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HomeMy WebLinkAboutWendy'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:. WENDY'S PROPERTIES LLC Whose place of business is: WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE PERSON(S) IN CHARGE: GHANDY RASSAS, GENERAL MANAGER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-96 BOARD OF HEALTH NichaeCNcCCean, Chairman Milk & Cream ❑� Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: WENDY'S PROPERTIES LLC having a place of business at: WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE 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-96 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Manufacture Frozen Desserts anal/or Ice Cream Mix The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made hereunder, hereby issues WENDY'S PROPERTIES LLC #166-2286 64 COPELAND DRIVE a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This license expires December 31 st of each year. License Number: FS-96 Freezers: 5 TOTAL: $125.00 MANSFIELD BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued FS96 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) j1) Establishment Name WENDY'S PROPERTIES LLC #166-2286 2 Establishment Address` ) 64 COPELAND DRIVE 3) Establishment Mailing Address (if different) 1 DAVE THOMAS BLVD. €I?f DUBLIN, OH 43017 4) Establishment Telephone No (608) 339-7284 5) Applicant Name & Title: WENDY'S PROPERTIES LLC #166-2286 6) Applicant Address 64 COPELAND DRIVE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (614) 764.3110 24 Hour Emergency No.: (606( 718-8414 i 8) Owners Name & Title WENDY'S PROPERTIES LLC 9) Owner Address (If different from applicant) 1 DAVE THOMAS BLVD., DUBLIN, OH 43017 Owner's telephone number (614) 764-3100 - 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers L : An Association or partner. I✓ A Corporation Name Title Address ! .] An Individual A Partnership 1_j Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) -- Name & Title: GHANDY RASSAS, GENERAL MANAGER Address: 64 COPELAND DRIVE, MANSFIELD, MA 02048 Telephone No: (508) 339-7284 FAX: (508) 339-3607 (978) 392-121 E-mail: BUSINESSLICENSE(a)WENDYS.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) 1 Name & Title: ! AISSA BADJI, DISTRICT MANAGER 24 Hour Emergency No: (506) 718.8414 Address: 3 CARLISLE ROAD, SUITE 250, WESTFORD, MA 01886 i Telephone No: (614) 756-9584 24 Hour Emergency No: (617) 756-4442 FAX: (978) 392-1212 E-mail: AISSA.BADJI-LO@WENDY'S.COM Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL. TOWN DEP Public Water Supply No: (If applicable) 16) NO of Food Employees: 17) DAYS/HOURS: MON-SUN 10 AM-1 AM 18) Name of Person In Charge Certified in Food Protection Management: GHANDY N. RASSAS 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 CARMEN LOPES VARELA certificate MICHAEL L. GAGNE Lis) Person Trained in Anti -Choking Procedures (If 25 Seats or more): J 20) Location: 'J Permanent Location _ I Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: J Annual ! Seasonal Seasonal Dates: Temporary Temporary Start Date Temporary End Date. Temporary Time: Rain Date: 22) Establishment Type Retail ( Sq. Ft) 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 [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 !i. Tobacco Products $25.00 23) Food Operations Definitions;PHF - Potentially hazardous food(!lme/temperalure controls required) Non-PHFs- non -potentially hazardous foodino time/temperature controls required) i(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 `._ ! Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs r Reheating of Commercially Processed Foods for Service Within 4 Hours L-. Customer Self -Service of Non PHF and Non - Perishable Foods Only f Fe Preparation of Non-PHFs Other Food Operations PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held '�, for More Than a Single Meal Service J Preparation of PHFs For Hot And Cold Holding For Single Meal Service i! PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer !_ Vacuum Packaging / Cook Chill _ ! Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) I Juice Manufactured and Packaged for I] 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 -Dale ---— - __. or Reconditioned Food I To be completed by the Board of Health Total Permit Fee: $126.00 Payment is due with application n 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 gepies q 105 CMR 590.000 and the fe eral -ood Code, ii a/ .1 t 24) Signature of Applicant i Pursuant to MGL Ch. 52C, se . 4 1 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 ` der law. 25) Social Security Number or Federal ID: 47-36611U 26) Signature of Individual or Corporate Name: Town of Mansfield - Board of Health 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: WEN DY'S PROPERTIES LLC #166-2286 ADDRESS: 64 COPELAND DRIVE TELEPHONE AT LOCATION: (508) 339-7284 FAX NUMBER: (508) 339-3607 OWNER OF BUSINESS: WENDY'S PROPERTIES LLC TELEPHONE OF OWNER: (614)764-3100 FEDERAL ID/SS NUMBER: 47-3661188 FEE: $10.00 PERMIT NUMBER: FS-96 A SIGNATURE: DATE: Town of Town of Mansfield - Board of Health 6 Pak Rowansfield Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board of Hcalth at the Town q/'rWanslicht In accordance with the provisions ofsection 05tl q/Chapter 94 q/the General Lanus, as most recently amended,, and the regulations made thereunder, the undersigned herebv applies fry a licensefor a R'HOLES 1LF�R87AIL nranr{fnclure of -oY e-n desserts and ice creonr mix and .subnilt.s the fblloming information: /. Full name of applicant: VVENDY'S PROPERTIES LLC #166-2286 2. Business address 1 DAVE THOMAS BLVD. DUBLIN, OH 43017 3. 1/'applicant is an individual: Fill) name: WENDY'S PROPERTIES LLC #166-2286 Residence: 64 COPELAND DRIVE, MANSFIELD, MA 02048 3u, l(opplicaw is a partnership, jell name andresidence ofall pmtnow: 3h. Ifapplicanl is a corporation: State of incorporation: DE Date of incorporation: _.4/7/2015 Full name and address of: Principal office: 1 DAVE THOMAS BLVD. president SEE ATTACHED (SCH. A) Treasar•er: Clerk 4. Loeationgfplants: MASSACHUSETTS 5. Nomes q/ brands and trade or corporation name, if only, under which the products are to be sold: FROSTY - THE WENDY'S COMPANY 6, Number and capacity q/fi•ce_ers and fires: 5 Fee: ($25.00 per,%i•eezer) $ 125 7, Is the nax purchased',' Yes Uso,,frnm whom purchased:' 8. Is the mix pasteurized.' Yes _ 9. Number gfgallons gf frozen desserts an(Yoi ice cream mLr to be sold in klas'saclnrsetts during the licensing period 5,000 - 10,000 1(1, rVuntber at'gailons of ftozen de.s errs and"or ice cream Mix sold in A tas.suchu,setrc durtug the previous licensing period / 1. Is the plant constructed and equipped as provided in the regulations? Yes - - 12. Is the waler supply public or not' Yes 13, Yes l hereby certify that tine frozen desserts and/or ice cream mfx l sell /n Massachusetts will be manufactured in compliance with all law of the Commonwealth ofMassaschusetts pertaining thereunder and al/ ruler and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be nlanutactured under sanitary conditions. I attest that the lnfortnation stated in this a vlicdnor�ts true andaccurate ndei,�ttre par penalties o(perjury. t (C any owner/gffl er's si"ature) (DATE) r (Title) (City or Town) 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. �ture of In ual 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 IthUaae's Documeots\PERWr APPLICATIONS\TAX CERTMICATION FORM.doc 14 The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 uIrl www tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FH,ED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leaibiy Business/Organization Name: The Wendy's Company Address: One Dave Thomas Blvd City/State/Zip: Dublin, OH 43017 Phone #: (614) 764-3092 Are o,u an employer? Check the appropriate box: Bu ' s Type (required): l i ♦ I I am a employer with 301VM,, employees (full and/ 5. etail 2❑ orpart-time).* 6. es cetrant/ mr/Eating Establishment I am a sole proprietor or partnership and have no 7. ffice and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] I. on -profit 3.❑ We are a corporation and its officers have exercised 9. ntertainment their right of exemption per c. 152, § 1(4), and we have 10 anufacturing 4.❑no employees. [No workers' comp. insurance required]* 11 ealth Care We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 1 ther *Any applicant that checks box #1 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 #1. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: Willis Insurance Services of Georgia, Inc. Insurer's Address: C/O 26 Century Blvd. P.O Box 305191 City/State/zip: Nashville, TN 37230 Policy # or Self -ins. Lic. # WCU C49109118 Expiration Date: 1 /1 /2018 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 cfy, under the pains and enalties perjury that the information provided above is true and correct Signature: ---_�\� Date: 10/13/2017 Phone #. (614) 764- 6� Official use only. Do not write its 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.n�ass.govima Page 1 of 2 A'CO/RQ® CERTIFICATE OF LIABILITY INSURANCE DgTE (M MIOD0YYY) 12/2B/2G1, 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 endorsements . PRODUCER NAMCONTACTE: PHONE FAX 1-688-467-2378 1 o E j._1-877-945-7378 qIC No), _ Willis Insurance Services of Georgia, Inc. c/o 26 Century Blvd P.O. Box 305191 -MAIL certificate.@willis.com ODRESS: INSURERS AFFORDING COVERAGE NAICN Nashville, TN 372305191 USA _ INSURERA: ACE American Insurance Company 22667 INSURED Wendy'... Properties,LLC. INSURERS: ACE Piro Underwriter. Insurance Company 20702 One Dave Thomas Blvd INSURERC: INSURER D: Dublin, OR USA INSURER E INSURER F rnVFRArFS CERTIFICATE NUMBER: W4902267 REVISION NUMBER: 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 R TYPE OF INSURANCE INSDADDL $ D POLICY NUMBER MMIDPOLIDIIYY)Y MM/ DDA'E1'XYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea o¢urtence $ MED EXP(Any one parson) $ PERSONAL B ADV INJURY $ AGGR EGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ GENT POLICY D jECT LOG PRODUCTS-COMPIOP AGO $ S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee accldenl $ _ _ BODILY INJURY (Per person) $ ANY AUTO "— OWNED 60HEDULEO AUTOS ONLY AUTOS e00iLY INJURY (Peraccitlenq $ PROPERTY DAMAGE $ AHIRED UTOS ONLY AUTOS ONLY — UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERIEXEOUTIVE YIN OFFICERIMEMBER EXCLUDED. (Mandatory lnNH) NIA WLR C64625263 Ol/OL/2018 Ol/Ol/2019. X STATUTE ERH E.L. EACH ACCIDENT $ 1, 000, 000 E.L. DISEASE -EA EMPLOYEE --- $ 1, 000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS be. B Workers' Compensation - WI SOP C64625287 01/01/2018 01/01/2019 E.L Each Accident 41,000,000 Per Statute E.L Disease - Ea Empl $1,000,000 E.L Disease - Pol Li $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD101,Additional RemarksSchedule,maybeaaach.difmurespaceisrequiredl Company #286 SEE ATTACHED r PPTIFIr.ATF I-IrH nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE j) 119 Mansfield, MA 02048 V'" ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD sa To: 15458435 sAscs: 553163 WENDY'S PROPERTIES, LLC OFFICER LISTING Name Title Todd A. Penegor President and Chief Executive Officer Gunther Plosch Chief Financial Officer Robert D. Wright Executive Vice President, Chief Operations Officer and International) Scott A. Kriss Senior Vice President — Chief Accounting and Tax Officer Abigail E. Pringle Chief Development Officer (effective 3.14.16) Scott A. Weisberg Chief People Officer Christopher A. Armbruster Vice President —Restaurant Development Leigh A. Burnside Vice President - Finance and Planning Joseph D. Hippler Kris A. Kaffenbarger Shawn H. Karasarides Kyndall J. Potts Gavin P. Waugh Mark X. White Dana Klein #347442 Vice President — Corporate Accounting and Financial Reporting Vice President— System Optimization Vice President — Corporate Counsel Vice President — Compliance and Tax Accounting Vice President and Treasurer Vice President — Engineering Assistant Secretary and interim General Counsel