The URL can be used to link to this page

Home My WebLink AboutChipotle -6/1/2010Commonwealth 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: FOOD 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:. CHIPOTLE MEXICAN GRILL OF COLORADO, LLC Whose place of business is: CHIPOTLE MEXICAN GRILL #1113 287 SCHOOL STREET, BUILDING B, SUITE 110 PERSON(S) IN CHARGE ERIK BURNS, AREA MANAGER Permit Expires: ,June 01, 2010 License Number: FS-78 Food Fee: $75.00 HEALTH Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION —(Application MUStbo Submitted a eas - aye a p anne open ng ate) 1) Establishment Name: CHIPOTLE MEXICAN GRILL #1113 2) Establishment Address 287 SCHOOL STREET, BUILDING B, SUITE 110, MANSFIELD, MA, 02048 3) Establishment Mailing Address (if different) ATTN: LICENSING 1401 WYNKOOP STREET, SUITE 500, DENVER, CO 80202 4) Establishment Telephone No: 508-339-2061 5) Applicant Name & Title: CHIPOTLE MEXICAN GRILL OF COLORADO, LLC 6) Applicant Address ATTN: LICENSING 1401 WYNKOOP STREET, SUITE 500, DENVER, CO 80202 7) Applicant Telephone No.: 303-222.2646 24 Hour Emergency No.: 8) Owners Name & Title SAME 9) Owner Address (If different from applicant): SAME 10) Establishment Owned By: IRK] An Association O A Corporation III An Individual ® A Partnership Other legal Entity LLC 11) If a corporation or partnership, give name title, and home address of officers orpartner. LIMITED LIABILITY COMPANY Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Erik Burns, Area Manager ..Address: 112 Newbury Street, Apt 2 K, Boston, MA 02116 Telephone No: 614-537-6303 24 Hour Emergency No: 614-537-6303 FAX: 614-232-0688 E-mail: Alt E-Mail: 13) District Or Regional Supervisor (If applicable) Name & Title: Bethany Strong, Regional Supervisor Address: 48 Ridgewood Avenue, Glen Ridge, NJ 07028 Telephone No: 703-624-5160 24 Hour Emergency NO: 703-624-5160 FAX: 973-707-7183 Food Establishment Information 14) WATER SOURCE: (J a t�1 t (, 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) _ 16) No. Of Food Employees: EST 25 17) DAYS/HOURS: 11:00 AM - 10:00 PM 7 DAYS A WEEK 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. -r'30 Required as of 10/l/2001 In accordance with 105 CMR 590.003(A) Please attach copy of certlltcate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): D 20) Location: x] Permanent Location Mobile Mobile Start Date: Mobile End Date: Mobile Comments: OX Annual r? Seasonal N/A Seasonal Dates: JJ Temporary Temporary Start Date: Temporary End Date: N/A Temporary Time: Rain Date: 22) Establishment Type B Retail ( Sq. Ft) X] Food Service up to 100 or up to 10' PHF display $75 0 Food Service up to 101 .200 or up to 26' PHF display $100 El Food Service up to 201 + or 26'+ PHF display $125 ® Food Service - Institution Meals/Day) E] Bakery $25 [j Caterer $25 El Food Delivery $25 El Milk & Cream $2 ( I Mobile Food & Consession $50 Mobile Food Temporary $25 Manufacture Frozen Desserts/Ice Cream $5/freezer Q Pushcart $25 * of Pushcarts: 71 Residential Kitchen $25 0, Retail Food $50 i] Retail Snack Food $10 Tobacco Products No Fee 23) Food Operations Dellnifims: PHF- Potentially hazardous food (tlmertergoeratum controls required) Non-PHF's -non-polentlellyhazardous food(no fimeRempemium controls required) (Cheek all that apply): RTE -ready-toeat foods (Ex sandwtclws, salads, murrins which need no furtherprocessing) H Sale of Commercially Pre -Packaged Non-PHFs n PHFCooked To Order jO Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs XJ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly ly [J Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of FooCo ds for Geri to be Prepared b Consumer Processed Foods for Service Within 4 Hours p y 0 Vacuum Packaging I Cook Chill Customer Self -Service of Non PHF and Non- Perishable Foods Only - e Customer Self -Service Requiring Use o Process Re ulrin A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) El Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for Retail Sale [I Offers Raw Or Undercooked Food Of Animal Oriain 171 E-gRetall fRTE In Bulk Quantities 9 Prepares Food/Single Meals for Catered Events or Institutional Footl Service lvage, Qut-Or Dated Food To be completed by the Board of Health ---- Total Permit Fee: Payment is due with application El 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 106 CMR 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 106 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 tax returns and paid slate taxes required under law. 25) Social Security Number or Federal to: 84-148599 26) Signature of Individual or Corporate Name: — CHIPOTLE MEXICAN GRILL OF COLORADO, LLC 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) By: Corporate Officer (Mandatory, if applicable) 84-1485992 ** Social Security Number (Voluntary) or Federal identification Number * 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 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 If www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le 'blv Business/Organization Name: CHIPOTLE MEXICAN GRILL 287 SCHOOL STREET, BUILDING B, SUITE 110 City/State/Zip: MANSFIELD, MA 02048 Phone #: PENDING Are you an employee? Check the appropriate box: Business Type (required): 1. IX] I am a employer with EST 25 employees (full and/ 5. ❑ 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' romp, insurance required] g. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §l (4), and we have 10.❑ Manufacturing 4. El no employees. [No workers' comp. insurance required]* We 11.❑Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box NI most also fill out the section below showing their workers' compensation policy information. **If the corporate ofoers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 01. I am an employer that Is providing workers' compensation Insurance for my employees. Below is dire policy Information. Insurance Company Name: ZURICH AMERICAN INS. CO. Insurer's City/State/Zip: 550 W. WASHINGTON BLVD. CHICAGO, IL 60661 Policy H or Self -ins. Lie.. # WC929911208 Expiration Date: 10/12/2009 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 coveraee verification. do herebycer*, corder the pains and penalties ofperjury that the information provided above it true and correct mature: L 6f W `� Date' _ =' M___ L. 303-222-2546 Official use only. Do not write /it this area, to be completed by city or town official City or Town: PermillLicense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, Cityffown Clerk 4. Licensing Board 5. Selectmen's Office 6.Other,__— _ Contact Phone www,mss.gov/dia Icn I I'"® MEXICAN GRILL June 23, 2009 VIA FED EX Town of Mansfield Health Department 6 Park Row Mansfield, MA 02048 508-366-3045 nnm 303.222.2517 CHIPOTLE MEXICAN GRILL, INC. FAX 303.376.5397 1401 WVNKOOP STREET, SUITE 500 w chipotle.com DENVER, CO 80202 III JUN 2 4 2000 RE: Food Establishment Permit Application for Chipotle Mexican Grill To Whom It May Concern: Enclosed, please find a Food Establishment Permit Application, along with a check in the amount of $75.00, made payable to the Town of Mansfield for Chipotle Mexican Grill of Colorado, LLC d/b/a Chipotle Mexican Grill #1 1 13 at 287 School Street, Building B, Suite 110, Mansfield, MA, 02048 For a timely response, please send future license, correspondence and/or invoices to the following address: Chipotle Mexican Grill Attn: Licensing 1401 Wynlcoop Street, Suite #500 Denver, CO 80202 I appreciate your assistance in this matter and please call Denise O'Brien with any questions (303-222-2546). Sincerely, f Renee Miller Licensing Coordinator Enclosures FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: �r 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: TED 5) Applicant Name & Title: 6) Applicant Address: 5,> 7) Applicant Telephone No: --�90 r 9960 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): P t l h 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of An association officers or partner. Name Title Home Address 6 A corporation — m An individual ® Apartnership C>,n %fie G /SYf y/c(ace, m Other legal entity L,Cy�" v �o �2t�0r�. AVE3f IOv- CFO 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc. Name & Title: Address: Telephone No: Fax: Emergency Telephone No: 13 District Or Regional Su rvisor if a licable Name & Title: Address: x '" GUF tl vzid O O Telephone No: / S Fax: >Yuappncauono-aaoc Food Establishment Information 14) Water Source: PGLW;C_ 15) Sewage disposal: c- DEP Public Water Supply No: (if applicable) r Lt iJ/l 16) Days and Hours of Operation: /0 4A - jjP/1 ��uy� 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: 713D Required as of 101112001in accordance with 105 CMR 590.003(A Please attach copy ofcgnlp afe. 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): 44es ® No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery Permanent Structure f/ Food Service - ( Seats) ❑ Residential Kitchen for Retail Sale ❑ Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service - Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) Annual ❑ Seasonal/Dates: ❑ Temporary/Dates/Time: Darinitions: PHF- potentially hazardous food(time/temperature controls required) 23) Food Operations: Non-PHFs - non- potentially hazardous food (no time/temperature controls required) check all that e I RTE- ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre- PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service. ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility Service. ❑ Delivery of Packaged PHFs ❑ Sale Of Raw Animal Foods Intended ❑ Vacuum Packaging/Cook Chill to be Prepared by Consumer. ❑ Reheating of Commercially ❑ Customer Self -Service ❑ Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ 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. ❑ Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged ❑ Prepares Food/Single Meals for Catered I for Retail Sale Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (q escribe): To be completed by the Board of Health CAh 'r6n "', "I- Total Permit Fee: coi 0�d&- ❑ Retail Sale of Salvage, Out -of Date Payment is due with application or Reconditioned Food I, 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 -05 CMfj9"00 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 tax returns and paid state taxes required under law. 26) Social Security Number or Federal ID: >;i C1 '" J�Z n "7 26) Signature of Individual or Corporate Name: 6 cZ G O LL Q X W Go ID PI O Ln N to W Q u LL M H W u m 1 y y o z ZO N _ R- U U N H T a q Jz