Loading...
HomeMy WebLinkAboutMansfield Lodge of Elks #2633i� FOR BOARD OF HEALTH USE ONLY Permit # Issue FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name 6ov6e or cto :u� Z� 3 Establishment Address l�O rJ, MA1/U S'7 htAn Gr6�9.M/l U?fi�l� Establishment Mailing Address (if different) Establishment Telephone No S68,Z6(--lS/S Applicant Name & Title: MA 9-I< w/tLS N ;C k (L%s / K� Applicant Address % fltt.LL((O'T ro AIT 3 FoXgpAG /�A 02CW Applicant Telephone No.: (717✓' °/ of b { 24 Hour Emergency No.: Applicant Email l t j<s 26 1J Co h,, AS F, ,) 67- 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 FA An Association partner. El A Corporation Name Title Address El An Individual O A Partnership 1-1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 6 4W Address: )o (ANo( P)-rll ba\v6 l�/� tsFieti9�rla PzoNS Telephone No: —7 71j- I Cs 6- / m 24 Hour Emergency No: FAX: E-mail: (Z?, Dr, C.0 t-V _ 13U(Kc _ t_0 M Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training PIfl ytic 6"/1)L,5 Name of pest control company routinely inspecting the premises for evidence of pests 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? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: A Annual kWRetail Food $126.00 0 Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 El Manufacture Frozen Desserts/Ice 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: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: -� Milk &Cream $10.00 0 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food (timaltemperafure controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no /urtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs 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 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 0 Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand ❑ Customer Self -Service [) 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 ❑Offers Raw Or Undercooked Food Of i] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 0 Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities 0 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,10`q,CPR 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns and paid state taxes required under law. Social Security Number or Federal ID: L ` Signature of Individual or Corporate Name: NATIONAL REGISTRY OF ���p4FOODs FOOD SAFETY PROFESSIONALS® CERTIFIES JAMES W BURKE HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER " CERTIFIED UNDER THE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: LAWRENCE J. LYNCH, CAE 1 ? ISSUE DATE: FEBRUARY 5, 2019 :.. EXPIRATION DATE: FEBRUARY 5, 2024 CERTIFICATE NO: 21544876 90656 TEST FORM: EZT17 6751 1°orum Drive, Suite 220, Orlando, FL 32821 Thk c,dikate is not valid for na.rc P (900) 446 0257 F (407) 352-3603 wwwNRFSEeorn Ihan ave years Gom dam of issue National Registry of Food Safely Professionals' �0"o.j4rT National Registry of Food Safety Professionals Notification of Test Results CERTIFIED FOOD SAFETY MANAGER ID#: xxx-xx- Scaled Test Score: 89 crxrmrun.. DAMES W BURKE Candidate Status: Pass Pest Date: February 5, 2019 msi turvmnnre '= sve.un naa,mw eua�at rnlRrsetWanubmssv "! _ : Certificate No; 21544876 eL ma {em)�s3-3an£ - Issue Date: February 5,2019' FunODe513�F _ Expiration Date; February 5, 2024 -ongratulations! Attached is your certificate and wallet card. Please notify he National Registry of name or address changes at the address below. 'reventing Contamination and Cross Contamination (Mastered) -nsuring Personal Hygiene and Employee Health (Competent) fictively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) -nsuring Product Time and Temperature (Mastered) conducting Cleaning and Sanitizing (Mastered) Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered) JAMES W BURKE 10 CANOE RIVER DR MANSFIELD, MA 02048 National Registry of Food Safety Professionals® 1 6751 Fonnn Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352,3830 1 Fax: 407.3523603 / \\/ \ . . a&»; \ ® z§( m■S�: f \ 4 % / ) k k 2 & / ) ( ) 2 \ ® \ « � � 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. Ad Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) ay- i—%J ¢I -I/ "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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations s 600 Washington Street y' Boston, MA 02111 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: /t1 A .i-sFi 6-t-D e-n (, 6 o c > j�,S # 2- (23 Address: l `! D A.), M /I 1 Al S i City/State/Zip: �.MR UlONF Phone #: S u8. 7� l_ it s-rlJ Are you an employer? Check the appropriate box: Business Type (required): I. El 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 (inel. 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 officer's have exercised 9. Entertainment their right of exemption per c. 152, § 1(4), and we have 100 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I Ln Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 #I. I ant an employer that is providing rvorlcers' compensation insurance for oty employees. Below is the policy information. Insurance Company Name: 7 (�/ivE�6te< I,JSuYC.� sl E Insurer's Address: 2 c] 20 L-914(Mp,ur /IUE Sul rE /06 City/State/Zip: Policy # or Self -ins. Lic. # (P v 6 --1 : (? t Al z --2. Q Expiration Date: A&20 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, under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: S F3sf 61 % - F i - DS 6 tl Official 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. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia TRAVELERSJ� INSURED'S NAME AND ADDRESS MANSFIELD LODGE OF ELKS 2633 140 NORTH MAIN STREET MANSFIELD MA 02048 THIS IS A QUOTE, NOT A POLICY WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY QUOTE PROFILE — VERSION 01 POLICY NUMBER: (6HUB-1 K05813-1 -19 ) RENEWAL OF (6HUB-iK05813-1-18) POLICY PERIOD FROM: 11-22-19 TO 1 1 -22-20 WORKERS COMPENSATION INSURANCE PLAN A/R (WCIP) # TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ PREMIUM DISCOUNT 0900-20 EXPENSE CONSTANT TERRORISM TOTAL ESTIMATED PREMIUM TAXES AND SURCHARGES DEPOSIT AMOUNT DUE Employer's Liability BI Limit: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA 251 NONE 250 8 529 9 538 MA Adjustments of Premiums shall be made ANNUALLY ■...****«********..**..*«*.*.* Deposit Amount Due: $ 538 POLICY NUMBER: (6HUB-1 K05813-1-19 ) DATE OF ISSUE: 09-27-19 WC OFFICE: ORLANDO INDUS AFF161 PRODUCER:ROBERT W EAMES INS 73M9B ST ASSIGN: MA Mansfield Board of Health Request for Fee Waiver for Food Permit Date i { 110H We, �j4 1S•F- 461,D 6-i,K . �k 26333 (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: ❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. Other: rk,�,I-e AL c �2r•,�s_,1 7 1 t?Ur� C nQ(,.0r, T) Thank you, �/ �i' I Signature( «cV- Y Title *Please provide proof of valid 501(c)(3) status BOH Use Only —Approved Denied Reason: Signature: Date: Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: M,9.JSF'1 e b f d oD6t oG 6to 1 2-07 Address: /10 h/ 1v11>IA) S! 111Aq)SFIELAFM40201/Jy Mailing Address: Phone/Fax Number: S"d�-` z-61 7S Email: tr L-K5 L6 2,3 @ < D Al CAST. A) 67` Contact Person/Title for Grease Traps: .J71 rn ES �V 1LKG Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: S01P 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. Si¢ned W ` Date % 1 // 6 b (j Print Name M4 Kv t.J Aj tjH 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): / z Seating Capacity (Actual Count): ( Zs - Normal Hours of Food Preparation/Service: ` Monday Lf— 1 I Tuesday �I Thursday Sunday c1-(1 l-7 Friday q— 1 { Wednesday L{ 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 Z ( 3 compartment sink 1 Handwashing sink Commercial Dishwasher If 0 Bar sink Mop Sink 0 0 Garbage Disposal 7- 0 Ice Making Machines Z U Fryolators z n Grills or Ovens © Exhaust Hoods 0 0 Floor drains A AJ 1/y 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? X Yes No If yes, at what station/sink? (<iraji-N (✓A7Tf2ci-t ISC\u t 2 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? I Please list fixtures attached to each grease trap Grease Trap l (,-1 3 (SAY SW K 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 )( 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? How often is this grease storage unit emptied? Please list the vendor who removes the Soares Sanitation Pumping, Inc. 285 Thrasher Street • Taunton, MA 02780-1505 (508)824-8370 & 1-800-464-8370 GATE OF SEPTIC (�+f FIND i I OVERFLOW SERVICE TANK 70 ECfF6Bt &DIG PIT AMOUNT PAID AMOUNTDUE Thank You For Being Our Customer, And For The Confidence You Have Placed In Us. CD m ( m N p ca o Cl) CO C A m