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HomeMy WebLinkAboutKohl's 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:. GEORGE TERRIEN/PROP MANAGER - INS DEVELOPMENT Whose place of business is: KOHL'S DEPARTMENT STORES, INC. #767 280 K SCHOOL STREET PERSON(S) IN CHARGE: NANCY SUAVE, STORE MANAGER Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: S-11 BOARD OF HEALTH ,Mlchaet .MCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued S 11 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name KOHL'S DEPARTMENT STORES, INC. #767 2) Establishment Address 280 K SCHOOL STREET NOV C 3) Establishment Mailing Address (if different) P.O. BOX 3139 MILWAUKEE, WI 53201- 4) Establishment Telephone No (508) 339-1817 5) Applicant Name & Title: SfW4Lr -:WILS©WFACILITIES COORD. gy aay (A� 6) Applicant Address N56 W 17000 RIDGEWOOD DRIVE, MEOMONEE FALLS, WI 53051 7) Applicant Telephone No.: (262) 703-1679 24 Hour Emergency No.: (866) 907-0048 8) Owners Name & Title GEORGE TERRIENIPROP MANAGER - WS DEVELOPMENT 9) Owner Address (If different from applicant) 1330 BOYLSTON STREET, CHESTNUT HILL, MA 02467 Owner's telephone number 6172328900 10) Establishment Owned By: 11) If a corporation or partnership, give name title, and home address of officers IJ An Assoaation By: partner. CJ A Corporation Name Title Address Ej An Individual —_ LJ A Partnership ❑ Other legal Entity ---_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title NANCY SUAVE, STORE MANAGER Address: 280 K SCHOOL STREET, MANSFIELD, MA 02048 Telephone No: (508) 339-1817 24 Hour Emergency No: (866) 907.0048 FAX E-mail. NANCY.SUAVEKOHLS.COM Alt E Mail: IBUSINESS.LICENSES(a)KOHLS.COM --- J -- - --- — - --- - --- - - — 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No: 24 Hour Emergency No: FAX: i rE mail: Food Establishment Information 14) WATER SOURCE. TOWN 15) SEWAGE DISPOSAL TOWN AA DEP Public Water Supply No (If applicable) fv 16) No of Food Employees 17) DAYS/HOURS: STORES HOURS 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 Seas or more): 20) Location: Iy] Permanent Location ❑ Moblie Mobile Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: iJ Annual [. ] Seasonal Seasonal Dates: -(_I Temporary Temporary Start Date: Temporary End Date: Temporary Time: _22) Establishment Type 1 Retail ( Sq. Ft') ❑ Food Service up to 100 or up to 10' PHF display $126.00 ❑ 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 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $26,00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 ❑� Retail Snack Food $25.00 Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) ;Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) E] Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- ----- -- ---- for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs [] Preparation of PHFs For Hot And _ _ _ - - - ----------- Cold Holding For Single Meal Service [] PHF and RTEFoods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility ------ --- ----- ---- ------------- ❑ Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours -- -- - — Customer Self Service of Non PHF and Non -- FI Customer Self Service ❑Use of Process Requiring di Variance Perishable Foods Only — Packaged for - - Ice Manufactured and Packaged and/or HACCP Plan (including bare hand contact alternative, time as a public health Preparation of Non PHFs Retail Sale control) _ ❑ Offers Raw Or Undercooked Food Of Other Food Operations ]] Juice Manufactured and Packaged for Retail Sale Animal Origin PREPACKAGED FOOD ONLY ❑ Prepares Food/Single Meals for _ Offers RTE PHF in Bulk Quantities _._.-.._._._______ Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date -- _ f Health o e com leted b fhe Board of-1 or econ i lone o0 - — - Total Permit Fee: $25.00 Payment isdue 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 copie,E of 105, CMR 590.000 and the federal Food Code. 24) Signature of Applicant: t_ Pursuant to MG L Ch.62C, sec. 4 A, I ce and paid state taxes required under law. under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 13-3357362 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. Signature of Individual or Corporate Name ,� -- 339-;x36 ? **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:\HmIthVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of fndustial Accidents 1 Congress Sheet, Suite 100 Boston, MA 02114-2017 r www mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeOblV Business/Organization Name:"Is Qa. r& - S hy,,, 4& 7 Address: jU).jl,W) Q VC. City/State/Zip: r,u jig W1 E&61 Phone #: -142.7a3 • J1, Z2 Are you an employer? Check the appropriate box: Business Type (required): I.P1 I am a employer with ji employees (full and/ S. P'Retail or part-time).* 6. ❑Restaurant/Bar/BatingEstablishment 2. ❑ 1 am a sole proprietor or partnership and have no y, ❑ 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. ❑ Manufacturing no employees. No workers' comp, insurance required]* l 1. ❑ 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 cbedc box 41. am an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon. Insurance Company insurer's Address: ^ y' City/State/Zip; ;ma nt�,4dfs trey, AA S,5� ,$"- Policy# or Self -ins, Lic, #- 9A%C'-o 1,1 Jf �jq 2 Expiration Date: `y Attach a copy of the workers' compensation policy declaration page (showing the policy numb r an 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. do hereby certify, under thepains and penalties ofperjury that the information provided 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: Permi/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 o CERTIFICATE OF LIABILITY INSURANCE """I`"4,2017 ,,I H,yIJI7 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 endorssd, 1 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 center rights to the certificate holder In lieu of such endonement(a). PRODUCER C0 ACT Ann Risk Services central, Inc. NAM Minneapolis mar Office •No. Em; (466) 283-7122 (AIC Md : $00-363-0105 yy`1 5600 West 83rd street Euda1. 8200 Tower, suite 1100 AODRE&a: _ Minneapolis mH 55437 USA INSURER(8) AFFORDING COVERAGE NAICN 5 NSURER B: National union Fire ins CO or Y1ttbDurgn 0`10 N6URFA C: INSURER D; NSURERE;' THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 15E ED 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 15 SUBJECT TO ALL THE TERMS. E%CLUSIONSAND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested OHR L R TYPE OF INSURArrCE AUDL SLUR POLICYNUYPER p R LIMITS X COMMERCNL GENEPALUABRRY CNNSMAPE �% OCCUR GL SIP applies per policy ter s b condi ions EACH OCCURRENCE $1,750,000 PREMISES S750,000 % ,(ynuJ Men SAP (Any and PA=N Excluded SISe.00nblR PERSONAL& AM INJURY $1,750,000 pENl.AGGRE0ATE OMIT APPUEB PSR GENERALAGGREGATE $10,000,000 % POLCY �./ECT LOC PRODUCTS•COIAP/OPAOO $2,750.000 OTHER; A AVTOMOBILELLABnJTY CA54056500 01/31/201701/31/2018 COMBINED SINGLE LIMIT $1,000,000 % ANYAUTO BODILY INJURY (Pt, pAgon( BODILY INJURY Irww4xIAA4 OWNED SCHEDULED HRMAUDMIOL3 HON-0 Nep ONLY AUTOS ONLY PROPERTYDAIMGE PA, ditewol B x umumu.ALIAe X OCCUR 281 9071 1 1 O3 1/203 BACH o000RRENOE $5,000,000 E%CESSLIAB OUIMSANOE AGGREGATE $5,000,000 DEO I % IRETEMIGNSIS,00P A A WORKER§ COMPENSATIONAND EMPLOYERS' LIABILITY YJN AG'PICRFRLEMeroanRJEItCL�PRI�tMI� O IMandmory In Min NIA LD5 All other states P54056487 WI 7 03/31/2017 '.. 01/11/2018 x I PER STATUTE I &H. EL EACH ACCIDENT $1,000,000 E L. DISWE•EA EMPLOYEE $1,000,000 It lleea.dnWim u de, pESCRIP QH OF OPERATIONS btu E.L, OISEASE8000Y LIMIT $1,000,000 A Excess WC SP4056504 SA, ON, 50 & WA 01/31/2017 01/11/2018 Employ Liab WC -Statutory $1.000.000 Included SIR applies per policy ter s 6 condi ions SIR $500,000 DESCRIPTION OF OPERATIONS I LOCATIONSI VBHCLES IACORD 101, Addmonal RdmaAs Schedule. MAY W MUChad If mon sock.ly M,UWl RE: Kohl's Store No, 551, Seekonk Square Shopping Center - one Commerce Way, Seekonk, MA D2771. Lander Address: 51 Madison Avenue, Room 909, New York, NY 10010, Loan Numl'er: 3727166. W-S-K Seekonk Associates LLC and WS Asset Management, Inc, are Included as Additional insured with respect to the General Liability policy where required by written contract. A waiver of Subrogation in favor of W-S-K Seekonk Associates LLC and Ws Asset Management, Inc, applies to the General Liability Policy where required by written contract. 41 CERTIFICATE HOLDER CANCELLATION 3Cd SHOULD ANY OF me ABOVE DESCRIBED POLICIES BE CANCELLED 89POM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WRN ME POUCYPROWEIONS. W-S-K Seekonk Associate$ LLC AUTHORIZED REPRESENTATIVE WS Asset Management, Inc. Attn: Lease Compliance 33 Boylston Street, suite 3000 194 tL�bYnL.2a Chestnut H111 H4 02967 USAiays'1e19 JntMx ®1988.2015 ACORD CORPORATION. All rights reserved, ACORD 26 (2016/03J The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER 10: 210000001618 LOC #: ADDITIONAL REMARKS SCHEDULE Page — of AoWcY Aon Risk services Central, Inc. NAMEDINSURED Kohl's Corporation POLICYNUMBER see Certificate Number: 570069229596 CARRIER see certificate Number: 570069229596 NACG'ODE MEcnVE DATE. ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certifeate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSUTALK INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corrciponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE Of INSURANCE ADDL Wsh SUDR W%D POLICY WAIYEN vouc' EF DATE IM )Irppg9l'Y I POLICY CT DATE ON DATE (ANI/I1 Dnlll'1 LIMITS OTHER A EE14056496 TX Excess Employer Liab SIR applies per policy to 01/31/2017 Ts 6 condit 01/31/2018 ons ACORD 101(0004101) 0 2000 ACORD CORPORATION. All dghts mminmd. The ACORD name and logo m rphland me*$ of ACORD