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Home My WebLink AboutMichael's 12/31/20182 Commonwealth 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 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:. MICHAELS STORES, INC. Whose place of business is: MICHAELS @ MANSFIELD CROSSING MALL #7737 280 SCHOOL STREET, SUITE 220 PERSON(S) IN CHARGE: AGNIESZKA HOAGLAND Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: S-13 BOARD OF HEALTH Michael 9McCCean, Chairman FOR BOARD OF HEALTH FOOD ESTABLISHMENT PERM IT'APPLICATION (Application must be submitted at least 30 days before the planned- 9pej 1) Establishment Name MICHAELS @ MANSFIELD CROSSING MALI 2) Establishment Address 280 SCHOOL STREET, SUITE 220 3) Establishment Mailing Address (if different) P.O. BOX 619566 ATTENTION: 4) Establishment Telephone No DALLAS, TX 75261-9566 339-6239 5) Applicant Name & Title: MICHAELS STORE, INC. 6) Applicant Address 8000 BENT BRANCH DRIVE, IRVING, TX 75063 7) Applicant Telephone No.: (972) 409-1300 (972) 831-4149 r date) t-0-C 2 3-20p t44 ItWN41EN T 24 Hour Emergency No.: (774) 266-2633 8) Owners Name & Title MICHAELS STORES, INC. 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers Ll An Association or partner. Wl A Corporation Name Title Address F1 An Individual L I A Partnership - E-1 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) ----- — ---------- Name& Title: ---16AUREN-DIMASCiO- j Address: Cb ?, k� [Name & Title: IBARBARA SALTER, BUSINESS LICENSE ANALYST 1 Address: !P.O, BOX 619566, DALLAS, TEXAS 75261-9666 Telephone No: i(972) 831-4149 24 Hour Emergency No: /7 I—LY FAX: 1(972) 831-4196 E-mail: -LI-CE-NSESAND-P-E-R-M-I-T-S-@-M—lCHAELS.c'om Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) _ -- _ 16) NO of Food Employees: 1 17) DAYS/HOURS: MON - SAT 9AM-9 PM SUN 10 AM-7 PM 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 Seats or more) ❑ 20) Location: ❑d Permanent Location 22) Establishment Type ❑ Caterer $25.00 [ I Mobile Mobile Start Date: ❑ Retail ( 17,502 Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Date: [] Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑ Manufacture Frozen Desserts/Ice Cream 21) Length Of Permit: ["_] Food Service up to 101 -200 25.00/ reezer Annual or up to 25' PHF display $150.00 ❑ Pushcart $25.00 # of Pushcarts: 0 1 ❑ Seasonal _ .I Food Service up to 201 + J Residential Kitchen $100.00 or 25'+ PHF display $275.00 Seasonal Dates. El Retail Food $100.00 ❑ Temporary ❑ Food Service - Institution ❑vl Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23)Food Operations Definitions: PHF Potentially hazardous food(tlmaAemperature controls required) Non-PHF's- non -potentially hazardous food(no time/lemperature 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 l PHFCooked To Order I ] 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 Susceptible Population Facility --- --- -- ❑ Reheating of Commercially -- r I Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours -- - -- - ---- Customer Self -Service of Non PHF and Non- -- -- ------ ------ ---- ❑ Customer Self -Service ❑_ Use of Process Requiring A variance and/or HACCP Plan (including bare hand Perishable Foods Only —_--- — _ I❑ Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin AMY SHAMBLIN ❑ Offers RTE PHF in Bulk QuantitiPrepares Food/Single Meals for ,_. Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date J or Reconditioned Food To be completed by the Board of Health L _-__-- ---_-- -- - Total Permit Fee: $25 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 ofy9T�CMR 590.000 and the federal Food Code. 24) Signature of Applicant: - J F`-� 7,11� Pursuant to MGL Ch.62C, sec. 49A, I 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 under law. 25) Social Security Number or Federal ID: 75-1943604�� 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 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:\HeatthVane's Docmnents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc f •'� 17ie Commonwealth of Massachusetts � Department of IndustrialAccidents t 1 Congress Street, Suite 100 Boston, MA 02114-2017 V . www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE PILED WITH THE PERMITTING AUTHORITY. Annlicant Information P1 Business/Orgaaiz(a�tion Nam(e�: � Address: J Emry"j I � � a 6�'l�w ��1 ' I J y #: Q 7A 63 / q (46 ' Areyouan employer? Check the appropriate box: Business Type (required): 1. / 1 am a employer with 0 employees (full and/ S. ❑ Retail or part-time).* 6. ❑Restaurant/Bar[FatingEstablishment 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. $• ❑ 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. ElManufacturing 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. **tf the corporate officers have exempted tbcrosclves, but the corporation bas other employees, a workers compensation policy is required and such an organization should check box 91. am an employer that ispr din -wo kerspp' mp a"isation lnsurxfnce for my employ(l� BjelJotY is the oolcy information. Insurance Company Name: j tt t � sGf,�1P� Insurer's Address: f 0 3 ,�r/./� City/State/Zip: � � _ l y,� Cl= ,f/�y 'a'�,7:✓ i `-i' Policy # or Self -ins, Lie. #- (� S q6` ( of/0 `"'L` Expiration Date: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer Krider the pains and, that the information provided above s true /¢fnd—cporrea nnfP- ( 1 t ...6 / ` P Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phon °'-""c" CERTIFICATE OF LIABILITY INSURANCE DFfD01Y, �--�' 61 zola 5Y26?62017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the cortlflcato holder Is an ADDITIONAL INSURED, the pollcy(ios) must have ADDITIONAL INSURED provisions or be ondorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an ondorsomont. A statement on this certificate does not Confer rights to the certificate hostler in lieu of such ondorsemaniiBl. 444 N. 47th Street, Suite 900 Kansas Ci* 41064112.1906 (N 16)960.9000 INSURERISI AFFORDING COVERAGE NAIOe INSURER SaletV National Casualt. Corporation I$IOJ IfiSVR6D MICH %rLS ST6Rl S. INC, iusun,eRa. VARIOUS CARRIERS (SEE ATTACHED I2.rI I 8000131 NT B(LINCLItDR, wsURERc \L 1'�SUR? CE 4VIERICI. INC. A \V _ IRVING IN 73063 INSURER INSURER E INSURER F. rC)VERArF;R 411 ('41.$f1J CFRTIFICATF MIIAA0.F0InMMGrr THIS i$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER.OD INDICATED NOTVATHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE:3PECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL. TW3 TERM$ EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR .....APSE POLICY EPK POLICY E%P _LTR WP6 OF INSURANCE N4 AID POLICY NUMBER IMM ODNY l IMM ODMY41 LIMITS \ \ COMMERCIAL GENERAL LIABILITY ti Cl 4 44':4 : '7 -: 2 9 ;EACH0=RRt WE S 2.000 O -- CLA'his MADE \, OC'UR __-.... lIM SETiSRE`+r=d PRI,DOO.00q PR a Fq 6I: ✓F,r,, 4 A oo:,s I S ...MEO EtPY I \V\V\�\ .... .. _.,I PERSONAL IA;Li^iV v i 2.000000 GJIL AGGP.EGAA EMIT APP: ',E$, ER :GENERAL AG 7RHG,itP S IO.00O OOO X POL CY',.. JET .._ .`::C PROGUCiS 'M"1„u,W',; 3 2,000OOO _ ...,... OTHER A AUTOMOBILE LIABILITY y' C:\S4 _A !: '. I: g COMBINED SihG. UM i. I.OQO Q{)O ANYAIA( a", 1 BRGn S \t\\\\\� AU7�9NI B.> 1 "-_woerb 5 A 7E 3.. \ (;q� II V I HN S DAVI S 51060 l,'UDIPICOLL DED C _X UMERELI.AMA9 �_. [];_n N N t,Sdf ):i Fo161.117A C 4 ^-E $ O,OOO OOO E%CE55 LIAR If A,,rE 5,000000 UFO r T C 3 WORKERS COMPENSATION N A F H AND EMPLOYERS LIABILITY LDS 44 02110S13 Yin : ( f f ANY PRGPRIETCrnr>111 z RCJI PS ,L .U.'51AAU - = I8 OFFu;ER, n1FMB�� f f h�> NIA CNACCICFNT $ 1,000 OOO ' ,� IMretlatary In Nu . 'EAS' EAEMPLOYEE $ LOOOOOO ityCr tlOPIT OESCReHT!ONO 11- .EASE PCOCY LIMIT $ 1 OOO.O( B PROPERTY -A1.LRISK N N VvRlot ti 13: VITvCHr[) 1 III a 1 2:.t8 51 ILNII PER000 BI , ISS1111FRRUPTION INl t "I I \:` IS PPR-i O;JAIL, PROP DESCRIPTION OF OPERATIONS/ LOCATIONS VEHICLES IACORD 101, A40llonal ROPPAS SchegvlF, maybe aeechnC 11 more sets to reggim( ' 10900269 S PECI M EN C F RTI P R_ ATE ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All riahts reserved. AQURD 25 (2018l00) The ACORD name and logo are registered marks of ACORD MICHAELS STORES, INC. OFFICER LIST Officers Position Held Navin Rao VP-Asst. General Counsel 8000 Bent Branch Dr. Asst. Secretary & COO Irving, TX 75063 Michael J. Veiterrheimer SVP General Counsel 8000 Bent Branch Dr. & Secretary Irving, TX 75063 Rebecca Shaffer Vice President Tax 8000 Bent Branch Dr Irving, TX 75063 Phone.# 972-409-7490 972-409-1655 972-831-4185 CERTIFICATE OF LIABILITY INSURANCE I OATEIMA1111 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIPICATE 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: It the certlflCate holder Is an ADDITIONAL INSURED, the poiicy(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 cortlgcate does not confer rights to the ceniflcate holder In lieu of such andnrsemnnirsl. 444 %k. 4701 Slrect. SUIIC 900 PHONE FAX Kansas Citt \ILA 64112.1906 EMAIL (816) 960A000 M0f'FS3_ _ INSURBR15l AFFOROVe COVERAGE NAIL r INSURER A Safety National Casuilt} Corporation 151 Qj INSURED MICI'I \ELS SIOR( S. INC, INSURERS VARIOUS CARRIERS (SEE ATTACHED I7S1 i SOOU BI \T BRANCH DR INSURERC \L INSURANCE A\ILRIC \. I\C, A \V •—_.^ IRVNO IN 73063 .�—_—..... INSURER D INSURER E INSURER P . COVERAGES 1NCHAO) CERTIPICATF NLIMRPP, Inonn'Rn ocvlelr.kl ouaar,om. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO`ICY PER OD INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPE' T TO WHI-CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO Al.%, THC: TERMS EXCLUSIONS AND CONDITIONS OP SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ILTN TYPE OF INSURANCE Aael, .R POLICY NUMBER IMOLDIDYEFF MWDDm%P WI LIMITS L COMMERCIAL GENERAL LIABILITY N ;v lit.A AA "A ' ') a 8 EAGHOCCT ,? S ?,bQO.00Q _ CLANS MADE \ OC'. LIT P.i i. y I,000.QQQ ..... _. RHMGE'rrrRE XX _... _ _.... PERSONA' 2000.000 GBTLAOGREGAT LA(TAPP'eE"-ER N4EtIERAL A6.RLG 4( i 10.000,000 FOCCv ':.. JECT "-'C _. :Maur, ?C i R000CTS , 2.0000LIO _. OTHER >. A AUTOMOBILE LIABILITY V y C %SA -4 1 21 y U dStN OmrIG:. t 5 .� �ANY AUY(I B:'. o tie ) \ AUTL c:, ;° lily V PI1)S 1) VVI A S10110 t oMPIC94L DED 3 ;cA]t\fit C 1< UMBRELLA WAS �. 4IX: 7 V 1i50t{)530161.I17 1 r IS A� c a- ,E 5 5,000,0 0 9 E%CEBS LIAR I si Atb4.G ,A AS CAT S 5,000,000 CEO 2 Y'CPIj S .Xxxxxx\. _.. WORKERS COMPENSATION y A AND EMPLOYERS LIABILITY LDSAJA0_21AOS .. ]i$ i ha r QnH y,N A ANY PRGPRIEIr e I la<o:J k "'^,I PSA.14 '�i 1A\q , 18 OFF CERnIFNB i,,„INtA ll ,CICelly S.1,, 000000 .f.,+ IMmdatary In NN) '—t _. EA CA 5VPLOYEE 5 1.000 000 .I at tlPTOn,la OESCR.PbOH 0 , . Ck[y cea>i E. TEASE I>OUf,YVM1+Ii 5 I QQO. O0 B PROPFRTY.ALL Rlsk N N V\RiI)I w,Ll, \I-FICHcn S. �rrreltocC D'.-ress I�TeltauPTiGv Isrl. T:. ti V I S Pl-lt':'.1 ,NIA.l. PROP DESCRIPTION OF OPERATIONS I LOCATIONS, VEHICLES fACORO 01, Add eenal Remarks Sahadub, may lro eeachad it mom aPa<s I. mdW. 90900269 SPGCI%IE\ CESRTIFK ATE ONLY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 8E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All Anhlc meowed ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Layer Company Policy Number Primar_v_S I0M11_ncl CA EQ & Flood • XV Anted World Assurance P0048981013 A XV Lloyds Syndicates PRPNA1702026 A+XV ACE American Insurance Co GPAD37387057011 Primary S25M (Inc[ CA Ul F. Flood) P, XV Lloyd's Syridicales PRPNA1702032 A+ XV Zurich American Insurance Co PPR 0171562.0.1 Pdmary,S50NI Onci CA EQ & Flood) A XV Lexmgion Inslnsrance C uo 25011605 either & Machine y Coverage .o That Part Of Excess All Risk 25.00% 2.500 10000 Primary At R sk 10 O0'90 1 000 10 000 Primary Ail Risk 10 00% 1 Ono 10 000 Primary Ail Risk 17 0% d 251 25 000 Primary All Rash 16 0% 4 500 25 000 Primary A I Risk 20 0% 10 000 50 000 Primary A- XV Travelers Indemnity Co of CT i3ME1608X5.143 TIU17 BEM 100.00% 00000O 100000 pods DEDUCTIBLES Per Occurrence Transit Earthquake Flood `'find .g Had WAITING PERIOD Miscellaneous Attachment: M65749 %-taster ID: 12311. Certificate ID, 10900269 $250 000 Except $100 000 Per Occurrence $250 000 Per Occurrence Except. 5% of TVs at time or:oss at each location involved in the loss or damage subject to a mmirnurn of $250,000 any one occurrence as respects local tens in the Stale of California ` Of TIV's at time of lass at each location involved in the loss or hall subject to a minimum of 5250 000 any one occurrence as respects locations .n (he New Madrid Earthquake Zone Counties 2% Of TIV S at time of oss at each location invgWed in the loss or damage subject to a minimum of S250,000 any one occurrence. as respects tocall0r15 in Pacific Northwest Earthquake Zone Counties 5250.000 Per Occurrence Except. 5% of TIV's at time of loss at each location involved in the loss or damage. subject W a murrourn deductible of 51.000,000 any one occurrence, as respects locations wholly or partially within Special Flood Hazard Areas Areas of 101 feeding, as defined oy the Federal Emergency Management Agency (FEMA): except 5500.006 Per Occurrence at New Lenox. IL Ovirlbullon Center S250.000 Per Occurrence Except. 5% HV s at the time or lass at each location involved In loss or damage arising out of a Named Storm in Tier One Counties (a $(orn that has been declared by the National VVeather Service to be a Hurricane, Typhoon_ Tropical Cyclone, Tropical 51orm or Tropical Depression) regardless of the number of Coverage. Locations, or Perils involved (including but not limited to, all flood, wind, wind gulls, storm surges, amadns, cyclones. hail or rain) and subject (o a minimum deductible of $250,000 any one occurrence 24 hour walling period with respect 10 Civil or Military Authority, IngressrEgress and Service/Off Premises Power Inlernlplioo