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HomeMy WebLinkAboutClaire'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: 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:. CLAIRE'S BOUTIQUES, INC. Whose place of business is: CLAIRE'S #5324 280 SCHOOL STREET, SUITE #J150 PERSON(S) IN CHARGE: JENNIFER DONAHUE, DISTRICT SALES MANAGER Permit Expires: June 01, 2010 License Number: RF-1 Food Fee: $10.00 BOARD OF HEALTH Dr. Raymond Martin, Chairman 1Y 05/27/2009 WED 10140 FAX ®0o2/ooe _._ FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued RF-1 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted a(least 30 days before the planned opening date__,_, 1) Establishment Name: CLAIRE'S #6324 2) Establishment Address 280 SCHOOL STREET, SUITE 9J150 3) Establishment Mailing Address (if different) 3 SW 129 AVENUE, SUITE 400 PEMBROKE PINES, FL 33027 4) Establishment Telephone No: (508) 339_6186 5) Applicant Name & Title: SONIA TEJEDA, LICENSE SUPERVISOR 6) Applicant Address 7) Applicant Telephone No.: (e54) ass-s900 8) Owners Name & Title 3SW 129 AVENUE, SUITE 400, PEMBROKE, FL. 33027 24 Hour Emergency No.: (000) CLAIRE$ (262.4737) CLAIRE'S BOUTIQUES, INC. 9) Owner Address (If different from applicant): 3 SW 129 AVE. SUITE 400, PEMBROKE PINES, FL. 33027 10) Establishment Owned By: n An Association n 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 s�- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: St�o d1�1r1SFj'a(d K Telephone No: 'Sox bqs-(�f FAX: SSOO...._ eyy�> 13) District Or Regional Supervisor (if applicable) Name & Title: Address: 24 Hour Emergency No: Telephone IN 24 Hour Emergency No: FAX: 05/27/2009 WED 10:40 FAX 0003/006 14) WATER SOURCE: TOWN DEP Public Water Supply No: (if appli0ab1e) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: IV 17) DAYS/HOURS: - 7 DAYS MALL HOURS 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required a5 of 101112001 in accordance With 105 CMR 590_003(A) Please attach cc L19) Person Trained in Anti -Choking Procedures (if 25 Seats or more): W 20) Location: Q Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: Retail ( 1.250 Sq. Ft) Mobile End Date: ❑ Food Service up to 100 of Mobile Comments: up to 10, PHF display $75 21) Length of Permit: �f Annual ❑ Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time; Rain Date: III Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 LJ Food Service - Institution N ❑ Bakery $25 Lj Caterer $25 Food Delivery $26 ❑ Milk & Cream $2 Mobile Food & Consession $50 n Mobile Food Temporary 325 n Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: 1 1 Residential Kitchen $25 Meals/Day) U Retail Food $50 2 Retail Snack Food $10 ❑ Tobacco Products No Fee 23 Food Opemttons Defimrions:pHF- Pofenflally hazardous food(limartemperature commis required) Non-PHFs -non-pofenliallyhozardous foud(no fime/temperalure controls requ/red) Check all that apply): RTC-roady-to-eaf loads (Er. sandwiches, salads, muffins which need no tudherprocessing) Sale of commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only .n Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service [-J Sale of Raw animal Foods Intended to be Prepared by Consumer Customer and Packaged for Retail Salo Juice Manufactured and Packaged Retail Sale Offers RT& PHF in Bulk Quantities Retail Sale Of Salvoge, Out -Of -Dail or Reconditioned Food ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ 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 ) ... _..... ❑ Offers Raw Or Undercooked Food Of Animal Origin LJ Prepares Food/Singla Meals for Catered Events or Institutional Food Service To be completed by Total Permit Fee: 1­3 Payment is due with application I, the undersigned, attest to the accuracy of the information vrdean IQd in th'�llcable plication and affirm that the food bosrdl�of health on holes to olblaln copies of 105 CMR 5900 00 and 1tJah dFoodCode,l have been instructed by the 24) Signature of Applicant:' Pursuant to MGL Ch.62C, sec. 49A, 1 certify under t e penalties of perjury that I, to my best knowledge and belief, have tiled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID; 36-20253 �� 26) Signature of Individual or Corporate Name: 0004/006 05/27/2009 PIED 10:60 FAX I certify under the penalties of perjury that 1, 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: Corpo t Offi er (Mandatory, if applicable) (o - 3o2 5-!)0 ** Social Security Number (voluntary) or Federal Identification Number k 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. 05/27/2009 WED 10t69 FAX QJ005/006 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Roston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C-lof"tres VJ°At�c�cS �c- Address: W 9 �V) Avg ' Sut /L (too City/State/Zip: P6rvv1�v0 �- PiRP FL'O�U�`FPhone #: Are you an employer? Check the appropriate box: 1.am aemployorwith 5 eGI (full) andl/ or pan -time).` tR�X Y` 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 We arc a corporation and its officers have exercised their right of exemption per c. 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 req.) Business Type (required): 5. ESERetail 6. © Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (!no]. real estate, auto, cta) 8. ❑ Non-profit 9, ❑ Entertainment 101-1 Manufacturing 11,❑ Health Care 12F1 Other *Any applicant that cheoks box NI must aIgo fill as the section below showing Their workcn' compcnsution policy information. +*If the corporate officers have exempted themselves, but the corporation has otha omployocs, aworkers' compensation policy is Mloircd and such an organ intion should chock box #1. I am an employer that isproviding workers compensation Insurance for my employees, Below is t/ee policy information, insurance Company Name: Apra (�t5 Sl:YvlrCe/3 �,ft)y- _r in .. Insurer's Address: m6l[ wq ky- ...... —_—,— Ci /State/zi tJ Y CJ\_ t% g:-' S_� Policy # or Seif-ins. Lie. #,_TPJu 13261 K05W 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 e. 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 i....nef;natimts of the MA for insurance coverago vorifloation. I do hereby res of perjury that the Official use only. po not write hi this area, to be completed by city or town ofciaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6, Other Contact Pormit/Licenso 0 is true and correct 3. City/Town Clerk 4. Licensing Board 5, Selectmen's Office Phone OFFICERITITLE CFO VICE PRESIDENT OFFICERS AND DIRECTORS NAME J. PER BRODIN DAVID G. OVIS ADDRESS 3 SW 129TH AVE PEMBROKE PINES, FL 33027 3 SW 129TH AVE PEMBROKE PINES, FL 33027 SECRETARY REBECCA ORAND 3 SW 129" AVE PEMBROKE PINES, FL 33027 ALORD OF L CERTIFICATE L4BIIITY`INSIJRAlVCE DATE(MM/DD/VYW) ,,,,, ,, ; ,, o2/os/2oos PRODUCER ADD Risk Services Northeast, Inc. New York NY office THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 199 Water street CERTIFICATE DOES NOT AMEND, EXPEND OR ALTER THE New York NY 10038-3551 USA COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAICN Pnorve-(866) 283-7122 FAX- 847 953-5390 INSURED INSURER A: charter oak Fire ins co 25615 INSURERS: Travelers Property Casualty Ins co 36161 Claire's Stores, Inc. Attn: Cynthia Machonis INSURERC: Travelers Property cas CO of America 25674 2400 W. central Rd. Hoffman Estates IL 60195 USA DISCREET) continental Casualty Company 20443 INSURERS 'COVERAGES i ., "'° "" =`,SIR' app I Tres er,,tePms"an coyi ti tilts �0,,t e= 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. AGGREGATE LIMITS SHOWN MAY HAVE, BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED INSR MR ADEPT INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MMUMANY) POLICY EXPIRATION DATE(MM\DIAW) LIMITS C ERALLIABILITV TJEXGL281KO591TIL09 01/29/09 01/29/10 EACH OCCURRENCE $1,000,0 00 DAMAGETORENTED PREMISES (Ea occurence) $1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMSMADE ®OCCUR NX P MERE yoneperson) SIR: $250,000 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGO $10,000,000 0POLICY ❑ JJECT ❑ LOC C C AUTOMOBILELIA➢ILITV X ANY AUTO TC23CAP281KO578TI1-09 All states TJBAPIIOOL15ATIL098 01/29/09 01/29/09 01/29/10 01/29/30 COMBINED SINGLE LIMIT (Eae,,idea0 $2,000,000 BODILY INJURY ALL OWNED AUTOS Physical Damage SCHEDULED AUTOS ( Per persoiQ HIREDAUTOS BODILY INJURY NON OWNED AUTOS (Per occiden0 Comp/collision Ded: $500 X PROPERTYDAMAGE (Per weir[M) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ANY AUTO OTHER THAN EA ACC B AUTO ONLY: AGO D EXCESS RNIBRELLA LIABILITY L2099751412 01/29/09 29 10 EACH OCCURRENCE ElOCCUR ❑ CLAIMS MADE AGGREGATE $16,000,000 BDEDUCTIBLE RETENTION $10,000 A B WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMSER EXCLUDED? TC 0OB281KO11209 AllTRJother state All Other states AZ{—MA,"OR,WI 0 29 09 01/29/09 01/29/10 X WC STATU- TORY LI O0r- ER E.L. EACH ACCIDENT $500,000 E EMPLOYEEL. DISEASE -EA EMPLOYEE $500, 000 We, descrilee under SPECIAL PROVISIONS E.L. DISEASE -POLICY LIMIT $500,000 belau OTHER DESCRIPTION OF OPERATIONSIIACATIONSNEfIICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE: Store No. 5324. As Per Attached Additional Insured Endorsement and Claire's Required certificate Attachment. CERTIFICATE HOLDER 'CANCELLATION, Route 140 School Street LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION S.R. Weiner and Associates, Inc. 1330 Boylston street, Suite 212 y chestnut Hill MA 02467 USA DATE TIIEREOF,THEISSUING INSURERWILL ENDEAVORTO MAIL JO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE •�� O 25 2001/OB AC✓ORD CORPORATION,19ifl