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Home My WebLink AboutKinder Care 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: KINDERCARE EDUCATION having a place of business at: KINDER CARE 515 WEST STREET 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-38 Board of Health MichaeC-McCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-38 FOOD ESTABLISHMENT PERMIT APPLICATION ... __.---.-..... -.. (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name KINDER CARE 2) Establishment Address 515 WEST STREET 3) Establishment Mailing Address (if different) 616 WEST STREET MANSFIELD, MA 02048 4) Establishment Telephone No p (508)337-6600 - 5) Applicant Name & Title: Mile"ELE-L:@RO, CENTER DIRECTOR 6) Applicant Address 516 WEST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: 24 Hour Emergency No.: (800) 322-0199 8) Owners Name & TitleK ( In - 9) Owner Address (If different from applicant) 650 NE HOLLADAY ST., SUITE1400, PORTLAND, OR 9723D- Owner's telephone number p (508) 337-8600 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers i 1 An Association I or partner. fi A Corporation 11 Name Title Address i 1 An Individual _ A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MtCUE4.9-6GR9JHA8E0eM, CENTER DIRECTOR Kal l�n Chu.pinsO Address: �515 WEST STREET, MANSFIELD, MA 02048 L f _ Telephone No. I(508) 337-8600 24 Hour Emergency No: (800) 322.0199 FAX: j(508) 261-1395 E-mail. MLh��hS l\� @ t\I CVr C or) J Alt E-Mail: 303012(&KLCORP.COM 13) District Or Regional Supervisor (if applicable) Name & Title: iJANICE HANDRAHAN, DISTRICT MANAGER Address: 69 WINTER STREET, WOONSOCKET, RI 02895 Telephone No: (401) 636-9177 24 Hour Emergency No: (800) 322.0199 _ ,- FAX: I E-mail: JHANDRAHAN@KLCORR. IM Food Establishment Information 14) WATER SOURCE, TOWN 15) SEWAGE DISPOSAL TOWN DEP Public Water Supply No: (If applicable) _ 18) NO Of Food Employees 17) DAYS/HOURS: --- --._... 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. i Required as of 10/l/2001 in accordance with -105 CMR 590.003(A) Please Which copy of certificate 19) Person Trained In Anti -Choking Procedures (If 26 Seals or more): f] 20) Location: N] Permanent Loca(lon 22) Establishment Type ]Caterer $26.00 Mobile Mobile Sled Dale: � Retail ( sq. F0 l iV,l Milk & Cream $10.00 Mobile End Date: i-) Food Service up to 100 or Mobile Food & Consesslon $75.00 Mobile Comments: 00 up to 10' PHF display $126. L ]Manufacture Frozen Desserlsllca Cream 21) Length of Permit: n Food Service up to 101-260 l0 25' PHF display $150.00 I $25.00/freezer i 1 [y] Annual or up rl Pushcart $26.00 R of Pushcarts: 0 J l.� Seasonal '.� Food Service up to 201 + ` 1 Residential Kitchen $100.00 or 25'+ PHF display $276.00 (J Retail Food $100.00 Seasonal Dates: -,•------- ------"_"' . ; Temporary - """" ❑ Food Service - Institution [ Retell Snack Food $26.00 Temporary Start Date, ( Meals/Day) `j Tobacco Products $25.00 Temporary End Date: ' Temporary Time: j Rein Date: ' Definitions PHF- Polenliully hazardous food ymeotempem(me controls required) 123) Food Operations Non-PHFs non -potentially hazardous timenompangme wasors required) ',(Check all that apply): R7E-reedy-to-eal roods (Ex. sandwtches, salads, muffins which need no further processing) IL Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs 1 -J Delivery of Packaged PHFs I Raheating of Commercially Processed Foods for Service Within 4 Hours iy' Customer Self -Service of Non PHF and Non. ; Perishable Foods Only - Preparation of Non.PHFs Other Food Operations ❑ PHFCooked To Order EJ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑❑ Preparation of PHFs For Hot And _ - -"- J Cold Holding For Single Meal Service F1 PHF and RTE Foods Prepared For Highly (] Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer 1 f 1 Vacuum Packaging t Cook Chill -- L.J Use of Process Requiring A Variance 1 Customer Self Service i and/or HACCP Plan (including bare hand 1 Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sala control) ._.._..._ .. ...... _ ___ _...; I. r I Julce Manufactured and Packaged for '_ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin j Retail Sale of Salvage, or Reconditioned Food I, the undersigned, attest to the accuracy of the Information provided In this establishment operation will comply with 105 CMR 690,000 and all other ap board of health on how to obtain copies-of906 CMR 590.00R and the fetter 24) Signature of Applicant: _ Quantities �.� Prepares Food/Single Meals for j Catered Events or Institutional Food Service i Dul-Of-Date ___ _.___ _..._____; iTo be completed by the Board of Health Total Permit Fee: $10,00 Payment Is due with application lion and affirm that the food law. I have been Instructed by the Code. �l Pursuant to MGL Ch.620, sea �9A 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 ~law. 25) Social Security Number or Federal ID: 63-0941966 '�� •„� n ^ /) I�y� 26) Signature of Individual or Corporate rc\Y\"k/ut) M�Czo 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. 1Ci ndtrCarn FAwfi on AA A, Signature of Individual or Corporate Name By: porate Officer (Mandatory, if Applicable) b3_6gglq(1U **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:\He IthVanes Documents\PERMI9' APPLICATIONS\TAX CERTIFICATION FORM.doc ` The Commonwealth of Massachusetts Deparhrient oflndushzal Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 lug www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTBORITX. Applicant Information Please Print Legib] Business/Organization Name: 15 W est City/State/Zip: MonM e, I n M A gm Phone At: Are ion an employer? Check the appropriate box: I. 1 am a employer with a� employees (full and/ or part-time).* 2: ® lam a sole proprietor or partnership and have no employees working for mein any capacity. [No workers' comp, insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per it, 152, § 1(4), and we have no employees. (No workers' comp. insurance required] 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance reci j Business Type (required): 5. ❑Retail 6, F1Restaurant/Bar/13ating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 17.❑ Health Care 12,1n otherYArn( h a r o,,, -f / *Any applicant that chocks box #1 must also fill out the section below showing their workers' compensation policy information, 41lf rho corporate officers have exempted thcroselves, but the corporadon bas otheremployces, a workers' compensation policy is required and such an organization should check box #i. lam an employer t/tat is providing workers' compensation insurance for my employees. BelIu p is the policy informado,. tnsuranceCompany Name: YN11111��,1VjSkAY(A"(Cp 3UVI(21 or ('QLIDYI Insurer's Address: C O AU /�i-'fit, f�i�_.p t v� p- b. F BOA 305 f g i City/State/Zip; QShVI I�CiI I ,V 31 R;J 0— ✓ III Policy # or Self -ins. Lie. #. t I U r t b J 1 2 3O `1 Expiration Date: 1211118 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 ccrdfZ under the pains and es ofp^/ jury that the information provided above 's true and correct Signatir / Date (fir I 1 I Phone #: 11 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 Person: Phone Page 1 of 2 A� o CERTIFICATE OF LIABILITY INSURANCE °11/2 /2017Y' 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 endorsemenl(s). PRODUCER Willie Insurance Services of California, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME:PHONE 1-877-945-7378 FAX 1-088-967-2378 AIC No: E-MAIL ADDRESS: certificates0!willis.com INSURERS AFFORDING COVERAGE NAIC If Nashville, TN 372305191 USA INSURERA: Arch Insurance Company 11150 INSURED KUEHG Corp., INSURER B: Travelers Indemnity Company 25658 INSURER C: XL Insurance America, Inc. 24554 KinderCare Education LLC, INSURER D: Arch Indemnity Insurance Company 30830 And Their Wholly Owed Subsidiaries 650 NE Holladay Street, Suite 1400 Portland, OR 97232 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: W4473229 DckIleti TN NIIMDDD. 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. ILTR TYPE OP INSURANCE ADOL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/ODNYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACHOCCURRN_TE $ 3,000,000 X AGETO RENTE CLAIMS -MADE OCCUR PREMISES Ea occurrence $ 3,000,000 MED EXP (Any one person) $ 0 A PERSONAL&ACV INJURY $ 3,000,000 71GPPOS12309 12/01/2017 12/01/2018 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 61000,000 POLICY �X PRODUCTS - COMP/OPAGG $ 3,000,000 JEC LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT En accident $ 2,000,000 X BODILY INJURY (Per person) $ ANY AUTO B BODILY INJURY (Par accident) $ AUTOS SONLY AUTOSED HC2E-CAP-477M5687-TCT-17 12/01/2017 12/01/2018 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY -DAMAGE Per acctle0f $ $ C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 EXCESS LIAa CLAIMS -MADE US00011222LI17A 12/01/2017 12/01/2018 DED %t RETENTION$ 10, 000 RETENTION $ 10,000 WORKERS COMPENSATION IER x SERH AND EMPLOYERS' LABILIITY YIN TATUTE E.L. EACH ACCIDENT $ 11000,000 A ANYPROPRIETOR/PARTNEWEXECUTIVE No N/A OFFICERMIEMBEREXCLUOEDT 71WCI4952009 12/01/2017 12/01/2018i E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below D Workers Compensation & 74WCI1000609 12/01/2017 12/01/2018 E.L. Each Accident $1,000,000 Employers Liability - E.L. Disease -Poi Lmt $1,000,000 Per Statute E.L. Disease -Each Em $110001000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Legal Entities: KUEHG Corp. KinderCare Education Holdings LLC Knowledge Schools LLC SEE ATTACHED �.cn r,rwe" r c na�wcrc (:ANL:ELLA I IL)N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Posting Notice - ADS VK 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD as ID, 15355155 6ATCH, 523971