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HomeMy WebLinkAboutWhole Foods Market - 9/20/2008TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD, MA 02048 PERMIT TO OPERATE A MOBILE FOOD TEMP ESTABLISHMENT 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: WHOLE FOODS MARKET GROUP Whose Place of Business is: WHOLE FOODS MARKET GROUP, INC. Permit expires September 20, 2008 License Number. MF-303T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH r--:- P) Dr. Raymond Martin, Chairman &a, Inspected Approved By Permit # Issued ,BLISHMENT PERMIT APPLICATION pitted at least 30 days before the planned opening date) 1) Establishment Name:v Olt'S 2) Establishment Address: _ L6/71c1q e • cr 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: Applicant Name & Title: 7 l4i I Ujasde^ r(j)Applicant Address: `7)F ant Telephone No.: 24 Hour Emergency No.: 8) Owner Name & Title (if different from applicant): //'' ,^J (yJ %JO e - kZ re d 9) Owner Address (if different from applicant): ,.- ��iYLI dn! �. � , � r(l 10) Establishment Owned By: 11) If a corpo lion or partnership, give name, title, and hom ddress of officers or partner. El An Association p'A Corporation ❑ An Individual .s---^ ._..-----^ ❑ A Partnership ❑ Other legal entity ,11 n-.., 11--M- o—---- ;W- CC r Dal! 0 erMRnnc (nwncr ncrcnn in charm Aimenrisnr Manager etc.) Narr- Title: rn AA/ .e- 'TclB lreNo: Fax: 617 Q —5-5- Emergency Telephone No: `j � 13 District Or Re Tonal Su ervisor if a frcable Name &title: Address: Telephone No: Fax: /C) / Vd BLANK FWD PERMITAPPLICAMN i Sup I�.,-ddrhi r'uuu LDU]Ullol lint, n n •.• 16) Sewage Disposal 14.) Water Source DEP Public Water Supply No: (if applicable): 16) '";ays and Hours of Operation: Y 17) No. of Food Employees 18) Name of Person in Charge Certified in Food Protection Management: Ala f Z `Required as of 1 (r1/2001 in accordance with 105 CMR 590.003(A) Please attach co of certfcate 19) Pe, n Trained in Anti -Choking Procedures (if 25 seats or more): s- ///''''''))) I _ ��j� 20 Location: r(gyvj�aS /` 22 Establishment Type: ) ❑ Retail ( Sq. Ft) ❑ Caterer ❑Food Delivery ❑ Food Service -( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Residential Kitchen for Bed & Breakfast Home ❑ Permanent ❑ Food Service - Institution ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast ❑ Mobile (Dates) Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 10(2. ;21) Length Of Permit: (check one)LL ❑Annual ❑Seasonal/Dates 5P� all Ij TerKporary/DatesRimes ix/3 A10 ,I i 23) Food_.perations: Definitions: PHF- Potentialy hazardous food(time/temperature Non-PHFs - non -potentially hazardous food (no controls required) i tlmeRemperature controls required) ,(eheel4;pf(,that apply): RTE-rea -to-eat foods Ex. Sandwiches, salads, muffins which need no further processing) ❑ Hot PHF Cooked and Cooled or Hot Held for `❑ Sale of commercially Pre- ❑ PHFCooked To Order More Than a Single Meal Service Packaged Non-PHFs ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Susce tible Po ulation Facility Packa led PHFs ❑ Delivery or Packaged PHFs Holding For Single Meal Service ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill Reheating of commercially be Pre ared b Consumer ❑ Customer Self -Service El Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact Processed Foods For Service alternative, time as a public health control Within 4 Hours. ❑ Customer Self -Service of Non ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Only. ❑ Prepnr.etion of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale ' U utters K 1 t- rill- In ouin Quauuua' To be completed by the aoard or Hearin i i >r (Describe): _ Retail Sale of Salvage, Out-0f--Date or Total Permit Fee: Reconditioned Food Payment is due with application '•� 1(,the undersigned, attest to the accuracy of the information provided in this application and I 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 the federal Food Code. 24) Signature of Applicant: 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 returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 141 H- 34,W 26) Sig^ u;ure of Individual or Corporate Name: t °' (^' Ile 161d tAcui k ( HLANK FCO'dPHHMITAPPLICATION IG*(' 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 Corporat Name By: Corporate Officer (Mandatory, if Applicable) *"Social Security No. (Voluntary) or Federal Identification Number *This license will not be is ued unless this certification clause is signed by the applicant. c ** 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 HhVand's Documents\TAX CERTIFICATION FORM.doc Whole Foods Market Group, Inc. Officers _ Officer Title Business Address Business Phone RoLmoa Lang Director 550 Bowie Street 512-477-5566 Austin, TX 78703 Anthony C. Gallo Director 125 CambridgePark Drive 617-492-5500 Cambridge, MA 02140-2393 President, Vice Roberta Lang President, Treasurer 550 Bowie Street 512-477-5566 Treasurer Austin, TX 78703 Albert E. Percival Secretary 550 Bowie Street 512-477-5566 Austin, TX 78703 Glenda Chamberlain Assistant Secretary 550 Bowie Street 512-477-5566 Austin, TX 78703 Patricia D. Yost Assistant Secretary 550 Bowie Street 512-477-5566 Austin, TX 78703 erfs Alb, j Whole Foods Market Group, Inc. Officers Officer Title Business Address Business Phone Roberta Lang Director 550 Bowie Street 512-477-5566 Austin, TX 78703 Antimony C. Gallo Director 125 CambridgePark Drive 617-492-5500 Cambridge, MA 02140-2393 President, Vice Roberta Lang President, Treasurer 550 Bowie Street 512-477-5566 Treasurer Austin, TX 78703 Alber E. Percival Glenda Chamberlain Patricia D. Yost Secretary 550 Bowie Street 512-477-5566 Austin, TX 78703 Assistant Secretary 550 Bowie Street 512-477-5566 Austin, TX 78703 Assistant Secretary 550 Bowie Street 512-477-5566 Austin, TX 78703 ➢ O m X D 0 z \T N C) C) rm a7 F' n m m X X D � m ►� O n p D g m z O Ul O N P. 0 oo N Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly % Business/Organization Name: City/State/Zip: (la�n6ilil%�I� Phone #: (,t7-l/I) SDOel Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. O 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] g• ❑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, t with no employees. [No workers' comp. insurance req.] 12.0 Other f4 J'"" p _ : e,) J *Any applicant that checks box Nl 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 M1. I am an employer that is provid' workers' compensation insurance for my employees. ,Below is the policy information. J( Insurance Company Name: C��lN�(1/!'!°17 ��Z �, Insurer's Address: �/�J � City/State/Zip: Y AU 1'lr l�['- � c' �ar nt/J --a S- `00 —�/ Policy # or Self -ins. Lic. # (y � L11:_?0 Expiration Date: i17e A 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, tinder the pains and penalties ofperjtny that the information provided above is true and correct. l-41o/ 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 #: www.mass.gov/dia MEMORANDUM OF INSURANCE 719= his Memorandum is issued as a matter of information only to authorized viewers for their internal use only and confers no rights pon any viewer of this Memorandum. This Memorandum does not amend, extend, or alter the coverage described below. This emorandum may only be copied, printed and distributed within an authorized viewer and may only be used and viewed by an uthorized viewer for its internal use. Any other use, duplication or distribution of this Memorandum without the consent of John L. ortham & Son L.P. is prohibited. "Authorized viewer" shall mean an entity or persons which is authorized by the insured named erein to access this Memorandum via http://ivww.worthaminsurance.com/moi/wholefoods. The information contained herein is as of he date referred to above. John L. Wortham & Son L.P is under no obihiation to update such information roducer COMPANIES AFFORDING COVERAGE ohn L. Wortham & Son L.P. O Box 1388 ouston, TX 77251-1388 nsured: hole Foods Market Inc. Attn: Margot Roth A. ACE American Insurance Company B. Westchester Fire Insurance Company 50 Bowie Street C. Indemnity Insurance Co. of North America Austin, TX 78703 OVERAGES HE 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 MEMORANDUM 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS Policy Effective Policy t ype of Insurance Policy Number ate MM/DD/YYYY ts GENERAL LIABILITY SLG21745212 9/30/2007 9/30/2008 OCCURRENCE $500,000 DAMAGE An one fireOMMERCIAL EXP An one ersonIABILITY GENERAL ONAL & ADV INJURY $500,000 GENERAL AGGREGATE $1,500,0 CCURENCE RODUCTS-cOMP/OPAGG $1,500,0 IR $1,000,000 PER CCURENCE UTOMOBILE LIABILITY SAH08216277 9/30/2007 9/30/2008 COMBINED SINGLE LIMIT Ea accident 2 000 000 ODILY INJURY Per erson ANY AUTO RED AUTOS ODILY INJURY Per accident ROPERTYDAMAGE Per occident ON -OWNED AUTOS GARAGE LIABILITY UTO ONLY - EA CCIDENT THERTHAN AACC UTO ONLY: ftGG 5,000,00 EXCESS / UMBRELLA G22015230002 9/30/2007 9/30/2008 ACH OCCURRENCE LGGREGATE 11$5,000,00g IABILITY OCCURRENCE Retention: $10,000 per ccurrence WORKERS WLRC4400768(AOS 9/30/2007 9/30/2008 CSTATUTCRv TH- OMPENSATION AND EXCEPT TX) LIMITS P.L. EACH ACCIDENT 1,000,00 EMPLOYERS' LIABILITY WLRC44007691 (AZ & The Proprietor/Partners/Executive CA) CFC4400769A(WI) .L. DISEASE -EA MPLOYEE 1,000,00 L. DISEASE -POLICY 1,000,000 IMIT Officers are Included The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any modifications hereto are not authorized ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION Named Insured Endorsement Number Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G21745212 9/30/2007 to 9/30/2008 9/30/2007 Issued by (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY Schedule Name of Person or Organization: Any Person Or Organization Whom You Have Agreed To Include As An Additional Insured Under A Written Contract Executed Prior To Loss. WHO IS AN INSURED (SECTION ll) is amended to include as an insured the person(s) or organization(s) shown in the schedule as an insured but only with respect to liability arising out of your operations or premises owned or rented to you. XS-BW25 (9/95) Ptd. in U.S.A. ADDITIONAL INSURED — VENDORS Named Insured Endorsement Number Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G21745212 9/30/2007 to 9/30/2008 9/30/2007 Issued by (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY SCHEDULE Name of Person or Organization (Vendor): Any Vendor whom you have agreed to include as an additional insured under a written contract. Your Products: WHO IS AN INSURED (Section II) is amended to include as an insured any person or organization (referred to below as a vendor) shown in the Schedule but only with respect to "bodily injury" or "property damage" arising out of "your products" shown in the Schedule which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions: 1. The insurance afforded the vendor does not apply to: a. "Bodily injury' or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor. 2. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products XS-6W31a (12/02) Ptd in U.S.A. ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION Named Insured Endorsement Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period Effective Date of Endorsement ISA H08216277 9/30/2007 to 9/30/2008 9/30/2007 Issued by (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM TRUCKERS COVERAGE FORM GARAGE COVERAGE FORM Additional Insured (s): Blanket as provided by written contract, provided such contract was executed prior to the date of loss. A. For a covered "auto", who is Insured is changed to include as an "insured," the persons or organizations named in this endorsement. However, these persons or organizations are an "insured" only for "bodily injury" or "property damage" resulting from acts or omissions of: 1. You 2. Any of your employees or agents. 3. Any person operating a covered "auto" with permission from You, any of your employees or agents. B. The persons or organizations named in this endorsement are not liable for payment of your premium. DA-9U74 (12/94) Ptd. in U.S.A. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Named Insured Endorsement Number Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period Effective Date of Endorsement XSL G21745212 9/30/2007 to 9/30/2008 9/30/2007 Issued by (Name of Insurance Company) ACE American Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY This endorsement modifies insurance provided under the following: EXCESS COMMERCIAL GENERAL LIABILITY POLICY Schedule Name of Person or Organization: Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss. We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. XS-6W34 (09195) Ptd. in U.S.A. (06/04/2007 TDM) Workers' Compensation and Employer' Liability Policy Named Insured Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period WLR C44007678 9/30/2007 to 9/30/2008 Issued by (Name of Insurance Company) Indemnity Insurance Co of North American Endorsement Number Effective Date of Endorsement 9/30/2007 Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NJ. CKE-3N13 (01/93) Ptd. in U.S.A. WC00 03 13 Workers' Compensation and Employer' Liability Policy Named Insured Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period WLR C44007691 9/30/2007 to 9/30/2008 Issued by (Name of Insurance Company) ACE American Insurance Company Number Effective Date of Endorsement 9/30/2007 Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NJ. CKE-3N13 (01/93) Ptd. in U.S.A. WC00 03 13 Workers' Compensation and Employer' Liability Policy Named Insured Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period SCF C44007678A 9/30/2007 to 9/30/2008 Issued by (Name of Insurance Company) Indemnity Insurance Co of North American Number Effective Date of Endorsement 9/30/2007 Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our right against the person or organization named In the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO THE DATE OF LOSS. For the states of CA, TX, refer to state specific endorsements. This endorsement is not applicable in KY, NJ. CKE-3N13 (01/93) Ptd. in U.S.A. WC00 03 13 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS Named Insured Whole Foods Market, Inc. Policy Symbol Policy Number Policy Period ISA HO8216277 9/30/2007 to 9/30/2008 Issued by (Name of Insurance Company) ACE American Insurance Comoanv Endorsement Number Effective Date of Endorsement 9/30/2007 Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIERS COVERAGE FORM TRUCKERS COVERAGE FORM GARAGE COVERAGE FORM We waive any right of recovery we may have against the person or organization shown in the Schedule below because of payments we make for injury or damage arising out of the use of a 'covered auto". The waiver applies only to the person or organization shown in the Schedule. Schedule [Any person or organization against whom you have agreed to waive your right of recovery in a written contract, provided such contract was executed prior to the date of loss.] DA-13115 (12/02) Printed in U.S.A.