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HomeMy WebLinkAboutTasty Ray's - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued r a '` FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name -—4,1-fy I7 aye L L C Establishment Address ;)Q ,Sou->L 7 )11 a-'Aj4r cc' Establishment Mailing Address (if different) S4m,4— Establishment Telephone No &6-S) 33 7— 6 93 $ Applicant Name & Title. Applicant Address -:PS L,J c,ud Boll il�;4 cA 5 rc,�- 1A.4-17 j Y✓aP44 W Mtboro rV 4 Od Applicant Telephone No.: 45-O -3) c/ (-6-7aS-I 24 Hour Emergency No.: sA mE Applicant Email + ,,. r 4 y-.) Oc y y h oo . co .-✓r Owner Name & Title (If different from applicant) Owner Address 5i4 mr—_ (hS A b6 uc__ Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ❑ An Association partner. ❑ A Corporation Name nn Title Address �er144c/ ❑An Individual cu�f5gy�tLC SSvnegs J ❑ A Partnership Other legal Entity L L_C., Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) l Name & Title: R`'7 M&mc' ')o'q f"t` OW„cf Address: �S Wes- GuI h`"nth S-}rc,a� iih, f t7 A101-A /7�T�t6cro A/j 0 0 � Telephone No: �c50 8) c/ (,5_ )a 5 $ 24 Hour Emergency No: S6 i( 9 6,5 FAX: E-mail: A00 • co", AltE-Mail: rdcoyrda, (y 4Aoo. coe District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 66 Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) JOW h No. of Food Employees: D DAYS/HOURS: CQYU,n' V q!', ij ft Q-daf% -; v l✓Y a�C Name of Person(s) In Charge Certified in Food Protection Management: ' 14yr40Aj a01(vly Name of Person(s) In Charge Certified in Allergen Awareness Training K7 „4YM0'14 OP..r1g-d(, 1� Name of pest control company routinely inspecting the premises for evidence of pests ��/ in 41 If there is seating for 25 peo a 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? e J If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ❑ R tail Food $125.00 ❑ Mobile Food Consession ❑ Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 ❑ Manufacture Frozen Dessertslice Cream ❑ Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ❑ Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ permarkets $400 ❑ Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 Vaterer $35.00 Food Operations: Definitions: PHF - Potentially hazardous food(timaimorperaturo controls required) (Check all that apply): Non-PHFs- non -potentially hazardous/ood(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs dpHFCooked To Order [ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs NA,Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours ❑ Customer Self -Service and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) ❑ Preparation of Non-PHFs Retail Sale p ❑Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑ Vacuum Packaging /Cook Chill ❑ Offers RTE PHF in Bulk Quantities .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 cosies of 105 CMR 59D.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. and paid state taxes required u I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: T[j J / R et � / / IDS "3 S C/ Signature of Individual or Corporate Name: / 5 Y / L L C 7 Sro Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: ! Q 3 % &,j L L C Address: c 0 So) -b M a n 5-Lee4 Mailing Address: �� S 0 j4 4 r» a 1n .S --r oc-/ Phone/Fax Number: ko -i) 33 i- 09,32 EmEmail:T/_Q.s +q retij t4)...�1gA00. C0ro Contact Person/Title for Grease Traps: A etymon ej Dc, A 9 r o /A - Name of Company scheduled to pump internal grease trap(s) monthly: Pet 0-% ,Se r u r C'cS Name of Company scheduled to pump external grease trap quarterly: All A 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 $50 container Each grease interceptor/trap over 3 $50 ($200 max) 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. Date ( 1/1)6/19 Print Name 9kymon4DArdY f � � 4 3 / t ® �« / k�) \\� (_ //®§ )\wc 3E§a (zj) \E )a0 \ _ \ a % � * \ � 3 �� S� >� � » ;_ < � 2 �©« � < $ - » < AX � ± � � � \ � $ \ � � \ � « � « . � w - >> # � � \ � . . � \ «�< % - dz: ; « y� & . \ � \ -ZY- y PATRIOT/SERVICES, INC. Your Grease Trap Pro & Drain Specialist P.O. Box 294 Bridgewater, MA 02324 LIKE (508) 697-9565 1 (800) 449-4480 (508) 759-0979 US ON www.PatriotServicesMa.com `1 I k '_,} Date of Service Invoice # q r Customer Name ' V i Phone # Address M f, City s Zip Job Address (if different than customer) DESCRIPTION OF, WORK j Apt. # I hereby authorize you to perform the above described services and I agree to pay the amounts indicated to the right. I certify that I am duly authorized to order and approve the work requested. Signature ( ! Terms: Cash PO # Bt�l Oi}t This is to acknowledge completion of the above described work whichhas been done to my complete satisfaction. A, irkhi PARTS LABOR 1 OTHER TAX TOTAL DISCOUNT 1 TOTAL DUE r Date f, Customer Name Customer E•Mail Address The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Let*ibly Business/Organization Name: G Address: ofOSOv-h4 m1r.", S'- Pc1e. _ /D City/State/Zip: / / t a it 3 Fr old , MA Phone #: CS6�� 3 3 Are you an employer? Check the appropriate box: Business Type (required): 1.® I am a employer with 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' comp. insurance required] 8• ❑Non-profit 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]* 11. Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12. Other C Gt + 49 *nny applicant that checks box #I must also SII 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 am an employer that is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company J+"GriG Insurer's Address: /a co c5 o u 44 a LS O O (i 1 L .s 8 0.3 City/State/Zip: _ p' c a S G� �i _Cp�q � ri � U 4 6 — D n Policy # or Self -ins. Lie. o 0 ) 7/'7$ 0 5— 9 6 Expiration Date: 1 a a 0 a d 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, Ander the pains glidpenalties 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia 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): SS q 11 Qy4 LC A Seating Capacity (Actual Count): 5 C) Normal Hours of Food Preparation/Service: V qP I eS f bm W Ge 1cI! 4-6 Monday Thursday Sunday Tuesday Friday Wednesday Saturday 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 Commercial Dishwasher Bar sink Mop Sink / Garbage Disposal /4/ t),Scd Ice Making Machines / Fryolators 3 Grills or Ovens a Ovtn ri l� 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? Yes m If yes, at what station/sink? /j O 1 f d;JHes are, used -ACV qrc, O:Aseq 2 Q+ I/cvi✓c ognd nc4unhe4 -ko rcn-�'t G6rntogny 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 p 'S k e S" n 1< 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)? Yes V No Size gallons Where isthe 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 Owners Name: Wi 1�, 4 W g2Z4 Property Owners Address: PC) 'BOX yS� U44Rnjgc,,3'1rr �Ii�a0379 Property Owners Telephone Number: G / 7 -7 / 9 - ya 6 6 Yellow Grease Waste Do you store yellow grease waste from fryolators? V #- S, A r e c y c I, n 5t b, n Where is the grease storage unit located? ACYJL 4-0 durn p S-4i- How often is this grease storage unit emptied? a vC11 y3 Moo A, Please list the vendor who removes the waste d e4, 1n, n A ; ala' 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. s--y Rcty.) L L e Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) y 6 - 0,5 V (.135 **Social Security No. (Voluntary) or Federal Identification Number *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\Scotts Documents\Pood Establishments- Temp\TAX CERTIFICATION FORM.doe c O •C L V c o O Ti o w V Q d Z :..m V o O z Q o Z o_ c X W Qy a �" F ... 1 0 Z O 2 ry li Q O ...::X W 00 a U t V l I i4 � I I � k � � a n $ � t � B k k t §CL d w � � 0 0 k `~ \ \\{� % \)\\ \ ~\ \ },$§ / }\ƒ\ ) P 4', / � / � P50 WE W" � » / � � f w «LL . C 0.LL 0 / \ � ^ - # — . nLU a d - 7 k � C H U S B° Chubb Group of Insurance Companies INFORMATION PAGE 202E Hall's Mill Road, Whitehouse Station, NJ 08889 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Item 1. Name & Mailing Address of the Insured Issued by Federal Insurance Company TASTY RAY'S a stock insurance company 20 S MAIN ST incorporated in INDIANA MANSFIELD, MA 02048 FEIN 46-0546835 TELM (508) 339-0938 # of EMP: UI#: Insured is: Limited Liability Company Name & Address of the Producer VERACITY INSURANCE SOLUTIONS LLC 260 SOUTH 2500 WEST S303 PLEASANT GROVE UT 84062-0000 Producer Number 0036669 N.C.C.1. Carrier Code 12890 Policy Number (20) 7178-05-96 Previous Policy Number NEW OTHER WORK PLACES NOT SHOWN ABOVE - SEE ATTACHED EXTENSION OF INFORMATION PAGE Item 2. POLICY PERIOD 12:01 A.M. standard time at the insured's mailing address FROM 08/12/19 TO 08/12/20 Item 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: All States, Except states designated in Item &A and ND, OH, WA, WY D. Endorsements (Form No.) Refer To Extension of Information Page "List of Endorsements & Schedules" Item 4. The Premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Refer to Extension of Information Page Minimum Premium: $215 Minimum Premium State: MASSACHUSETTS Expense Constant: MASSACHUSETTS ($250 INCL) Premium Adjustment Period: AT EXPIRATION CHUBB GROUP OF INSURANCE COMPANIES: 400 INVERNESS PARKWAY SUITE 300 ENGLEWOOD, CO 80112-5847 Issue Date: 08/12/19 Total Estimated Premium: $663 Total State Surcharges: $11 Total Estimated Charge: $674 Deposit Amount: $674 Q—A"o 08/12/19 Authorized Representative and Date Signed Form WC 00 00 01A (Rev. "B) Includes copyright material of the National Council on Compensation Insurance,used with its permission. Copyright 1987, National Council on Compensation Insurance Insured Copy "C"RCERTIFICATE OF LIABILITY INSURANCE 0910412019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyges) must 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 PRODUCER Veracity Insurance Solutions, LLC. 260 South 2500 West, Suite 303 Pleasant Grove UT 84062 INSURED Tasty Ray's 20 South Main Street Mansfield MA 02048 COVERAGES CERTIFICATE NIIMRIPI RFVI.CInM NIIMFER' THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR I TYPE OF INSURANCE ADOL I INSRO SUBR -- POLICYNUMBER POLICY FEE IMNRONYYYI POLICY EXP MMIDD LIMITS GENERALLIABILITY EACH OCCURRENCE 5 1,000,000 X COMMERCIAL GENERAL LIABILITY 6AMAb`ET6RENTE PREMISES(E 300 ggg _ 7 CLAIMS -MADE n OCCUR MED EXP (A y Oerson) s 5.000 A PL2260060-F075382X OB/0612019 08/06/2020 1,600,666 PERSONAL BAOV INJURY S GENERAL AGGREGATE 5 2,0fi6A66 GEN'L AGGREGATELIMIT APPLIES PER: PRODUCTS COMPIOP AGO S 2.000,000 X POLICY PEO LOC ANIMALBAILEE s AUTOMOBILE LIABILITY F_ COMBINE -SINGLE LIMIT ___ ANY AUTO IEaare de BODILY INJURY (Per Deraanl 5 S AOSCHEDULED AUTOS AUTOS i _._ ci T BODILY INJURY (Per accidel)f s OWNED - AUTOS HIRED AUTOS AUTO$ PROPERTY DAMAGE "" Peraud nl "-- -- 5 s UMBRELLAUAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE is S DED I I RETENTIONS 5 WORKERS COMPENSATION WC STATW I LOTH AND EMPLOYERS' LIABILITY YIN TORY UMITS _LER ANY PROPRIETORNARTNEWEXECUDVE OFFICEJMEMBER EXCLUDED? NIA f I ELEACH ACCIDENT 5 EL DISEASE - EX, EMPLOYEEMPLOYEE1 --- - s (Mandatory lnNIH If yea. describe ender UESCRIPTIONQFOPERATONSualiss EL DISEASE -POLICY LIMIT S 7F_ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAItac11 ACORD 101, Additional Remarks 5cbetlule, If more space is required) Certificate holder had been added as additional insured regarding the above mentioned policy per attached Additional Insured - Designated Person or Organization (CG 20 26 Ed. 0413) CERTIFICATE HOLDER CANCEL I ATICM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BOQSdeS Acres THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Pine Street Middleboro, MA 02346 AUTHORIZED REPRESENTATIVE ��/��/�'��� •� 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 rz014011