HomeMy WebLinkAboutHarry's Place - 12/31/2020FOR 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 Nafry 5 hla t t
Establishment Address roLi/el f r ✓v>u ^ 5
Establishment Mailing Address (if differeqq )
Iq
Establishment Telephone No 5-6 ,S, L/
Applicant Name & Title: �p k� I1o1"A tJwher
Applicant Address I0� 6aft c�� Sj_ ,AN
Applicant Telephone No.: rO3 24 Hour Emergency No.:
Applicant Email .t yy yy / II
Owner Name & Title (If different from applicant)
Owner Address
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.
El A Corporation
Name Title Address
[ i'An Individual
El A Partnership
El Other legal Entity
Person Directly Responsible` For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 'KVT1 4 00-tl C' U P et -
Address: I C roc k el" A
Telephone No: M 36 5 lkl l 24 Hour Emergency No:
FAX:
E-mail:
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: "Tvw1
It
SEWAGE DISPOSAL: To wiry
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
�G`7 e
I IDG^y
Name of Person(s) In Charge Certified in Allergen Awareness Training
F_�«y Icc
s'd�y
ff
Name of pest control company routinely inspecting the premises for evidence of pests I y V1 h
If there is seating for 25 people 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? Y e 5 If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
El Retail Food $126.00
L] Mobile Food Consession
Gel] Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
O Manufacture Frozen Dessertslice Cream
P
Temporary Start Date:
�] 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:
i 1 Supermarkets $400
Residential Kitchen $100.00
Rain Date:
$4-Milk &Cream $10.00
Caterer $35.00
Food Operations: Definitions., PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous food(no time/lemperature controls required)
RTE - ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Vsale of Commercially Pre -Packaged Non-PHFs 5ZPHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
E] Sale of Commercially Pre -Packaged PHFs F !I 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
Susceptible Population Facility
�] Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer
0 Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Customer Self
and/or HACCP Plan (including bare hand
-Service
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only Di Ice Manufactured and Packaged for
control)
EJ Preparation of Non-PHFs Retail Sale
�i Offers Raw Or Undercooked Food Of
E Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
_..a Vacuum Packaging /Cook Chill
]] Offers RTE PHF in Bulk Quantities
c,i 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 690.000 and all other applicable law. I have been instructed by the
board of health on how to ogtain copies of,105 CPO 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A tI eertif
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
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.
bun K, /n
Signature dua Corporate Name
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, 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\ScoR's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
UlfDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization N
City/State/Zip:
Phone
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. El Retail
� �or part-time).* 6. �estaurant/Bar/Eating Establishment
2. LD 1 am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (inc1, 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. n Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp, insurance required] * 11.Q Health Care
4.� We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' camp. insurance req.] 12.0 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 N.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. #
Expiration
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 WORD 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, under the pains and penalties of petjury that the information provided above is true and correct.
Phone #:
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
www.mass.gov/dia
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Form Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/Food Establishment Name: 1.1wrL)S ['1ac.-
Mailing Add
T An) f
5+
Phone/Fax Number: Ql ,) (r V �--2 y
IV\
Contact Person/Title for Grease Tra
Name of Company scheduled to pump internal grease trap(s) monthly:
Name of Company scheduled to pump external grease trap quarterly:
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
Print
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. A / �r1
Seating Capacity (per Fire Department Regulation): /U ! I
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday S- /O J 3 O Tuesday
Thursday 1 d'3 O Friday
Sunday
Wednesday 0 1� 36
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
Ice Making Machines
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?
Yes
No
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
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 t/ No Size -*0 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?
How often Is this grease storage unit emptied?_
Please list the vendor who removes the waste:
Documents to Assist with Illness Reporting Policy
According to the 2013 FDA Food Code:
2-201.11 Responsibility of Permit Holder, Person in Charge, and Conditional
Employees. [590.002(E)]
(A)The PERMIT HOLDER shall require FOOD EMPLOYEES and CONDITIONAL
EMPLOYEES to report to the PERSON IN CHARGE information about their
health and activities as they relate to diseases that are transmissible through
FOOD. A FOOD EMPLOYEE or CONDITIONAL EMPLOYEE shall report the
information in a manner that allows the PERSON IN CHARGE to reduce the
RISK of foodborne disease transmission, including providing necessary
additional information, such as the date of onset of symptoms and an illness, or
of a diagnosis without symptoms...
The code goes on to outline symptoms and illnesses that must be reported to the
Person in Charge. It also describes when an employee should be excluded or restricted
in their duties.
Forms 1-A through 1-C are designed to assist those responsible for managing
employees in order to prevent foodborne disease. The Food Code specifies that the
permit holder is responsible for requiring conditional employees or food employees to
report certain symptoms, diagnoses, and past illnesses, as they relate to diseases
transmitted through food by infected workers. The conditional employee or food
employee is personally responsible for reporting this information to the person in
charge. These documents can be found in the 2013 FDA Food Code Annex 7.
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6751 Forum Drive, Suite 220, Orlando, FL 32821
(800) 446-0257 F (407) 352-3603 w ..NRFSPcom
National Registry of Food Safety Professionals'
fotification of Test Results
:)#: xxx-xx-
caled Test Score: 86
.andidate Status: Pass
'est Date: February 5, 2019
NATIONAL REGISTRY OFF,.
FOOD SAFETY PROFESSIONALS®
CERTIFIES
�.
HARRY J KELI�OWAY
HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE
s '-
FOOD SAFETY MANAGER
UNDER THE
CONFERENCE FOR FOOD PROTECTION STANDARDS
ongmtulations! Attached is your certificate and wallet card. Please notify
e National Registry of name or address changes at the address below.
'eventing Contamination and Cross Contamination (Mastered)
isuring Personal Hygiene and Employee Health (Competent)
:lively Managing Controls in a Food Establishment (Competent)
onitoring the Flow of Foods (Needs review)
isuring Product Time and Temperature (Competent)
onducting Cleaning and Sanitizing (Mastered)
anaging:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered)
V S
ssx (b'Ze
LAWRENCE J. LYNCH, CAE
ISSUE DATE: FEBRUARY 5, 201 9
EXPIRATION DATE: FEBRUARY 5, 2024
CERTIFICATE NO: 21 S44878
TEST FORM: EZS43
This certificate is not valid for mre
the. five years from dete of issue
National Registry of Food Safety Professionals
CERTIFIED FOOD SAFETY MANAGER
01 FYA RY 1iKi)aLOWAY
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0dmd,M328a
'IF (aM)M6-035J
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Phone(9a))352-38J0
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T-00))M-3603
ISsue Fe'oNary5,2Vlg
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Expiration Date: February 5, 2024
wwwNPFSP
HARRY J KELLOWAY
19 GARFIELD ST
FOXBORO, MA 02035
National Registry of Food Safety Professionals® 1 6751 Forum Drive Ste 220 1 Orlando, FL 32821 I Phone: 407.352.3830 1 Fax: 407.352.3603
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