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HomeMy WebLinkAboutLL Bean 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:. L.L. BEAN Whose place of business is: L.L. BEAN, INC 280 SCHOOL STREET PERSON(S) IN CHARGE: PEGGY ZARET, MANAGER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RF-11 BOARD OF HEALTH Michaet.McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued RF-11 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name L.L. BEAN, INC 2) Establishment Address 280 SCHOOL STREETNov j 417 3) Establishment Mailing Address (if different) 15 CASCO STREET_____---- FREEPORT, ME 04033 4) Establishment Telephone No 5) Applicant Name & Title: PHYLLIS CYR -- — — -- ------ - -- --- ---- -- — -- 6) Applicant Address 15 CASCO STREET, FREEPORT, ME 04033 7) Applicant Telephone No.: (207) 552-4300 24 Hour Emergency No.: (207) 552-33171503I361-7696 Kann DEVANNEY 8) Owners Name & Title L.L. BEAN 9) Owner Address (If different from applicant) 15 CASCO STREET, FREEPORT, ME 04033 Owner's telephone number 2075522000 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers I_1 An Association or partner. f l A Corporation Name Title Address ❑ An Individual CI A Partnership Other legal Entity _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title FISH, MANAGER Address. 280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone No: 1(888) 552-5547 FAX: j(207) 552-3317 E-mail: n Alt E-Mail: CBOUYEA(ZDLLBEAN COM ' 13) District Or Regional Supervisor (if applicable) 24 Hour Emergency No: (207) 552-3317(603) 361-7696 KIM DEVANNEY Name & Title: ICHRIS DIAGOSTINO OPERATIONS MANAGER _ ___ - - -1- Address: i15 Telephone No: (20 CASCO STREET, FREEPORT, ME 04033 552-2295 24 Hour Emergency No: FAX: ___ I E-mail: N I _ - - 1 ,,01 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 SAT . &-RM SUN 6-.00-A Y-'B PM -- --- -- —_ -Pm -_clpm _.__- IQarn - `p-m— — 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 l 1,9) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: [J Permanent Location ❑ Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: [] Annual ❑ Seasonal Seasonal Dates: ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): 22) Establishment Type EV 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) ❑ Caterer $25.00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 L] Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 [V_I Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Definitions: PHF- Potentially hazardous food (timeltemperature controls required) Non-PHF's - non -potentially hazardous food(no timeAemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) LJ] Sale of Commercially Pre -Packaged Non-PHFs F -.] Sale of Commercially Pre -Packaged PHFs I_ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service 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 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 Oriain Offers RTE PHF in Bulk Quantities _ ❑ 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: $100.00 Payment is due with application ❑ waived I I, the undersigned, attest to the accuracyof the information provided in th' application and affirm that the food establishment operation will comply with CM 0Tol nd all othe�plicable law. I have been instructed by the board of health on how to obtain copie o fQ5 C f 5 a d the f e IF d C 24) Signature of Applicant: ? t.t'j ff /� t- Pursuant to MGL Ch.62C, sec. 49A, I certify un er 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: 01-0026590 26) Signature of Individual or Corporate Name: lam. �., �P1j �'► 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. L.1—dean, Inc. ' - " \ ) 0---S: Signature of Individual 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:\HmIthVane's Doo mentsTERMIT 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 Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNITTTING AUTHORITY. Applicant Information Please Print LedblY Business/Organization Name: L-L.Bean Address: 210 5e-JAW6 S { City/State/Zip: Phone Are you an employer? Check the appropriate box: Business Type (required): 1,jiq.1 am a employer with _ employees (full and/ 5. Retail or part-time).* "' 6. Restaurant/Bar/Eating Establishment 2. EJ I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. 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 10. El manufacturing no employees. [No workers' comp, insurance required]* l 1. [� Health Cue 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 theirworkers' 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 #]. I am an employer that is providing workers' compensation insurance for "my_��employees. Below is the policy information. Insurance Company Name: Maine Fmb �LYiQ/s � �%�j�'n5. 62 . Insurer's Address: 2 iG I (- o mfne,[ I City/State/Zip: Telr4IOrdt Y(V- Qz%/Dl Policy# or Self -ins, Lic. # Jr ( f) j R/S7 q-o Expiration Date: 03 L 4{ 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. f do hereby ofperjury that the information provide] above is true and correct Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License 4 [3 Issuing Authority (circle one): t. Board of Health 2. Building Department 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office 6. Other Contact Person Pb on a #: ACORO® CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDM'YY) 03/13/2017 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 policy(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 Ann Risk Services Northeast, Inc. Boston MA Office CONTACT NAME: (aCNNu.Ext): FAX (866) 283-7122 Me Na; (800) 363-0105 One Federal Street Boston MA 02110 USA E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC q INSURED INSURERA: Men1ic Indemnity Company 11030 L.L. Bean Inc. 15 Casco street INSURER B: Maine Employers' Mutual Ins Co 11149 INSURER C: Freeport ME 04033 USA INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570065740605 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. Limits shown are as requested S LTR TYPE OF INSURANCE IDDL SUB POLIGYNUMBER MMIDDA^/F Y EXP POLIO YWY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS MADE ❑ OCCUR PREMISES Ea occurrence MED EXP(Any one person) PERSONAL 8 ADV INJURY GENIAGGREGATE LIMITAPPLIES PER GENERAL AGGREGATE POLICY ❑PET �LOC PRODUCTS- COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acchlenl BODILY INJURY (Per person) ANYAUTO BODILY INJURY (Per acdden) OWNED SCHEDULED AUTOS ONLY AUTOS HIREDAUTOS NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE fpm.cadarb UMBRELLALIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAR CLAIMS -MADE DED I RETENTION e A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR I PARTNER I EXECUTIVE YIN OFFICERAIEMBEft EXCLVOEDi (Mandatory in NH) NIA 5101800821 MaStEr 3102801302 CO,DE,K5,MI,MN,RI,WI 03 01 2017 D3/01/2017 03 01 2018 ' 03/01/2018 X PER STATUTE OTH- E.L. EACH ACCIDENT $1,000,000 E,DISEASE-EA EMPLOYEE $1,000,000 It re deambe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addillonal Remarks Schedule, may be anached If more space Is required) Evidence of Insurance. CERTIFICATE HOLDER 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. L.L. Bean Inc. AUTHORIZED REPRESENTATIVE 15 Casco Street Freeport ME 04033 USA Wass ✓LKVE e/eGLueb10 c/Y �n0. ©1908.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD