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Home My WebLink AboutGeneral Nutrition Center 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: RETAIL 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:, GENERAL NUTRITION CORPORATION Whose place of business is: GENERAL NUTRITION CENTER #8844 280 SCHOOL STREET PERSON(S) IN CHARGE: J. RINN, MANAGER Permit Expires: December31, 2018 Food Fee: $100.00 License Number: RF-8 BOARD OF HEALTH Michae(McCCean, Chairman -- �- FOR BOARD OF HEALTH USE ONLY Permit # Issued RF 8 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name GENERAL NUTRITION CENTER #8844 i 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (if different) 300 SIXTH AVENUE, RETAIL PITTSBURGH, PA 15222 4) Establishment Telephone No (508) 261-8707 5) Applicant Name & Title: ROSEANNE FABINA, SR. TAX ADMINISTRATOR 6) Applicant Address 300 SIXTH AVENUE, PITTSBURGH, PA 16222 7) Applicant Telephone No.: (412) 288-4662 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: _] An Association ICI A Corporation (.__i An Individual L', A Partnership 24 Hour Emergency No.: (877) 840-1719 GENERAL NUTRITION CORPORATION 300 SIXTH AVENUE, PITTSBURGH, PA 16222 4122884662 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: J-S607f_MANAGER Address: 1280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No: i p 1(508) 261-8707 24 Hour Emergency No: (877) 840-1719 FAX (412) 338 8878 E-mail: 700110(a�GNC-RETAIL.COM Alt E-Mail N E-FABI NA(aDGNC-HQ.COM 13) District Or Regional Supervisor (if applicable) Name &Title: JEFF PEREIRA, MANAGER i Address: Telephone No: i(508) 415-6247 24 Hour Emergency No: (877) 840-1719 700110@GNC RETAIL COM FAX: I (412) 338-8878 Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SAT 10 AM-9 PM SUN 11 AM-5 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 2-4 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 Seals or more) ❑ 20) Location: ❑d Permanent Location Mobile Mobile Start Date: Moblie End Date: Mobile Comments: 21) Lengtn of Hermit: ] Annual Seasonal i Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Establishment Type [i Retail ( 1,280 Sq. Ft) [] Food Service up to 100 or up to 10' PHF display $125.00 [ f 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 ❑ Milk & Cream $10.00 1-1 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 Il Retail Food $100.00 1 1 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 time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ez sandwiches, salads, muffins which need no further processing) ❑Ji Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order [] Hot PHF Cooked and Cooled or Hot Held ------- --------- -- - - ] ] Sale of Commercially Pre -Packaged 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 ❑ Reheating of Commercially - to be Prepared by Consumer Packaging-i - _-- -_-- ❑Vacuum /Cook Chill Processed Foods for Service Within 4 Hours [ ] Customer Self -Service of Non PHFand Non- - -- [, Customer Self -Service [_� Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only -- ❑Ice Manufactured and Packaged for contact alternative, time as a public health [_1 Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities _ I ❑Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $100.00 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 therfedefel Food Code. 24) Signature of Applicant: _�`-�L�- Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of erjurythat 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: 25-1124574 ��>�-�.�%f't 26) Signature of Individual or Corporate Name: �=fiCti �--t`- TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. 6� AL 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:\HmIthUane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc F4. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: GENERAL NUTRITION CORPORATION Address: 300 SIXTH AVE City/State/Zip: PITTSBURGH, PA 15222 Phone #: (412) 288-4662 Areluam an employer? Check the appropriate box: Busine Type (required): 1. a employer with 3 employees (full and/ 5. Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑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 #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 1sproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: SENTRY CASUALTY COMPANY (WILLIS OF PENNSYLVANIA, INC.) Insurer's Address: C/O 26 CENTURY BLVD; P.O. BOX 305191 City/State/Zip: NASHVILLE, TN 37230-5191 Policy # or Self -ins. Lic. # 90-05341-02 Expiration Date: 1/31/2018 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 certify, under the pains and nenaides' ofperjury that the information provide/d above is true and correct Signature: �� }i J A._��Za,C Date: (412)288-4662 Official use only. Do not write in 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 www.mass.gov/dia Phone AC" 01 CERTIFICATE OF LIABILITY INSURANCE ATE DDIYYYYL 0l/2]/201] O01/2 /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(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 lieu of such endorsement(s). PRODUCER Willis of Pennsylvania, Too. CONTACT NAME: c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA PHONE FA% 0 No Ext: i-87]-945-7378 AIC No: 1-088-967-23]B E-MAIL ADDRESS: certificates@w_llia.core INSURERS AFFORDING COVERAGE NAIGN INSURER A: Sentry Insurance a Mutual Company 24988 INSURED GNC Corporation INSURERS: Sentry Casualty Company 28460 300 6th Avenue, llth Floor Pittsburgh, PA 15222 INSURER C: INSURERD : INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W1943752 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 LTR TYPE OF INSURANCE ADDLSUBR POLICYNUMBER POLICY FEE flMMflDD1YYYYI POLIOYEXP (MMIDDNYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGETORENTED PREMISES its occmance $ MED EXP (Any one person) IS PERSONAL &ADV INJURY $ AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ GEHL PCHOY � PRJECT 0. � u LOC PRODUCTS - COMPIOP AGO _ $ $ OTHER: AUTOMOBILE LIABILITY OMBI tleD SINGLE LIMIT $ 2,000,000 BODILY INJURY(Pe,marsn) $ X ANYAUTO A OWNED SCHEDULED ALL ONLY AUTOS 90-05341-03 01/31/2017 01/31/2018 BODILY INJURY (Par ecciden) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (P0 acddmd S $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGAT_E____ $ EXCESS HAS i CLAIMS -MADE DED I I RETENTION $ S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOMPARTNERMXECUTIVE OFFICERIMEMBER EXCLUDED] No (Mandatory in NH) NIA 90-05341-01 01/31/2017. 01/31/2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1, 000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 B Workers Compensation 90-05341-02 01/31/2017 01/31/2018 E.L. Each Accident $1,000,000 and Employers' Liability E.L. Disease -EA Emp. $1,000,000 Pei Statute E.L, Disease -Policy 1$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES LAGGED 101, Additional Remarks Schedule, may be attached If more space is required) Evidence of Coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ONE Corporation AUTHORIZED REPRESENTATIVE 300 6th Avenue t� 11th Floor Pittsburgh, PA 15222 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD in, za: 13989389 axxce: eateh p: 201421 GENERAL NUTRITION CORPORATION 300 Sixth Avenue Pittsburgh, PA 15222 10/29/03 - PA TAX IDENTIFICATION NO. 25-1124574 (412) 288-4662 Ken Martindale, CEO 300 Sixth Avenue Pittsburgh, PA 15222 Tricia Tolivar, Executive Vice President & CFO 300 Sixth Avenue Pittsburgh, PA 15222 Michael C. Smith, Vice President 300 Sixth Avenue Pittsburgh, PA 15222 Gavin M. O'Connor, Secretary 300 Sixth Avenue Pittsburgh, PA 15222 David J. Sullivan, Assistant Secretary 300 Sixth Avenue Pittsburgh, PA 15222