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Home My WebLink AboutCorporate Chefs @ Smith/Nephew - 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:. CORPORATE CHEFS Whose place of business is: CORPORATE CHEFS @ SMITH & NEPHEW 130 FORBES ROAD PERSON(S) IN CHARGE: SUE TATTERSALL Permit Expires: June 01, 2010 License Number: FS-10 Food Fee: $75.00 Milk & Cream ❑O BOARD OF HEALTH Dr. Raymond Martin, Chairman 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., CORPORATE CHEFS having a place of business at: CORPORATE CHEFS @ SMITH & NEPHEW 130 FORBES ROAD 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 Licen§e'No.: FS-10 Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-10 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: CORPORATE CHEFS @ SMITH & NEPHEW 2) Establishment Address 130 FORBES ROAD 3) Establishment Mailing Address (if different) 130 FORBES ROAD MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 261-3710 5) Applicant Name & Title: SHAYNA CAMPIOLA, LICENSE ADMIN. 6) Applicant Address 22 PARKRIDGE ROAD, HAVERHILL, MA 01835 7) Applicant Telephone No.: (978) 372.740D 24 Hour Emergency No.: (978) 372-7400 8) Owners Name & Title CORPORATE CHEFS 9) Owner Address (If different from applicant): 22 PARKRIDGE ROAD, HAVERHILL, MA 01835 10) Establishment Owned By: ❑ An Association V 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 d /� 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 6 u 2 —��/d^cSQGf Address: Telephone No: �6k 3 1-6� �+1 24 Hour Emergency No: - �CEi �� FAX: //al. % 1 C 13) District Or Regional Supervisor (if applicable) Name & Title: !' L.i�f` Address:�� _ Telephone No: `� (} {f �}� r �° 24 Hour Emergency No: Gq-2� 322- 4) f l FAX: 'j - Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: M-F 6:30 AM-3 PM 18) Name of Person In Charge Certified in Food Protection Management: SUSAN D. TATTERSALL 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 Anli-Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location 22) Establishment Type ❑ Bakery $25 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Caterer $25 Mobile End Date: Food Service up to 100 or ❑ Food Delivery $25 Mobile Comments: up to 10' PHF display $75 ❑ Food Service up to 101 -200 I] Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: ❑� Annual or up to 25' PHF display $100 ❑ Mobile Food Temporary $25 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ❑ Manufacture Frozen Dessertslice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Retail Food $50 Temporary End Date: ❑ Retail Snack Food $10 Temporary Time: ❑ Tobacco Products No Fee Rain Date: ----- 23) Food Operations Definitions: PHF-Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑J Sale of Commercially Pre -Packaged Non-PFHs ❑d PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non- ❑� Customer Self -Service - ❑Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for contact alternative, time as a public health ❑J Preparation of Non-PHFs Retail Sale - control) 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 Health l _ Total Permit Fee: 0 �, Payment is due with application ❑ 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 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtaiino/pie, s of 1105?CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 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 ID: 04-2981626(',1� y�se_Tjt_. �y 26) Signature of Individual or Corporate Name: C , f., r d �'c.` . �� ' 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: CORPORATE CHEFS @ SMITH & NEPHEW ADDRESS: 130 FORBES ROAD TELEPHONE AT LOCATION: (508) 261-3710 FAX NUMBER: (978) 372-0150 OWNER OF BUSINESS: CORPORATE CHEFS TELEPHONE OF OWNER: (978) 372-7400 FEDERAL ID/SS NUMBER: 04-2981626 FEE: $2.00 PERMIT NUMBER: FS-10 SIGNATURE: DATE: 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) ** 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 taws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations V�'' l 600 Washington Street Boston, MA 02111 •t ;� www.lnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: &,,P_40eArS (�9Wt-'5 Ale _ _— A.ddress: a'/r2 City/State/Lip:�d fflLL A4 01&r Phone #: ffP -37-- - 75L� Are you an employer? Check the appropriate box: Business Type (required): 1.0 1 am a employer with .1 S employees (full and/ 5. ❑ Retail or part-time).* 6. ®Restaurant/Bar/EatingEstablishmeilt 2. ❑ i am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g. ❑ Non-profit (No workers' comp. insurance required] 3. ❑ We arc a corporption and ita officers have cxcr6sed ................ 9. ❑ ButeAainmctic . ' ..... their right of exemption per c.152, ¢1(4). and we have 10.0 Manufacturing no employees. (No workers' comp. insurance required)' 11.0 Health Care 4.[] We are a non-profit organization, staffed by volunteers, ...:n. .... ......rm.ane INn rmmn insurance real 12.❑ Other -Any applicant that checks boa ill mutt also fill out the sectimbelow shoving their wtokea' compmsatioa policy infomsstiaa. •elf the corporate officers have exampled themselves, but the eosporadon has other employ—, a "tk— compensation policy is rrquired and such an otganiudou should check box Ill. iamanimployerthatisprovidingworkers'compensationinsuranceformyemployees. Below sfhepolicyinforma.non. lasuranceCompany Name: LUAUSA W r7llS/rt1F5S /,t/pUw?e4(NF ele oA,t/1/ Insurer's Address: 3l00 4GL..490M�CIZ 1 City/State/Zip.� GfJsub fades CT ejL0V Policy # or SW ins. Lie. N_ Q1lC kit 9/�f3SS�1�iOP% Expiration Dater/Zoi fla 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 a 152 can lead to the imposition of criminal penalties of a fine up to S 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. f do hereby ce d,64 under the pains and penalties ofperjury that the information provided above is true and correct: 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): 3. Board of Health 2: Building Department 3. City/Town Clerk 6.Other 4. Licensing Board 5. Selectmen's Office- _ r ._F.. Contact Person: Phone Client#: 79670 CORPOCHEF ACORDra CERTIFICATE OF LIABILITY ' INSURANCE l;24120008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION WAUSAU SIGNATURE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 360 BLOOMFIELD AVE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. --- SUITE 405 WINDSOR, CT 06095 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Wausau Business Insurance Company 26069 CORPORATE CHEFS INC INSURERB: Employers Insurance Company of Wausa 21458 22 PARKRIDGE ROAD INSURERC: Wausau Underwriters Insurance Co. 26042 HAVERHILL, MA 01835 INSURER D: NSURER E: COVERAGES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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, LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM D POLICY EXPIRATION DATE M DD LIMITS A GENERAL LIABILITY YYKY91435574018 10/01/08 10/01/09 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAPREMGE TO RENTED $300000 CLAIMS MADE QOCCUR MEDEXP(Anyoreperson) $10000 PERSONALSADV INJURY $1 0OO OOO GENERALAGGREGATE $2 00O 000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO 52000000 POLICY JET LOC A AUTOMOBILE X LIABILITY ANY AUTO ASKY91435574028 10/01/08 10/01/09 COMBINED SINGLE LIMIT (Ea accident) a1000,000 , BODILY INJURY (Per Person) $ ALL OWNED AUTOS SCHEOULEDAUTOS X BODILY INJURY (Per ar denl) $ HIREDAUTOS NONOWNEDAUTOS X X PROPERTY DAMAGE (Per acciden8 $ COMPREHENSIVE $500 DED ACV $500 DED ACV - X COLLISION GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO _ $ AUTO ONLY: AGO B EXCESSIUMBRELLA LIABILITY THCY91435574078 10/01/08 10/01/09 EACH OCCURRENCE $10000000 OCCUR CLAIMS MADE AGGREGATE $10000 000 S $ DEDUCTIBLE X $ RErENrION $ 10000 A WORKERS COMPENSATION AND WCKY91435574089 01/01/09 01/01/10 WC STATu OTH- EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACC IDEM ESOO OOO E.L. DISEASE -EA EMPLOYEE $SOOOOO OFFICERIMEMBER EXCLUDED? If es, desesniae under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT 1 $500000 C OTHER GENERAL LIAB TOJY91435574068 10/01/08 10/01/09 AGG LIMIT $2,000,000 EACH COMMON CAUSE $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS i FOR INFORMATION ONLY THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATIC THE ISSUING INSURER WALL ENDEAVOR TO MAIL _Rn DAYS WRITTEN JERTIRCATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL GATION OR LIABILITY OF MY KIND UPON THE INSURER ITS AGENTS OR S of 2 fR45339931M522d35 - - Kmn - "'" " -o ACORD CORPORATION 198E Susan Tattersall 0 Keith Thomas o has completed the requirements for u ` o has completed the requirements for (� 0.0 o `Chokesaver W/Restaurant Emergencies ,yV aVy „ Chokesaver w//Restaurant Emergencies 60 E Q� y 3 conducted by y 3 conducted by a Corporate Chefs @ BBN Technologies Date completed a Corporate Chefs @BBN Technologies Date completed to II/28/2007 ro 11/28/2007 The American Red Cross recognizes this certificate The American Red Cross recognizes this certificate as valid N/A years) from completion date. as valid foN/A year(s) from completion date. C: Cy v0 Q V 9 Q 0: 1: M 0 c a v P 9 i N a 3 a w w N a 3 w a r This recognizes that Joseph Toppi has completed the requirements for Chokesaver w//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed 11/28/2007 The American Red Cross recognizes this certificate as valid f�/A year(s) from completion date. This recognizes that Dirceu Veiga has completed the requirements for Chokesaver w//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed The.dmencan Red Crass seco;mz0e this certificate as valid for N/A year(s) from completion date. \ This recognizes that Dina Wardwell has completed the requirements for Chokesaver vy//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed 11/28/2007 The elnrerican Red Cross recognizes this certificate as valid for year(s) from completion date. N/A This recognizes that Sarah West has completed the requirements for Chokesaver w//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed 00 The American Red Cross recogn s zethis certificate as valid for year(s) from completion date. nize u C0 0 V� rV 0 go: o' 'a w, U 3 u w a N 0 3 v m N U 3 w a i N U 3 0 ti This recognizes that Dayson Veiga has completed the requirement§ for Chokesaver W/Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed 11/28/2007 The American Red Cross recognizes this certificale as valid fob/A vear(s) from completion date. This recognizes that Melissa Vejar has completed the requirements for Chokesaver w//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed I ecog2007 TheAmerican Red Cross recognizes this certificate m valid toN/A war(s) from completion date. This recognizes that Donna Warne has completed the requirements for Chokesaver w//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed 1 1 /28/1007 The American Red Cross recognizes this certificate as valid for )ear(s) from completion date. \ N/A This recognizes that 1,rsa Whitney has completed the requirements for Chokesaver w//Restaurant Emergencies conducted by Corporate Chefs @ BBN Technologies Date completed The American Red Crass 11/28/2007recognizes this certificate it as valid for year(s) from completion date. S7118 Universal Cert. 653998 (Rev. Oct. 2001) CORPORATE CHEFS OFFICERS Ken Bickford President t0 Windmill Lane Atkinson, NH 03811 Alan Ayres Treasurer 34 Sable Run Lana Methuen, MA 01844 David DesRusiers Vice President 52 River Mead 01836 w. Newbury,