HomeMy WebLinkAboutBertucci's - 6/1/2010Commonwealth 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: FOOD SERVICE
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:.
BERTUCCI'S RESTAURANT, CORP.
Whose place of business is:
BERTUCCI'S ITALIAN RESTAURANT
280 SCHOOL STREET
PERSON(S) IN CHARGE:
TRAVIS FOSTER, GENERAL MANAGER
Permit Expires: June 01, 2010
License Number: FS-4
Food Fee: $125.00
Milk & Cream
BOARD OF HEALTH
srn....e-.•�:4
Dr. Raymond Martin, Chairman
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Milk and Cream Permit
I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year.
NAME OF BUSINESS: BERTUCCI'S ITALIAN RESTAURANT
ADDRESS: 280 SCHOOL STREET
TELEPHONE AT LOCATION:
FAX NUMBER: (508) 393-7657
OWNER OF BUSINESS: BERTUCCI'S RESTAURANT, CORP.
TELEPHONE OF OWNER: (401) 524-1311
FEDERAL ID/SS NUMBER: 04-2844750
FEE: $2.00
PERMIT NUMBER: FS-4
r
SIGNATURE:
DATE: _ J��
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS-4
FOOD ESTABLISHMENT FERMI I AtJHLI(-;A I IUN
Iannlinntinn must be submitted at least 30 days before the planned opening date)
1) Establishment Name: BERTUCCI'S ITALIAN RESTAURANT
2) Establishment Address 280 SCHOOL STREET
y
3) Establishment Mailing Address (if different) 280 SCHOOL STREET
MANSFIELD, MA 02048
4) Establishment Telephone No:
5) Applicant Name & Title: BERTUCCI'S RESTAURANT
6) Applicant Address 155 OTIS STREET, NORTHBOROUGH, MA 01532
7) Applicant Telephone No.: (508) 351-2500 24 Hour Emergency No.: (508) 351-2554 (401) 524-1311
8) Owners Name & Title BERTUCCI'S RESTAURANT, CORP.
9) Owner Address (If different from applicant): 155 OTIS STREET, NORTH BOROUGH, MA 01532
10) Establishment Owned By:
❑ An Association
O A Corporation
❑ An Individual
❑ A Partnership
❑ Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
PO n ro,np �m CI'�'Y� P.G'�o11/
12) Person Directiv Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
//
J CLY Qi
Address:
ff
Telephone No:
-a �J 24 Hour Emergency No: 50)
FAX:
5a& -jq3 ' 7& J y
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
e� t (n lJ l f% f� 53�
Telephone No:
5� _ 7 3 24-Hour Emerg ncy o:'5���__ j
FAX:
(5 b � -3cl 3 - ( _ / T 7 7 ��
14) WATER SOURCE: TOWN
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 25+
17) DAYS/HOURS: MON-THURS 11 AM-10 PM SAT &SUN 11 AM-11 PM
18) Name of Person In Charge Certified in Food Protection Management: rJUSTIN CONANT-
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): I]
20) Location: ❑d Permanent Location 22) Establishment Type
❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft)
Mobile End Date: ❑ Food Service up to 100 or
Mobile Comments: up to 10' PHF display $75
21) Length of Permit:
I] Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date
Temporary End Date:
Temporary Time:
Rain Date:
❑ Food Service up to 101 -200
or up to 25' PHF display $100
] Food Service up to 201 +
or 25'+ PHF display $125
❑ Food Service - Institution
( Meals/Day)
❑ Bakery $25
❑ Caterer $25
❑d Food Delivery $25
❑ Milk & Cream $2
FI Mobile Food & Consession $50
❑ Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
❑ Pushcart $25 # of Pushcarts:
❑ Residential Kitchen $25
❑ Retail Food $50
❑ Retail Snack Food $10
❑ Tobacco Products No Fee
23 FoodO Operations
P
(Check all that apply):
Definitions.PNF- Potentially hazardous food(time/temperature controls required)
Non-PNF's - non -potentially hazardous tood(no time/temperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PFHs
I] 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 RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Delivery of Packaged PHFs
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
I] Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
❑ Customer Self -Service of Non PHF and Non-
Perishable Foods Only
❑ Customer Self -Service
❑ Ice Manufactured and Packaged for
Retail Sale __.
n Preparation of Non-PHFs
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
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 Healfh
Total Permit Fee: $125.00
Payment is due with application F1 waived
I, the undersigned, attest to the accuiacy e I ormation provided in this application and affirm that the food
establishment operation will comply with C 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain c6Ries� f 0 MR 590.000 and the federal Food Code.
24) Signature of Applicant: \Ay"(/ -
Pursuant to MOL 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 to: 04-2844750
26) Signature of dividual or Corporate Name: p I 0 z
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 (Mandatory)
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Numb
* This license will not be issued unless the 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 Mass. General Laws, Chapter 620, Section 49A.
r The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
*aS�uuzaxY
Phone zleoee) ,_4�g=. 12S-C)o
Are you an employer? Check the appropriate box:
Business Type (required):
1.9
I am a employer with employees (full and/
5. ❑ Retail
or part-time).*4Gt.us A CCk5-stylt
6. Restaurant/Bar/Eating Establishment
2. ❑
1 am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (me], 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]*
] ❑Health Care
4.
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. rNo workers' comp. insurance req.j
12.0 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 check box # 1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. # W,4 9 It D a54o a(B 3 — 0;( 6 Expiration Date: hot? _
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 dayA ai st the�violator. Be advised that a copy of this statement may be forwarded to the Office of
InvestiQatletls of the,fSIA r itt�urance coverage verification.
I do hereby certify, and t pains penalties of perjury that the information provided
{/a/boove istrue and correct.
Phone #: �0 g 4' (_3.5/ ` g 5 oC)
Official use only. Do not write in this area, to be completed by city or town offlelal
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
-his certificate is useculed by Liberty Mutual Insurance Group as respects such insuance as is r1haded by do,conl I1MU0ha
Certificate of Insurance
This ceuificros is issued as a nroue, of intonation only and confers no rights upon the ceuificats bolder. This ceuifcate is not on insurance policy and does not aImitatively or negatively amend, extend, or
alter the covert, afforded by the Policies listed below. Policy limits are no less than those listed, elt came, policies may include additional subli ous not listed below. Policy limits may be reduced by claims
or other payments.
This is to certify that (Name and address of Insured)
Bertucci's Corporation and as per attached
155 Otis Street
Northbon ough, MA 01532-2414
m not altered by any requirement.
Exydration Type
Continuous*
Extended
X
Policy Term
Workers Compensation
General Liability
HClaims Made
X Occurrence
Retro Date
Automobile Liability
X Owned
X Non -Owned
X Hired
07/01/2008 / 07/01/2009 1 WA7-IID-256263-048
07/01/2008/ 07/01/2009 1 TB2-111-256263-038
to all their (eons, exclusions and conditions and
Coverage afforded under WC law of
the following states:
CT, DC, DE, MA, MD, ME, NC, ND, NH,
NJ, NY, PA, RI, SC, VA, WA
Employers Liability
Bodily Injury By Accident
$1,000,000 Each Accident
Bodily Injury By Disease
$1,000,000 Policy Limit
Bodily Injury By Disease
$1,000,000 Each Person
General Aggregate -Other than Prod/Completed Operations
Products/Completed Operations Aggregate
Bodily Injury and Property Damage Liability I Per
Personal and Advertising Injury I Per Person /
Other Liability Other Liability
Fire Legal Liab $1,000,000 Medical Exp $2,500I
07/01/2008107/01/2009 1 AS2-I11-256263-058 I Each Accident- Single Limit- B. I. and P. D. Combined
Each Person
Each Accident or Occurrence
Each Accident or Occurrence
LIQUOR LIABILITY 07/01/2008/07/01/2009 ITOI-111-256263-028 I 1,000,000 Each Common Cause Limit
$2,000,000 General Aggregate Limit
C I The workers compensation and General Liability policies include deductible endorsements.
O Ther is a $250,000 deductible limit for WC and a $250,000 limit per occurence on the general liability with the provision that Liberty Mutual will advance payment ofthe
M deductible amounts.
E
N
T
HAPORTANT If the cenioene holder is an ADDITIONAL mSDRED, the peloo,ba) most be endorsed. A scaa c,nt em no, laureate ears no, caner items a the cenmeme name, Inn emit. I
SUBROGATION IS NAIVED, subject to the foe¢ and conditons of the policy, ..mainpalicies may require an endorzemem. A statement on this cedificme deer not confer rights to the Atli&ate holder in lieu ofsoch endorsements.
The follmvin, al,arat nnly,vitb respect to mocunce fonnoWearrias registered in flerida As provided to, in Fla. Sta11320a2(5)wL he listed insurance polity may not be cancelled on less than 30 days written notice by the insurer
to the Deparin¢nl of they Safety & Motor Vehielto, such 30 days notice to coin......¢ from date ounce is received by the Depamnent.
mill not cancel or reduce the insurance anordd under deserve policies
Office: WESTON, MA -SOUTH Phone: 781-891-8900
Certificate Holder:
FOR RECORD PURPOSES ONLY
c/o Bertucci's Corporation
155 Otis Street
Northborough, MA 01532
muse ofacel, caacdlmmn has beer mailed to the the. hated Cemelate Holder.
CLARE HALLAHAN
Date Issued: 10/29/2008 Prepared By: KS
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Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Sell Milk and Cream
This is to certify that:
BERTUCCI'S RESTAURANT, CORP.
having a place of business at:
BERTUCCI'S ITALIAN RESTAURANT
280 SCHOOL STREET
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 June 01, 2010, unless previous to that time is
suspended or revoked.
Expires: June 01, 2010
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred