Loading...
HomeMy WebLinkAboutCafe on the Common - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued / l �Il' FOOD ESTABLISHMENT PERMIT APPLICATION ` � (Application must be submitted at least 30 days before the planned opening date) Establishment Name CQ- • A"Yl 7n -c- (�(% rp m M `LN yC , ,o Establishment Address Id � Establishment Mailing Address (if different) /6 /}ud-ilb ey, or)v�e Establishment Telephone No 50 6? , 33 Applicant Name & Title: Dl a r )e Seat Applicant Address /,�' ,4140 h1X .✓ Applicant Telephone No.: &03 • 817-0:03 24 Hour Emergency No.: 67d 3 - 60/ 2 -ee?93 Applicant Email _I t Lp� q 6I t Owner Name & Title (If different from ap licant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or I._ An Association partner. VA Corporation Name Q i Title Addddre-s/s- c I An Individual )ane Be(4 4 �/ -e_4V eo �� /%�� - ./� d.,Ablw L A Partnership !/✓I% �/� �/00�/ Other legal Entity Person Directly Responsible For DailyOperations(owner, person in charge, supervisor, manager etc.) Name & Title: I Si)�il ri)a_r)Q '1 1l t U ypA 4V7 go Address: 3O -H ey- I�Gt� %Q.l <r �6�- Telephone No: -17?N .6_1 0- q.4 5 3 24 Hour Emergency No: 7? q FAX: E-mail: {J illy )L) 0q'? yAAoo. eam Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: �0 u SEWAGE DISPOSAL: wWyL DEP Public Water Supply No: (If applicable)2 No. of Food Employees: DAYS/HOURS:A _- -- Name of Person(s) In Chane 4`77,01W Certified in Food Protection nagement: SO/ ,,skr rprden Jer)rW Ca l�cartr� r ►- �+of. �► �a v, I +� y i Name of Per on(s) In Charge Certified in Allergen Awareness Training $)')I �"-is r (ej'lcn�t '1'uhiu.✓ 411i5ln R_,eA ihP,s r1 C Geyy Dif fiw Sea Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 peeppl,e or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. ,<SYes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: i Annual E Retail Food $125.00 i_:J Mobile Food Consession J Temporary ..'; Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 --i Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ,(j�ood Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: E Food Service up to 201 + $300.00 E Pushcart $50.00 # of Pushcarts: Temporary Time: E Supermarkets $400 L] Residential Kitchen $100.00 Rain Date: �Ik & Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (tlmeRerperalure controls required) Chk all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required) (ecPP y)' RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs JePHFCooked To Order U Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service I Sale of Commercially Pre -Packaged PHFs [_J Preparation of PHFs For Hot And _i Delivery of Packaged PHFs Cold Holding For Single Meal Service EPHF and RTE Susceptible Population Prepared pared For Highly Reheating of Commercially E Sale of Raw Animal Foods Intended to be Prepared by Consumer n Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Sell -Service of Non PHF and Non- F]Customer Self -Service contact alternative, time as a public health ❑ g control Perishable Foods Only Ice Manufactured and Packaged for ) J Preparation of Non-PHFs LI Retail Sale Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale IJ Vacuum Packaging / Cook Chill F -I Offers RTE PHF in Bulk Quantities n Prepares Food/Single Meals for E Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 obtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: ' "" ' i Pursuant to MGL Ch.62C, sec. 49A, I certify under the pen as of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. A�—tj oZ f 3� Social Security Number or Federal ID: Qy— .3 L Signature of Individual or Corporate Name: �� �' 0 �I for successfully completing the standards set forth For the SewSo(o® Food Protection Manager Certificalion Examination, which is accredited by the American National Standards Institute (ANSIf-Conference foe Food Protection (CFP). �.:..,�....,,Q . 5340 $ER EXAM FORM NUMBER itrt.. 3/12/2018 ` 3/12/2023 DATE Of EX DATE OF EXPIRATION ,cy for recertification requiremenh. Solutions mem-4 6 11N—d.e. C wW quvr ,.2135. Wol a6.N, Si 3M,, O ,. IL 60M003w5w re�swwg. 0 WILLIAM FISHER for saccessfulFy completing the standards set forth for the sawSafes Food Protection Manager Certificalion Examination, which is accredited 6y the American Nalional Standards Institute (ANSI) -Conference for Food Protection (CFP). 42381 5185 -: UMBER EXAM FORM NUMBER. 0% !AAlT 9/10/2021 E OF E DATE OF EXPIRATION w, apply. Cf, my for recerliflcaltoe regWreme.4. r � A r IIGP�C4A� _ m � �iaR.van ����❑ 1 iw� �� a y3o (a0+p in „'+ti m +�on,e I)Swblacn P}J. sro )Soo. G'+.qp, k. e060a a. sa.SdR�cnr�a.wn E°% E&D \o p -� u) m o'y ° goy f � &J QM * * mom} E§ �© �r � ({ ( Z . 0 /( ` (\ [( ,2 ) l � 77777, � L17 J\ M. m»� ra ( ` ! ° . {\ � Bp ; - ©r }� \,OD \�� ) $} z Do \ �\ \: � d»\/ 2 �_ a:.. � \\� {2 l � 77777, � Im I p W -d \ ® , \ ) � \ m ƒ (aJ \ 41 A )kƒ) \ u / \ / « \ a,\ m ƒ (aJ \ 41 )kƒ) \ % % to , \ #{\\ k \\\} \ m I .� On Im / \ § ) ƒ / \ )){{ \ \ \ \ \ %®\ -Jz0 o ©2< q§ /� 9! t ) u / \ )){{ \ %®\ \\\\ ) Rt? a \ \ � / � #E �5 I I I [ ) � } ) 0\ � aeza ` y»& 2 ) 00 { \ / ( \ );± ; z ® : \ t Cd 2 2 / k / 4.) \ ) / \ \ \ . zo o> G! Ln za�< 2 ) � } ) 0\ � aeza ` y»& 2 ) 00 / 42 \ );± ; z (\\\ � 2 2 � } aeza ` y»& / 42 \ z (\\\ � /� / / 2 I I ± $ )GF r --- � \ § ( § § e § § ) ƒ ƒ \ ) \00 # U 14� }\\\ \ u � \ \ f ± $ )GF r --- � \Ia,� /Ila 8 : «� ®> \�( ;q7 ) Al a■} \k\ / }\\\ R , f � ) m f Merrie Levy u 4z~ rlccere./flFccLGgj Y111" crr�sszJ/�.eteci The Always Food Safe Company Allergen Awareness Employee Food Safety Online Course & Exam Date: 01/25/2019 (valid+ until 1/25/2022) Course reference: ALGN Learner reference: ALGN100162141 This training is approved for 1 continuing education hourtoward the initial or recertification application for ACF certification Nick Eastwood The Always Food Safe Company President 899 Montreal Circle , St. Paul, MN 55102. The Always Food Safe Company www.alwaysfoodsafe.com Congratulations! Go ahead and frame the big copy-- you've earned it! Keep in your wallet for anytime, anywhere proof you passed! Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! ACCAEDIiED,- For your manager to keep and admire v,. the Always y Safe company al company Aa Y Alm, „x Meme Levy Merrie Levy the Alwe" Food sale Company Allergen Awareness Fmph,ee Food salary Online Celina & Exam W ne: 01/25/2019 (validt user 1/2512022) coa,a. rertr<a[c ALGN l......0 raa[<. ALGN100/62141 m.ma..amraaa<, This training Is approved for l coutinuing educatapplkalieion hour toward the initial or recertification n for ACF eedAkalbn 1 NI[4 Eailwaatl :e5itlmt ThONwaya raW sale Company 99 Menlreal Cirtle.SL VaW. MN 551oE. a1Sa3 iM1e Plwaya footl]a(a Cvnyany muWNwaysroopu(e<am Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! ACCAEDIiED,- For your manager to keep and admire v,. the Always y t, Safe' 7 company Aa Y vx Merrie Levy rM1e Always Fear) sola Company Allergen Awareness Employee Food salary Onaae Oauro, & ivere Dare: 0125/2019 (valWt until 125/2022) eoulae.erarew.: ALGN m.ma..amraaa<, ALGN10ing is a/ This training h approved for 1 congnublg etlucet -u hour toward the Initial or rocertilirali&n appi�atbnior 1 ACF certification waeu]w<m iM1a Nway[(aW 6are[emPanY a99Mm4eu1[4Cq.ELpauI, MN 33101. alio] In.1( ]M1<Nways Watlbre tmnpany www,alway. roo0ula.com ALUMNI REFERRAL CODE vc-alumref-30272-1129734 Managers: Get the best training for your staff at alwaysfoodsafe.com/manager and get 10% off $25 or more with this referral code! a 3, `r eellf�casfeOf" XY.012/PYP/�IZP/!2�`!+L /J4V,114O'r��fb: William Fisher the f Safe company Congratulations! Go ahead and frame the big copy-- you've earned it! Keep in your wallet for anytime, anywhere proof you passed! �clasc la -aloe .rtcrceerl�-e:e� co�i��Gea U' The Always Food Safe Company the Always Allergen Awareness ) Employee Food Safety Online Course & Exam Dater 01/24/2019 (valid+ until 1/24/2022) Course reference: ALGN Learner reference, ALGN1001601172 William Fisher This training is approved for 1 continuing education hourtoward the initial or recertification application for ACF certification Nick Eastwood The Always Food Safe Company #1203 President 899 Montreal Circle, St. Paul, MN 55102. The Always Food Safe Company www.alwaysfoodsafe.com -- Congratulations! Go ahead and frame the big copy-- you've earned it! Keep in your wallet for anytime, anywhere proof you passed! Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! For your manager to keep and admire x� the Always : ) ) Safe company company William Fisher William Fisher me Always Food sate company Allergen Awareness EmpI.Y.e Food S.1. Cnane Court.&Exam wre: 0112412019(validt until 112412022) _ cov,:..u.ren,u ALGN a.me.rm -- ALGN1004601172 ream.nerm.nw. This training is approved for t continuing eduwflon hour towaN theithat or recertification opplicalion for t ACF wnilication 1 rack s.aw.otl Feoa s.r. <.mpany m,eftlMt 4/99 Mmlreal[Irc1e.5L VaW. MH SlIo]. tl1E01r .niway. woo son mmvarn mw,.:lwaylooacalemm Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! For your manager to keep and admire x� ) Allways . Safe company William Fisher Tae N.Y, rood Solo Company Allergen Awareness Empley.e Food Wary Online Co.. & Exam oae: 012412019(validt until 1124/20n) eau... metre..., ALGN ream.nerm.nw. ALGNIC01601172 This training Is approved for 1 continuing education hour toward the inhixl or raceniticaflon applbetionfor 1 ACF certification w.x eum.ve mannan Faatl sam<omya ny enol w.m.m s9s M.,:esarasLvam.mH snov U. Plwaya FaaJ Sara fomvem vnmalwayafoatlsa(e.com ALUMNI REFERRAL CODE vc-alumref-30202-1127370 Managers: Get the best training for your staff at alwaysfoodsafe,com/manager and get 10% off $25 or more with this referral code! 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 Corporate Name By: Corporate Officer (Mandator, ifA cable) ,�- 355 aq3 l .Social Security No. (Voluntary) or Federal Identification Nuinber *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORMAm 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 Business/Organization Pho e #:3391 9/1-30 Are ygu an employer? Check the a propriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 2.❑ I 6. 09estamant/Bar/Eathng Establishment am a sole proprietor or partnership and have no 9. F] Office and/or Sales (incl. 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]* 4.® We are a non-profit by 1 IE] Health Care organization, staffed volunteers, with no employees. [No workers' comp. insuance req.] 12.Q 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 ane an employer that is providing workers' compensatiW insuryltce for my employees. Below is the policy information. Insurance Company Insurer's Address: 3&M 1 5eW_aJ-1 62/ 1/t7( City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date:-.q//ky 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, tender the pains and penaltys of perjury that the information provided above is tree and correct Offrcial use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Budding Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/din (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: The Twin City Fire Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 14974 Company Code: 7 POLICY NUMBER: 08 WEC NK6212 Previous Policy Number: 08 WEC NK6212 1. Named Insured and Mailing Address: CAFE ON THE COMMON INC (No., Street, Town, State, Zip Code) 16 AUDOBON RD WALPOLE MA 02081 FEIN Number: 04-3552431 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 12-14 MAIN ST MANSFIELD MA 02048 2. Policy Period: From 04/01/19 To 04/01/20 ANNUAL 12:01 a.m., Standard time at the'insured's mailing address. Producer's Name: UNDERWRITERS INS BKGE INC/PHS PO BOX 796 NORFOLK MA 0205607 Producer's Code: 08088324 Suffix LARS TRENEWAL C I 14 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866) 467-8730 Total Estimated Annual Premium: $9,906 Deposit Premium: Policy Minimum Premium: $265 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8,33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by d'4w,"-f 02/20/19 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 02/20/19 Policy Expiration Date: 04/01/20 Town of Mansfield Health Department APPLICATION FOR FATS. OILS, and GREASE DISCHARGEPERMIT '.i -h. •f►,, ,.. 0:. ,. Business/ Food Establishment Name: ('// ( g -l-? Phone/Fax Number: 00 9/70323 Contact Person/Title for Grease Traps: s l- &IA—A. /'SP/17Tl/ J)Y`P,1 1G/r9�i�� Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: '114%i Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) S I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Print Date i ty'lle l q RM C., ". a, Cc" , , Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): %025 Seating Capacity (Actual Count): 015 Normal Hours of Food Preparation/Service: Monday J nh m -_ 3 „m Thursday -` Sunday Tuesday �A m- 3Prn Friday Wednesday Saturday Please indicate the NUMBER of kitchen fixtures used in your establishment and if itis attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 110 3 compartment sink Q Handwashing sink Commercial Dishwasher no 1149 Bar sink Mop Sink Garbage Disposal {7Q Ice Making Machines Q Fryolators Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? / -5 f __lyes No & Z�f�� Sing 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 s Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? X_ Yes No Size 5Z gallons Where is the existing outdoor GRU located? ne X + 'q df=�� If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: !f<01, ��—