHLAK, MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-77 BOARD OF HEALTH Michae(MCC(ean, Chairman Milk & Cream 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. QDOBA RESTAURANT CORPORATION having a place of business at: QDOBA MEXICAN EATS #2365 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-77 Board of Health MichaeCMcCCean, 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 77 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name QDOBA MEXICAN EATS #2365 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 9330 BALBOA AVENUE SAN DIEGO, CA 92123 0 , mf 4) Establishment Telephone No (508) 337-2400 5) Applicant Name & Title: KAREN VAN RICKLEY, ACCOUNTING SPECIALIST 6) Applicant Address 9330 BALBOA AVENUE, SAN DIEGO, CA 92123 7) Applicant Telephone No,: (868) 671-2263 24 Hour Emergency No.: (774) 218A964 8) Owners Name & Title QDOBA RESTAURANT CORPORATION 9) Owner Address (If different from applicant) 9330 BALBOA AVENUE, SAN DIEGO, CA 92123 Owner's telephone number SS - 5-1 1-1--(P3 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑I An Association or partner. W1 A Corporation Name Title Address ❑ An Individual Key L) t_C ��au l it{rxus v� 93ao Baltimu q we SQL aic,G9 4su3 ❑ A Partnership M«6tul �n(LQ✓ �R_ls�cr�,�, �3av �1� eA,SmL�Lcfa,c�} 9y(yi ❑ Other Legal Entity-_ —_----_--__-_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: f1 MANAGER n Address: i L{ 44ot lfr/I ac�; A4 !ZbO -D t mA. CQ:ID 3 Telephone No: () ri Zl 9 Zg 24 Hour Emergency No: FAX. E-mail: IQMG365(cDQDOBA.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title ITERRI FRIA DISTRICT MANAGER ItGE� L! I r Address 31 'CIL, /Upw �irry�G% DIQD$7 Telephone No: I(508) 838 8987 3 3 d Koo 24 Hour Emergency No: 0 135- g61 y FAX: E-mailKAREN VANRICKLEY@JACKINTHEBOX.COM Food Establishment Information 14) WATER SOURCE: TOWN 55) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 16 17) DAYS/HOURS: MON SAT: 11 AM - 10 PM SUN: 11:30 AM - 9:30 PM 18) Name of Person In Charge Certified in Food Protection Management: JASONL If more than 3 individuals are certified, complete list is on file. 4£T( /') ! �" 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): C] j 20) Location: [V] Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: ij Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type Retail ( Sq. Ft) i:V:] 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 [—I Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) Caterer $25.00 ❑J 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 23) Food Operations ! Definitions:PHF - Potentially hazardous foodtime/temperature controls required) Non-PHFs - non -potentially hazardous food(no time4emperature controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing) Ll Sale of Commercially Pre -Packaged Non-PHFs L_] Sale of Commercially Pre-PackagedPHFs ] Delivery of Packaged PHFs [_] Reheating of Commercially Processed Foods for Service Within 4 Hours I Customer Self -Service of Non PHF and Non Perishable Foods Only „ ] Preparation of Non-PHFs Other Food Operations [ 1 PHFCooked To Order [/1 Preparation of PHFs For Hot And Cold Holding For Single Meal Service [ Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufa( 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 Animal Origin Offers RTE PHF in BPrepares 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 I _ - Total Permit Fee: $125.00 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 105 CMR 590.000 and the federal Food Code, 24) Signature of Applicant: on?_� L ILr Ili-+-t.�l��l Pursuant to MGL 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 state taxes required under law. 25) Social Security Number or Federal ID: 84-1480725 �� T� 26) Signature of Individual or Corporate Name: LV[ l. u/'ont oo(/ f.1 t IM' Town of Mansfield - Board ofHealth u - wf Application for Milk and Cream Permit Town of Mansfield 6 Park Row Mansfield, MA 02048 I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: QDOBA MEXICAN EATS #2365 ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 337-2400 FAX NUMBER: (508) 337-2477 OWNER OF BUSINESS: QDOBA RESTAURANT CORPORATION TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: 84-1480725 FEE: $10.00 PERMIT NUMBER: FS-77 SIGNATURE: DATE: 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. 0t9 a_ Vt(46t1tr6At- (W Iy tt)Vy� Signature of Individual or Corporate Name <su- tLt?)y-t D- J *"Social Security No. (Voluntary) or Federal Identification Number By: Corp Officex (Mandatory, if Applicable) R- *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. CAUsers\sleite\Desktop\Scotes Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE, PERAUTTING AUTHORITY, Applicant Information Please Print Ledbl Cy Business/Organization Name: Q( �J G I Y (� 1 [ Gt� L (+-c :(+1A3 (P s Address: 2�D 5' Phone#: fig" 33-1-'a-Li0O Are you an employer? Check the appropriate box: Business Type (required): 1. E I am a employer with employees (full and/ 5. ❑ Retail orpart-time).* 6. QRestaurant/Bar/EatingEstablishment 2.0 1 am a sole proprietor or parttrersliip and have no 1. Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' camp, 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 I0. El Manufacturing no employees. [No workers' comp. insurance required]* I I. ❑ 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 infonnadon. **If the corporate officers have cxompLed themselves, but the corporation has other employees, a workers compensation policy is required and such on organization should check box 91. lam an employer that is providrl. rg workerA' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: lq't `'/ 51 City/State/zip: J 6o 0 1 /' doLl Policy # or Self -ins, Lic. #- LULQI (0 q .C> Le�0 0 / Expiration Date: 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 cjarr/�y' under the //Pains(��/and pen//,aldes of perjury that the information provided above is true and correct: .Qionnfirre. oar, - I //.n It, 1i.& hate' 40/a gIn Phone #: 6 59 - 511 - d-,'- Lo 3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Parmit/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 #: Client#: 4A2178 JACK(N1 ,?CORD,,, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYWy) 812912017 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 CONTACT Monica Powell NAME Marsh &McLennan Agency LLC -PHONE Marsh & McLennan Ins. Agency LLC AI4No. Ex0: AIC, No) ADORN Monica.powell@MarshMMA.com --:- Monica.powell@MarshMMA.com PO Box 85638 INSURER(S) AFFORDING COVERAGE --- NAICM San Diego, CA 92122 A; --- INSURER A; ACE American Insurance Company 22667 INSURED INSURER B: ACE Property & Casualty Insuran 20699 Qtloba Restaurant Corporation INSURER C:XL Insurance America, Inc. 24554 c/o Jack in the Box Inc - INSURER D:Indemnity Ins. Co. of North Ame — — --------- 9330 Balboa Ave - ----- INSURER E; San Diego, CA 92123.1524 INSURER I: OUVtKAUtS CERTIFICATE NUMBER: REVISION NUMRFR- 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 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—�ADDLISUBR POLICY EFF POLICY E%P "' --- LTR TYPE OFINSURANCE INSR Me POLICY NUMBER MMIDDIVYYV MMDDM'YY)_ LIMITS A X COMMERCIAL GENERAL LIABILITY CLM AIMS-ADE Xi OCCUR HDOG27871306 D9/0112017 0910112018 EACH OCCURRENCE- S1 000000 PAEMI6ES EeEaNccv Ir ante $1 000 000 X MEDEXP(Anyonepersw) $0 Owner's & Contractor Liquor Liability PERSONAL B ADV INJURY $1000,000 X AGGREGATE LIMIT APPLIES PER. POLICY JECOT ` LOG GENERAL AGGREGATE 52,000,000__ GEN'L X PRODUCTS-COMPIOP AGO $3,000,000 $ OTHER' A AUTOMOBILE LIABILITY CALH09062841 9/01I2017 09/01/201 COMBINED SINGLE LIMIT Ea e«mem $1 r00Q000 X ANY AUTO BODILY INJURY (Per person) 5 X ALL OWNED SCHEDULED AUTOS AUTOS .._ NON -OWNED HIRED AUTOS X AUTOS BODILY INJURY Perauidenl) I _. _ ... PROPERTY DAMAGE Per.< dent $ -_____-—__ S _ S B _._it UMBRELLA LIAB X OCCUR G46807893001 9/01/201709/01/201 EACH OCCURRENCE S1000000 - EXCESS LIAB CLAIMS -MADE AGGREGATE $1,000 000 DED ''" RETENTION$ S A D WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE �YI N OFFICERIMEMBER EXCLUDED? `J NIA WLRC64619081 WLRC64619093 910112017. 09101/201. _-_--_. X IPER OTH- - E.L. EACH ACCIDENT 51000000 E.L. DISEASE - FA EMPLOYEE 51 000,000 (Mandatory ndztory In b.NH) DESS, dP.FCION OF O DESCRIPTION OF OPERATIONS belmv EL DISEASE -POLICY LIMIT $1,0D0,000 C Property US00057839PR17A 9/01/2017 _ _ 09/01/2018Agreed Amount Real & Personal 100% Replacement Cost Property Deductible $750 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be.UaChed If more space Is required) Proof of Insurance Qdoba Restaurant Corporation Attn: Leslie Whittaker, Risk Mgmt. 9330 Balboa Avenue San Diego, CA 92123.1516 ACORD 25 (2014101) 1 of 1 #52944727/M2944471 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD W8JZH Print Page I of 1 Number: COMMONWEALTH OF MASSACHUSETTS Fee: 65200065 TOWN OF MANSFIELD 850oo This Is to certify that Qdoba Restaurant Corporation dba Qdoba Mexican Grill of 260 SCHOOL ST, Mansfield, MA 02048 Any changes to the management of this Ilcense requlres notification within three days to the Board of Selectmen's office and fourteen days to file a new application. IS'HERE13Y GRANTED A COMMON VICTUALLER'S LICENSE in said Mansfield, Massachusetts, and at that place only and expires- 12/3112017 , unless sooner suspended or revoked for violation of the laws of the Commonwealth of Massachusetts respecting the licensing of common victuallers. This license is Issued In conformity With the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In testimony, Whereof, the undersigned have hereto affixed their official signatures. 12/7/2016 Date of Approval Section 8. A common victualler who, upon request, on any day but Sunday, refuses to supply food to a stranger or traveler shall be punished by a fine of not more than fifty. dollars. Section 9. If, in the opinion of the licensing authorities, a licensee as an innholder or a common victualler ceases to be engaged In the business he Is licensed to pursue, or fails to maintain upon his premises the implements or facilities required by this chapter, they shall immediately revoke his license. If a licensee at any time conducts his licensed business in an improper manner, the licensing authorities, after notice to the license. A common victualler who violates section eight shall forfeit his license. '"'A licensee who is convicted a second time of the violation of any of the provisions of sections six to eighteen, inclusive, shall forfeit his license. Section 18. Every innholder and common victualler shall at all times have a board or sign affixed to his house, shop, cellar or store, or in a conspicuous place near the same, with his name legibly inscribed thereon, In large letters and the business for which he is licensed inscribed thereon, and upon neglect thereof shall forfeit twenty dollars. Section 20. Whoever assumes to be an innholder or common victualler without being licensed as such under this chapter shall forfeit one hundred dollars. Section 21. Whoever is convicted a third time of a violation of any provision of the preceding sections, except those contained in sections even and eight, shall, In addition to the penalties before provided, be punished by imprisonment for not more than three months. http://wctr-app2:160001imaginglfacesIPagesIPrintImages.j sp?documentId=4.IPM_5276607... 5/25/2017 9 Y Q q 4 q® :y CO x 0 IN U G \ ; \ ; { / 0 } ® 0 \ § \ o » �41 2