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HomeMy WebLinkAboutVillage at Willow Crossing 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: FOODSERVICE 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:. BENCHMARK SENIOR LIVING Whose place of business is: VILLAGE AT WILLOW CROSSINGS 25 COBB STREET PERSON(S) 1N CHARGE: ANNE DEMINICO, EXECUTIVE DIRECTOR Permit Expires: December31, 2018 Food Fee: $125.00 License Number: FS-95 BOARD OF HEALTH .MichaeC.McCCean, Chairman Milk & Cream❑ Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: BENCHMARK SENIOR LIVING having a place of business at VILLAGE AT WILLOW CROSSINGS 25 COBB STREET 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-95 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred �l FOR BOARD OF HEALTH USE ONLY Permit# Issued FS 95 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name VILLAGE AT WILLOW CROSSINGS 2) Establishment Address 25 COBB STREET b 3) Establishment Mailing Address (if different) 25 COBB STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 261-1333 x203 5) Applicant Name & Title: ANNE DEMINICO, EXECUTIVE DIRECTOR 6) Applicant Address 25 COBB STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (339) 222-8479 24 Hour Emergency No.: (608) 261-1333 8) Owners Name & Title BENCHMARK SENIOR LIVING 9) Owner Address (If different from applicant) 201 JONES ROAD WEST, 3RD FLOOR, WALTHAM, MA 02451 Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name title, and home address of officers An Association or partner. A Corporation Name Title Address ::An Individual ./I A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'ANNE DEMINICO, EXECUTIVE DIRECTOR Address: 25 COBB STREET, MANSFIELD MA 02048 Telephone No (508) 261-1333 X203 24 Hour Emergency No: (508) 261.1333 FAX: (508) 337-4663 (781) 489-721 1, E-mail: ADEMINICO(a)BENCHMARKQUALITY.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SUN 6 AM-8 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 130 18) Name of Person In Charge Certified in Food Protection Management: FLORENCE A. BOTTI 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). L__ �20) Location: , j Permanent Location 1, 22) Establishment Type ❑ Mobile Mobile Start Date: 1 r- Retail ( Sq. Ft) Mobile End Date: Mobile Comments: 21) Length of Permit: [] Annual j , Seasonal Seasonal Dates: [_', Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): J' 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) ❑ Caterer $25.00 IV] Milk & Cream $10.00 I_] Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer [j Pushcart $25.00 # of Pushcarts: 0 [� Residential Kitchen $100.00 L ] Retail Food $100.00 ❑ Retail Snack Food $25.00 Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (timeRempenuine controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ['':. Sale of Commercially Pre -Packaged Non-PHFs FJ; PHFCooked To Order !-Sale of Commercially Pre Packaged PHFs ,J Preparation of PHFs For Hot And [ Delivery of Packaged PHFs Cold Holding For Single Meal Service [; Reheating of Commercially Sale of Raw Animal Foods Intended �', to be Prepared by Consumer Processed Foods for Service Within 4 Hours 'd; Customer Self -Service of Non PHF and Non- Customer Self -Service Perishable Foods Only - -- - L] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service W 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 .Ice Manufactured and Packaged for contact alternative, time as a public health [JI Preparation of Non-PHFs Retail Sale control) Other Food Operations Juice Manufactured and Packaged for I Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities LJI 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: $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 11-other applicable law. I have been instructed by the board of health on how to obtain copie 105 C R 59//0.00 n he federalFood �.Code. 24) Signature of Applicant: Ao 'l �'1.� � 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: 27-4452440�r (-,: 26) Signature of Individual or Corporate Name: U- G,) 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: VILLAGE AT WILLOW CROSSINGS ADDRESS: 25 COBB STREET TELEPHONE AT LOCATION: (508) 261-1333 x203 FAX NUMBER: OWNER OF BUSINESS: TELEPHONE OF OWNER: (508) 337-4663 BENCHMARK SENIOR LIVING FEDERAL ID/SS NUMBER: 27-4452440 FEE: $10.00 PERMIT NUMBER: FS-95 SIGNATURE: DATE:'J/` 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 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate 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. R:\He IthUa ds Docu Dats\PERMPr APPLICATIONS\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 fnsurance Affidavit: eneral Businesses. TO BE FILED Wl fll TILE PERNIFITING l'TIIORITY. Business/Organization Are on an employer? Check the a p'opriate box: 1'. 1 am a employer with_7memployces (full and/ of part-time'),* 2.0 1 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.] Any applicant that checks. beoz Hr musndso fill out the section below showing. 'lithe corporate officers have egempred themselves, but the Corporation has at Phone Business Type (required): 5. Q Retail 6. E] Restaurant/Bar/Eating Establishment 7. [( Office and!or Sales line]. real estate, auto, etc.) 8, [] Non-profit 9. ❑ Entertainment 10:El Manufacturing 11.0 Health Care 12.t�Other &f70' It V1/1l') �✓�172U�1i employees, a- vorkcrs' coinpeasation policy is required and such an I ant an employer that is providing workers' compensation insurIcefor my employees, Below is file policy latbrmmaom, Insurance Company Name: Nan—_1?Sy{'a{i'o Insurer's Address:_ Jb 6QS'Jf 770 City/State/Lip: PO U/ M /Q 5SI Q If Policy N orSelf-Ins. Lie. # 4 f WC1 `t l 4 1 [ Q3 Expiration Date:_�iratio,!dat), Attach a copy of tine workers' compensation policy declaration page (showing the policy numberand c 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 aSTOP WORK ORDER and a fine of tip 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 that the Official itse only. Do trot write in this area, to be completed by city or town official, City or Town: Permit/License f f, above is true issuing Authority (circle one): 1. Board of Flealth 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone BENCASS-02 D NE DATEIMMIDDYYYY) 3t3it2017 CERTIFICATE OF LIABILITY INSURANCE 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 poiicy(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 Ileu of such endorsements). PRODUCER 5R&OT Willis Towers Watson Certificate Center Willis of Illinois Inc, c/o 26 Century §Ivd P.O. Box 306191 PHONE"v FAX (AID, No, Est): (877) 945.7378 IAIc, Nor(888) 467.2378 AI .certlf(cates@willisscom� Nashville, TN 37230-5191 _ INSURERS AFFORDING COVERAGE NAIL If INSURERA:Arch Insurance.Company 11150 INSURED INSURER B:Lloyd's B7874 INSURERC: Benchmark Senior Living LLC 201 Jones Road, Suite 300 West Waltham, MA 02451 INSURER D: u INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELOW 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 SY 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. INSii rypE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY CLAIMS•MADE OCCUR IMAGE TPRE 1.5EaORENTED —�—" $ MEOEXP An one rson $ PERSONAL & ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY❑PECT �LOC GENERAL AGGREGATE S PRODUCTS. COMP/OP AGG S 5 OTHER: A AUTOMOBILE X LIABILITY ANY AUTO AUgT�O�S ONLYHXAUUToTNOOSoywUyLNNEDpp AUTOS pNLYAVTOS ON0LV C011 Detl 51,000 Comp Detl $1,000 ffCA134987704 0410112017 04/0112018 COMDINED SINGLE LIMIT oWdallil 5 1,000,000 BODILY INJURY Per arson 5 BODILY INJURY Par earldom $ F&k` � Ill AMAGE S X _....... S B UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE SB-LTCAX-01413-17 04101/2017 04/01/2018 EACH OCCURRENCE S 20,000,000 X X AGGREGATE 5 20,000,600 DEO I I RETENTIONS 5 A WORKERS COMPENSATION AND EMPLOYERs'UAMIDTY ANYPROqMeEMTppO�RgIPACTNERIELUDED? ECUTIVE Y� PMaadAr."MR NH) II yes, desulbo antler DESCRIPTION OF OPERATION below NIA 1WC)4987904 0410112017 D4101I2018 X PER OTti• E.L. EACH ACCIDENT 5 1,060,660 E.L. DISEASE• EA EMPLOYE S 1,000,000 E.L. DISEASE -POLICY LIMIT S 1,000,660 A Business Auto 1CA64987804 04/01/2017 04/0112D16 Any AutolCSL 1,000,000 DESCRIPTION OFOPERA71ONSI LOCATIONS/ VEHICLES ACORD101 AddlImmil Remarks Schedule, may be attached lfmom space la required) Included as an additional Named Insured: B-X Csfield LLC Re: The Village at Willow Crossings .25 Cobb Street, Mansfield, MA 02048 Evidence of Insurance Town of Mansfield - Board of Health 6 Park Row 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 ORIIZED REM r 1 ti Auumij LD (ZUTema) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD wr 3 k S oAo rv'n o ehc qV rc$ EO ggE �02 �z voo man s°a \\ \\ f\ \�x\ \\ S »\ «o j± a . �