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HomeMy WebLinkAboutFresh Catch, Inc. - 12/31/20201:7777 FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 4s eta I'AE Establishment Address (j %1-•$'et(A Ak 0200 Establishment Mailing Address (if differ t) pG d�k -214 M4r.1t4eCk MA 62eq f Establishment Telephone No 6,08-01"-61W Applicant Name & Title: Willwjrel, E Applicant Address AIS 'ttf&iL si. ulqf �L. *.sa4ps Applicant Telephone No.: c e f -a10 y.. W.1b 24 Hour Emergency No.: Me Applicant Email J,%'8ir Fdcsh e+t,kk;ne• eom Owner Name & Title (If different from applicant) Owner Address S4AU &4 4�6vc Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. iKA Corporation Name Title Address O An Individual t& _ Prat ��� lV6Y� kr $�• •�c34� El A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ltt.'4 Address: 153 TOra- S4-. Z. SAJI"h, F45 14 Telephone No: Sly 24 Hour Emergency No: S07 -*4-" hb FAX: Sty S -33 f.31gl E-mail: bi{.14f 00Rezk ukLivte. eo Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: brtA, )kuAt4L C °ed1 Address: , d341 Telephone No: D P -331- 31 R 7 24 Hour Emergency No: FAX: 0'7'_;3g- JINN E-mail:fL - z sker ne Com _�'q WATER SOURCE: DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge Ci Food Establishment Information SEWAGE DISPOSAL: No. of Food Employees: �® in Fob4 Protection Management: Name of Persons) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests to f �� tl If there is seating for 25 peop�,e or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. �YeS — — - Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: [Annual El Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Establishment Type: El Retail Food $125.00 [] Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Wood Service up to 101 -200 $250.00 E] Food Service up to 201 + $300.00 E] S permarkets $400 Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer [] Pushcart $50.00 If of Pushcarts: [ Residential Kitchen $100.00 VCaterer $35.00 Definitions: PHF- Potentially hazardous food dimellemperature controls required) Non-PHF's - non -potentially hazardous lood(no tlmeltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 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 E/Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) le of Commercially Pre -Packaged Non-PHFs 9541-1FCooked To Order [Sale of Commercially Pre -Packaged PHFs ' V Cold Holding For aration of iSingle FS rMeat SHot ervice 0 Delivery of Packaged PHFs eheating of Commercially Processed Foods for Service Within 4 Hours 0 Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations [i Sale of Raw Animal Foods Intended to be Prepared by Consumer customer Self -Service Ice Manufactured and Packaged for Retail Sale Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Retail Sale 0 Vacuum Packaging / Cook Chill Offers RTE PHF in Bulk Quantities E Prepares Food/Single Meals for 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 CMIR OY and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify ;d tate taxes required under law. penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns and pat se °��i� Social Security Number or Federal ID: evi- Signature of Individual or Corporate Name: 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 Indivi al or Corporate Name mE "Social Security No. (Voluntary) or Federal Identification Number W;11`14 By: Corporate Officer (Mandator, if Applicable) *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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc FRESCAT-01 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) THIS E TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT ORGE AFFORDED BY THE POLICIES BELOW. THIS CERT FIICATEF OF INSURANCE DOES NIOTLCONST TUTEAMEND,XAECONTRACT BE ND WEENOR ALTER THEOVETHEISISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of sucho.nd.rsement('s). AM PRODUCER PHONE FAX 508 695.3597 x_ S. Gilmore Insurance (wC N. Exlh 508) 699.7511 (A/c, Nola( ) INSURED ro, MA 02760 The Fresh Catch, Inc. PO Box 34 Mansfield, MA 02048 DVERAGES CERTIFICATE NUMBER: ICY THIS IS TO CERTIFY THAT THE REQUIREM ENT, OF INSURANCE NSU TA TERM OR DCONDIIT ONAOF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOLPERIOD BELOWBEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE WHICH THIS INDICATED. CERTIFICATE pMidn BE ISSUED T ONS OF MAY POLICIES: ITHE SHOWN MAY HAVE BEEN REDUCED BY /PAID CLAIMS ED HEREIN IS SUBJECT TO ALL THE TERMS, vvn„ie _ .,n, iry ccc Pf11.ICY EXP IIMIT5 2/2812019 1212812020 2128/2019 12/2812020 2/2812019 1 212812020 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be anachetl it more space Is requiretl) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION WITH DHE POLICY PROVISIONS.TICE WILL BE DELIVERED IN 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE © 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD CLAIMS -MADE OCCUR 8500069643 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT � LOC OTHER' AUTOMOBILE LIABILITY 1020060964 ANY AUTO OWNED AUTOS ONLY X SCHEDULED AUpTOpS X AUTOS X E AUTOS ONL� ONLY X UMBRELLA LIAR K OCCUR 4600069644 EXCESS LIAB CLAIMS -MADE DED X RETENTION$ 10,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY y/ry 2/2812019 1212812020 2128/2019 12/2812020 2/2812019 1 212812020 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be anachetl it more space Is requiretl) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION WITH DHE POLICY PROVISIONS.TICE WILL BE DELIVERED IN 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE © 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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 Name: m e & Address: city/State/zin: M M Phone # Are yo an employer? Check the appropriate box: 1. I am a employer with 15 employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3Q We are 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,n We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. Retail 6. Restaurant/Bar/Eating Establishment 7. F� Office and/or Sales (incl. real estate, auto, etc.) g. Non-profit 9. Fj Entertainment 10.❑ Manufacturing 11.Q Health Care 12.0 Other *Any applicant that checks box 8t musr aisu uu ��. 1,� ---- ---- -- oir workers' compensation policy InIORnauou. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and sue an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Be[ow is the policy inforrnation. Insurance Company Name: ak l & Insurer's Address: To V, City/State ip.' Zfi ( 7-Q- yy c°p'(�s„� Expiration Date: Policy # or Self -ins. Lic. # 0 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 a 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pa ns d penalties of perjury that the information provided above is true and correct. Phone #: `� iF 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Phone Contact Person: www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PER RESTAURANT & FOOD PREPARATION ESTABLISHMENTS tai Business/ Food Establishment Name: 4 of Ine i �_ Mailing Address: 6 �A 6* Phone/Fax Number: Contact Person/Title for Grease Traps: T CAA L Name of Company scheduled to pump internal grease trap(s) monthly: JVW I& VIS, -V4r�AAU Name of Company scheduled to pump external grease trap quarterly: Le k'1 il Ad ' §Q 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) Fee Food Establishments 3 grease interceptors container Each erease intercep' ps or less and/or 1 yellow grease collection $50 over 3 $50 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 t d complete and acknowledges that the inforrja�ion submitted in these documents is true, accurate an Date $0-1 f Print Name I 1 1A to 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): Seating Capacity (Actual Count) Normal Hours of Food Preparation/Service: Monday II Thursday //-f:3° Sunday j/_ ?PM FRA fill Tuesday //" Friday A — f" Wednesday &: Saturdayji—zoo Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 compartment sink Handwashing sink t Commercial Dishwasher Bar sink Mop Sink Garbage Disposal t Ice Making Machines Fry tors Grills or Ovens Exhaust Hoods 9 Floor drains Other: How are hood vents I! o In thraa (31 bav sink. off site by private company): Is dinnerware pre -rinsed before being washed? Vr Yes No If yes, at what station/sink? MAIA Oh Se Ak 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? 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? A+t4 A -D k u S How often is this grease storage unit emptied? Please list the vendor who removes the waste: C D m AuO ieA Please list fixtures attached to each grease trap Grease Trap 1 c S F4 �E� `S ALA Grease Trap 2 �"S Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? 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? A+t4 A -D k u S How often is this grease storage unit emptied? Please list the vendor who removes the waste: C D m AuO ieA IN RECOGNITION OF SUCCESSFUL COMPLF ION IN; Standard - CPP / AED (Adult / Child / Infant) Automated External Defibrillator (ALD) Beth Stewart Thr'. above mentioned Strttient is now certified in the above mentioned course by demonstrating proficiency in the subjec i by passing the examination in accordance with the Terms & Conditions of National CPR Foundation - Valid far 2 years. Course administered in accordance with the 2015 ECC/11 COR and AHAO guidelines. IDil: F2r39P8 Completion: November 6, 2018 Instructor: Paul J. Scruton ° COUI t r ROVID1 D Gy, f*t �t.�a5rat�'F=t�Fo3 r�� a;iexF£ Signature: AMU, l.niia ana Intan[ I.YK/AtU %U'e' CATL lurk+nee 156398649773388 I I Brenna Audette �' I 1. clba) I'hY CVa pI b-111CYOR ' 24 Ju12019 26 Jut 2021 ROY W. SHAW #100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATION"' COGNITIVE OVAL UATION IN ACCORDANCE WITH PAOTALMNINGS CURRICULUM AND THE 2015 AMERICAN HEART ASSOCIATION:! GUIDELINES WWA.prouainings.com SuppaftRpmtrainingS Com Dear Brenna, Your Community CPR certificate is printed above. You can access this page anytime by logging into www.protrainings.com and clicking Print Certificate. Expect your durable card in the mail 5-7 business days from now. If there are any errors with your card or your mailing address below, please contact us at support@protrainings.com BRENNA AUDETTE PO BOX 23 MONPONSETT, MA 02350-0023 us Sincerely, The ProTrainings Team P.S. If you had a good experience with us, please tell others about ProTrainings! 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C Ntio w a � 0 E o o W a N C 0 ti � v � Ntio w a � 0 o a �r� a N O C O v C C w �, w O W U w W V v_ 4 r^ O N r ^ N = w Z -! 3 W a g d CL p w 0 °D E a Q 0 x W ^� 1 C C C O Z R C a r -z O W-4 Vul C e V •�ti V Y ti Ih' wl� 0 W-4 � � u � � � � ;W u 0 z � z *MNO V) Un 6w z r-4 61 a \ 00 ® 2 � \ e fLL c � 2 LL \(\\ B $ / L k t ui © k 2 ) c 0 k � \(\\ \ \ \ƒ? a ƒ)ƒ( \ ~�\ \ & W-4 0 W U w W U V z z ry JJ V J W z P4 .4p wl z W P4 W r W Ci Z w 0 Q d p N N Q N N N 75 o �- EC W o CD o o o E z `n C Q � v fi N v rt [Z o c ,� dJ v Brenna From: Jacqueline Killion, Esq. <js1<710880hotmail.coin> Sent: Tuesday, July 23, 2019 11:01 AM To; brenna@frLzshcatchinc.com Subject: Allergen training certificate C -1 ERTIFICATE OF ALLERGEN AWAKEN ESS TRAINING Name of Recipient: Jotcluellne S Killion Date of Completion: July 23, 2019 Date of Expiration: July 22, 2024 1 rt 1 z 0 LLMV ui v W 0 ry LL z LLI RM O W Z O m = c Z oC m a, E X .- O N N LL O ..J 00 N � w R