HomeMy WebLinkAboutMansfield Council on Aging - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION/0
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(Application must be submitted at least 30 days before the planned opening date)
Establishment Name I(V\P_ R t-L0(�»��-�
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Establishment Address 3 . 1` �✓ Si'l.� e r�
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title: J QPI r n Q- i eft lV elt 6
Applicant Address
Applicant Telephone N 24 Hour Emergency No,:
Applicant Email IvtAr�Yr� y p Il/1G-Vl��i f gyp( vL{�� •C I�YV�
Owner Name & Title (if different from applicant) 1
.Owner Address % Yea-,, e. P-0 [a -a YyIG.?/lS�%j' f •� y {Y r .. l�e7 e)
Owner telephone number v- — 2 la (
Owner email: {� y
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
El An Association partner,
❑ A Corporation Name Title Address
❑ An Individual
❑ A Partnership
El Other legal Entity
Person Directly Responsible For Daily operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 3 pta�vl t �R P A�� %t•V_A-7iU { J I It LQ(91i"TiY % )
Address: �Js ��CS
Telephone No: , yl) j �� 24 Hour Emergency No: Jam i-
FAX: , a %j 7i I g 4 L� pp y
E-mail: \ IY\ �Y..� '(�C�'a(t �C�../1S��.J(/ ma" Af��
All E -Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address;
Telephone No:
FAX:
E -Mail:
24 Hour Emergency No:
01 �,
Food Establishment Information
NATER SOURCE: t'1 SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No of Food Employees:
DAYS/HOURS; 10
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Persons) In Charge Certified in Allergen Awareness Training
�e
Name of pest control company routinely inspecting the premises for evidence of pests De we l PCS 1,
If there Is seating for 26 peopl r more, a person trained in manual choke saving procedures will be onsite at all times
food Is being prepared. es
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit: I Establishment Type:
I<nnual ❑ Retail Food $125.00 ❑ Moblle Food Consession
❑ Temporary I Qeood service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ PH Cooked To Order
FOOD TRUCKS $175.00
❑ Manufacture Frozen Dessertshce Cream
Temporary Start Date:
for More Than a Single Meal Service
I ❑ Food Service up to 101 -200 $250.00
$26.00/freezer
Temporary End Date:
LV�KIivery of
[] Food Service up to 201 + $300,00
❑ Pushcart $60,00 # of Pushcarts:
Temporary Time:
to be Prepared by Consumer
E] Supermarkets $400
E] Residential Kitchen $100.00
Rain Dale:
and/or HACCP Plan (including bare hand
I B - 011k & Cream $10.00
❑ Caterer $35,00
Food Operations:
Oefinlllons: PHP - AolanUeAyhaaardaus rood (flmaAemperelure controls required)
Non-PHFs- non-polentlelb, hazardous tood(no limalemperelure controls required)
Check oil that I
( pp Yl
RTE -ready-to-eal roods (E, sandwiches, salads, mu/frns which need
no further Processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ PH Cooked To Order
❑ Hot PHF cooked and Cooled or Hot Held
for More Than a Single Meal Service
El Sale or Commercially Pre -Packaged PHFs
Packaged PHFs
Cold Holding For S nglerHot And Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
LV�KIivery of
❑ Sale of Raw Animal Foods Intended
❑ 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 of Non PHF and Non-
❑ Customer Self -Service
contact alternative, time as a public health
Perishable Foods Only
❑ Ice Manufactured and Packaged for
control)
E] Preparation of Non-PHFs
Sale
E]Retail
Offers Raw Or Undercooked Food Of
❑ Juice Manufactured and Packaged for
Animal Origin
Other Food Operallons
Retail Sale
Packaging / Cook Chill
❑,,_,
❑ Offers RTE PHF in Bulk Quantities
�Vacuum
( Prepares Food/Single Meals for
❑ Retail Sale of Salvage, Out -Of -Data
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 i05R 590.000 and all other applicabl Flow. I have been Instructed by the
board of health on how to obtain copies of 05 C
o.
and tfp eral F it Code.
Signature of Applicant:
Pursuant to MGL Ch.02C, sec. 49A. I certify undo t e penaliles of perjury 1 aLI,-t my best knowledge and belief, have filed all state tax returns
and paid slate taxes required under law.
Security Number Federal ID:
1 ,y'�
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Social or
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Signature of Individual or Corporate Name:%r
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.
Signator f ffidividual or C "to Name By: Corporate Of icer (Mandatory, if Applicable)
o L-1 U c2 u 1 ?Wt
"Social Security No. (Voluntary) or Federal
tdentifi'cation 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:\lkcrs4sleilo\Desktop\Scott's Doeumenls\Foot) Estobtishments-Temp\TAX CERTIFICATION FORMAOC
The Commonwealth of Massachusetts
UlfDepartment of Industrial Accidents
Office of hivestigatlons
600 Woshington Street
Boston, MA 02111
wtviv ntass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Arc y9xt an employer? Check the a propriate box:
i.n I am a employer, employees (full and/
or part-time).*
2.0 1 am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' camp, insurance required]
3.0 We are a corporation and its officers have exercised
their right of exemption per c, 152, §1(4), and we have
uo employees, [No workers' comp. insurance required]*
4, 0 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. 0 Retail
6. 0 Restaurant/Bar/Eating Establishment
7, 0 Office and/or Sales (incl. real estate, auto, etc.)
8, QNon-profit
9, Q Entertainment
10.0 Manufacturing
11.0 Health Care
12.[50ther 8AbL jj
*Any applicant that chocks bas Hl must also fill ont Iho section below showing their workers' wmpensntion policy Infonnati6n.
**II'the corporate onicers have esmnpled anansolves, bul the cogromtion has other eappioy,s, n workers' compensniion paIley is required and sucb an
organization should check box N 1.
I (till au eneployer (hal is pr'avlding tvorkers'~canpenlsMlorl insinyince for• my employees. Below is lite polk), Ir formallon,
insurance Company Nan
insurer's Address:-
-City/State/zip:
Policy S or Self -ins. Lie.
Expiration
Attach a copy of the workers' compensation policy declaration page (showing the policy nanrbo' and expiration date).
Pailure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a
Mile 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 DTA fevinsurance coverage verification,
Into hereby cerlify,, under the polns and penallies of perjury that the brforaadipn provlded above Is tare and correcb
ofj1cini rise apply, Do not write In this area, to be completed by city or lown off 0fift
City or Town:
Permit/License If
Issuing Authority (circle one):
t. Board of Health Z. Building Department 3. City/Town Cleric 4. Licensing Board s, Selectmen's Office
6, Other
11 Contact Pelson: Phone M: 11
wa•w.npass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, on 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
rcceiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than tree 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 it business or to construct buildings in the commonwealth fm• 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 requited. 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 tine 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 pernuit/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 tins 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 burn 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 its 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
Fax # 617-727-7749
www,mass.gov/dia
Form Revised 5-26-05
Town of Mansfield Health Department
APPLICATION FOR FATS, OILS, and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Buslnes:
Address
Mailing
Phone/Fax Number:___l;it�tJ
./A ,z e) F �'-� d �fi t%� it l ✓��fi'� ` �c."+�-i.,. +!
Contact Person/Title for Grease Traps:,
Name of Company scheduled to pump Internal grease trap(s) monthly: ( . - r•f 6: �� i
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application; f tw
• 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)
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 Informatlo ,Submitted in these documents is true, accurate and complete.
Signed � Date
Print N
Facility Operational Information
Please answer all questions in this section. If an Item is not applicable, Indicate "N/A". Uniess otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation)
Seating Capacity (Actual Count): %
Normal Hours of Food Preparation/Service:
� H
Monday �,Y
U
�WednesdayVb
Thursday Friday Friday9gy�- Saturday
Sunday
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
J
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? Yes No
If yes, at what station/sink?
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 )C _ 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 waste;_
3
1 b -- NO
&J drys
Please list fixtures attached to each grease trap
Grease Trap l
Grease Trap 2
i I—'
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes )C _ 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 waste;_
3
1 b -- NO
&J drys
December 9, 2019
Members of the Board of Health:
Town of Man#ield
255 Hope Slreel, A4an#iiek Massaebnseus 02048
Mansfield Council on Aging
Enclosed is an application for the 2019 renewal of the Food Establishment Permeant Application
package for the Mansfield Council on Aging, I respectfully request that any fees are waived to
the agency is a not for profit government establishment.
Thank you for your
Mansfield Council on Aging
Pbone (508)261-7368 Fax (508)33911886 F.nrniljurnrlratio@rrmnsficlrlma.conr
Mansfield Board of Health
Request for Fee Waiver for Food Permit
We, %%�/�j Q ��� (,tVl%��i� �aestaurant/organization)
request a waiver of the Food Service Permit Fee for the following reason:
This is a request from a town department. t
Please list the department: i ' /I1L}a(>>t
❑ 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:
Thank you, C_
Signatur A
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
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