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Home My WebLink AboutWeight Watchers 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 SNACK 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:. WEIGHT WATCHERS NORTH AMERICA, INC. Whose place of business is: WEIGHT WATCHERS NORTH AMERICA, INC. 321 SCHOOL STREET, BLDG. A, STE. 150 PERSON(S) IN CHARGE: SUZANNE HURLEY Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: S-19 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued S=19 J FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name WEIGHT WATCHERS NORTH AMERICA, INC 2) Establishment Address 321 SCHOOL STREET, BLDG. A, STE. 150 3) Establishment Mailing Address (if different) 300-JE1RIGH"6A0RAidG6"TE. 350 f r' 4) Establishment Telephone No (508) 272-5197 } C 5) Applicant Name & Title: x n 6) Applicant Address 999 STEWART AVENUE, STE. 215, BETHPAGE, NY 11714 _ 7) Applicant Telephone No.: (508) 390-1385 24 Hour Emergency No.: 8) Owners Name & Title WEIGHT WATCHERS NORTH AMERICA, INC. 9) Owner Address (If different from applicant) 999 STEWART AVENUE, STE. 215, BETHPAGE, NY 11714 Owner's telephone number 5163901400 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers Li An Association or partner. tl A Corporation Name Title Address L'' An Individual L' A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in Name & Title: SUZANNE HURLEY Address: supervisor, manager etc.) c� Telephone No: '(508) 272-1407 24 Flour Emergency No: FAX: - E-mail: SUZANNE.M.HURLEY(a)WEIGHTWATCHERS.COM 1 District Or Regional Alt E-Mail: egional Supervisor (if applicable) Name & Title: CHRISTINE HORAN, REGIONAL MANAGER Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: (509) 918-0235 — ( 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: VARIOUS Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Iequired 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) FO) Location: v Permanent Location ! 22) Establishment Type El Caterer $25.00 [111, Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: Annual [.'.. Seasonal Seasonal Dates: -1 Temporary Temporary Start Date: - Retail ( Sq. Ft) 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) E] Milk & Cream $10.00 I I Mobile Food & Consession $75.00 —! Manufacture Frozen Desserts/Ice Cream $25.00/freezer ] Pushcart $25.00 # of Pushcarts: 0 -� Residential Kitchen $100.00 EJ Retail Food $100.00 ij Retail Snack Foo 25.00 ' _. Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous lood(no timeRemper-uture controls required) Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) [', Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs E 1-Delivery of Packaged PHFs i_. Reheating of Commercially Processed Foods for Service Within 4 Hours E_l. Customer Self -Service of Non PHF and Non - Perishable Foods Only i Preparation of Non-PHFs Other Food Operations PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer (-J Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service L I PHF and RTE Foods Prepared For Highly Susceptible Population Facility E_J Vacuum Packaging / Cook Chill - Customer Self -Service LI 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 Retail Sale control) 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 Salve e Out Of -Date -- — - — ----- - - or Reconditioned Food To be completed by the Board of Nealth ----------------_-III Total Permit Fee: $25.00 Payment is due with application E J 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 IF AV� l X I A__A . f: Pursuant to MGL Ch.62C, sec. 49A) I certif(nder"Ihe 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: 52-1656141 26) Signature of Individual or Corporate Name: 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. 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:\Hm1th\f=e's Doem mtAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department oflndusttzal 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 PERMITTING AUTHORITY. Applicant Inform28on PIease Print Ledbly Business/Organization Name: Address: C, c�l Ct t City/State/Zip: Phone #:_ Are you acremployer? Check the appropriate box: 1. ❑` I am a employer with employees (fall and/ or part-time).* 2: ❑ 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 tbeir 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 Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/HatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10, ❑ Manufacturing 11. ❑ Health Care 12.❑ Other � *Any applicant that chee6s box #I 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 91. lam an employer that is providing workers' compensation insurance for my employees. Below i, the policy information. Insurance Insurer's City/State/Zip: Policy # or Self -ins. Lic. # (, k, t`� l Lr �i C� �t Expiration Date: Attach a copy of the workers' compensation policy declaration page (sbovdng the policy number and er piration 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 ofthc DIA for insurance coverage verification. certify, under the pains and penalties ofperjury that the information provided above is true and correct ' A—SSK Date: j i Official use only. Do not write in this area, to be completed by city or town offcciak 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 srCOR®® CERTIFICATE OF LIABILITY INSURANCE v/z9/zols DATEIMM/DO/YYYY) 9T "y"pom 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(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 LOCKTON COMPANIES 500 West Monroe, Suite 3400 CHICAGO IL 60661 (312) 669-6900 CONTACT _ PHONE - FAX C o Eat AIC Net: EMAIL ADDRESS: ' INSURERS AFFORDING COVERAGE NAICp INSURER A: LeXln ton Insurance Company 19437 INSURED Weight Watchers International, Inc. 1357624 675 Avenue of the Americas, 6th Floor INSURER B: National Union Fire Ins Co Pitts. PA 19445 INSURER c:Insurance Company of the State of PA. 19429 INSURER o: New Hampshire Insurance Company 23841 New York NY 10010 INSURER E: ACE American Insurance Company-22667 INSURER F: American Home Assurance Company 19380 COVERAGES CERTIFICATE NUMBER: 14973495 REVISION NUMBER: XXXXXXX 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 CONTRACT OR 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 LTR rypE OF INSURANCE ADOL SUBR POLICY NUMBER MMIDD/Y1'EYVY XP ,POLIO IYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY LJ OCCUR Y Y 6796754 9/29/2017 9/29/2018 EACH OCCURRENCE $ 1000000 DRESESCLAIMS-MADE PMEa occurrence) $ 1,000,000 MED EXP(Any one person) $5000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3000000 POLICY [�:] PROJECT- ❑ LOC X PRODUCTS - COMP/OP AGO $ 1,000,000 $ OTHER: B AUTOMOBILE LIABILITY N N CA7093294 9/29/2017 9/29/2018 COMBINED SINGLE LIMIT Ea accident $ ] QQQ QQQ BODILY INJURY (Per person) 5 XXXXXXX AUTO IANY OWNED SCHEDULED AUTOS ONLYNAUTOS HIRED NON -OWNED X AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) S XXXXXXX PROPERTY DAMAGE Per accident $ XXXXXXX sXXXXXXX UMBRELLA LIAB OCCUR NOTAPPLICABLE EACH OCCURRENCE $ XXXXXXX H AGGREGATE $ XXXXXXX EXCESS LIAB CLAIMS -MADE DELI I RETENTION$ $XXXXXXX C D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA N WC086326427((MA WI) WC086326425(AOSt) 9/29/2017 9/29/2017 9/29/2018 9/29/2018 X STATUTE ER E.L. EACH ACCIDENT $ 1000000 E.L. DISEASE -EA EMPLOYEE S 1,000,000 E L DISEASE -POLICY LIMIT $ 1,000,000 describe under It DESCRIPTION OF OPERATIONS below E Property N N MAU D37412247 005 9/29/2017 9/29/2018 Replacement Cost- subject to terms F WC (CA) WC086326428 9/29/2017 9/29/2018 and conditions of the policy. Plate D WC (FL) WC086326426 9/29/2017 9/29/2018 Glass included DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder and any applicable required parties are named as additional insured as respects to the General Liability in accordance with a written, signed and dated contract. The above referenced insurance is primary and non-contributory in accordance with a written, signed and dated contract. Waiver of subrogation applies in accordance with a written, signed and dated contract where permitted by state law. CERTIFICATE HOLDER CANCELLATION 14973496 Weight Watchers International Attn: Tax Department 999 Stewart Ave, Ste. 215 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ACCORDANCE WITH DATENOTICE WILL BE DELIVERED IN THE POLICY THEREOF, PROVISIONS. Bethpage,NY 11714 AUTHORIZED REPRESENTATIVE _I ACORD 25 (2016/03) @ 1968-2M6 ACORD CORP- ORA-fibN. All rights reserved. The ACORD name and logo are registered marks of ACORD