The URL can be used to link to this page

Home My WebLink AboutCorporate Chefs @ Smith & Nephew - 12/31/2020II , FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION _ _-(Applicafion must be submitted at least 30 days before the planned opening date) Establishment Name Corporate Chefs @ Smith & Nephew Establishment Address 130 Forbes Road Establishment Mailing Address (if different) 22 Parkridge Road Haverhill, MA 01835 508-261-3710 Establishment Telephone No Applicant Name & Title: Lori Bramble Applicant Address 22 Parkridge Road, Haverhill, MA 01835 Applicant Telephone No.: 978-372-7400 24 Hour Emergency No.: Same lori.bramble@corporatechefs.com Applicant Email Owner Name & Title (If different from applicant) Corporate Chefs, Inc. Owner Address 22 Parkridge Road, Haverhill, MA 01835 Owner telephone number 978-372-7400 Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 1-1 An Association partner. [� A Corporation Name Title Address El An Individual see attached El A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Ann Marie Hathaway Address: 130 Forbes Road Telephone No: 508-261-3710 24 Hour Emergency No: FAX: annmarle.hathaway@corporatechefs.com E-mail: lorl.bramble@corporatechefs.com Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Sue Peloquin - District Manager Address: 22 Parkridge Road, Haverhill, MA 01835 Telephone No: 508-254-0398 24 Hour Emergency No: FAX: Sue. peloqu in@corporatechefs.com E-mail: aysTOMF1 E rTiTTiRRi. ir=.6 WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 3 DAYS/HOURS: Monday - Friday 6:30 am - 3:00pm Name of Person(s) In Charge Certified in Food Protection Management: Ann Marie Hathaway (attached) Name of Person(s) In Charge Certified in Allergen Awareness Training Ann Marie Hathaway (attached) Name of pest control company routinely inspecting the premises for evidence of pests—Terminix 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 Ann Marie Hathaway - attached Does this establishment require a FOG permit? no If yes, please attach the FOG permit application. Length of Permit: Establishment Type: A Annual Retail Food $125.00 Mobile Food Consession 0 Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 EJ Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 [] Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 g Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food ismeltemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardousfood(no time/tempersture controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing) Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Ell 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 D 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 Q 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 0 Ice Manufactured and Packaged for control) Ej Preparation of Non-PHFs Retail Sale n Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale B Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities is 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 CMR 590.000 and the federal Food Code. Signature of Applicant: Ce aV el 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 tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 04-298-1626 Corporate Chefs, Inc. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. A•pDlicant Information Pleasti Business/Organization Name: Corporate Chefs, Inc. Address: 22 Parkridge Road City/State/Zip: Haverhill, MA 01835 Phone #: 978-372-7400 Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with 500 employees (full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales (incl, teal estate, auto, etc.) employees working for me in any capacity. $• Non-profit 3. ❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing ''.. no employees. [No workers' comp. insurance required]* I I0 Health Care ''.. 4.0 We are a non-profit organization, staffed by volunteers, '... 12.0 Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box 91 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 #1. I ant an employer that is providing workers' compensation insurance for my employees. Below is Insurance Company Name: Sentry Insurance a Mutual Company Insurer's Address: P.O. Box80232 City/State/Zip: Stevens Point, WI 54481 Policy # or Self -ins. Lic. # 901884090-18840-01-00 191 Expiration Date: 09/01 Attach a copy of the workers' compensation policy declaration page (showing the policy number a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of ci fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WO of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded t Investigations of the DIA for insurance coverage verification. information. expiration date). inal penalties of a . ORDER and a fine ie Office of I do hereby certlity, un/f4r, the pbons and penalties of perjury tltat the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city a• town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact Person: 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 SENTRY INSURANCE A MUTUAL COMPANY Carrier Code No. 15571 STEVENS POINT, WISCONSIN NON-ASSESSABLE•POLICY (A PARTICIPATING MUTUAL COMPANY) A MEMBER OF THE SENTRY FAMILY OF INSURANCE COMPANIES WORKERS COMPENSATION'AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE ITEM CORP. POLICY NUMBER 90-18840-01 00 191 RENEWAL OF POLICY NUMBER 90-18840-01 00 181 1. INSURED NAME AND ADDRESS: PRODUCER 9018.4112 ELIOR INC LOCKTON COMPANIES LLC .DBA ELIOR NORTH.AMERICA STE 510 300 SOUTH TRYON ST STE 400 4725 PIEDMONT ROW DR CHARLOTTE NC 28202 CHARLOTTE, NC 28210 7D4-556-4100 Phone Number (704) 424-1071 1st Named Insured Federal ID 262223.480 See Schedule of Entities for Other Insured Entities Other workplaces not shown above: See Schedule of Entities and Locations 2. POLICY PERIOD: This policy period is from 09-01-2019 TO 09-01-2020, 12:01 A.M., Standard time at the Insured's mailing address. 3. COVERAGE A. Workers Compensation.Insurance: Part One of the policy applies to the workers compensation.law of the states listed here:. ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST. OF COL. NA SOUTH CAROLINA SOUTH DAKOTA TEXAS UTAH VIRGINIA WEST VIRGINIA B. Employers Liability Insurance: Part Two of -the policy applies to work in.sach state listed in -Item 3.A. The limits of our liabil- ity under Part Two are: Bodily Injury by Accident S 1,000,000 each accident Bodily Injury by Disease S 1,000,000 each employee Bodily Injury by Disease 9 1,000,000 policy limit C.. Other States Insurance: Part Three of -the policy applies -in all states except those listed in Item 3.A., and the following: ND OH OR WI WY D. This policy includes these Endorsements and Schedules: NAWC990672 0911 WC 00 00 OOC 0115 WC 00 01 04A 1004 WC 00 01 06A 0492 WC 00:02 OIB 0115 WC 00 03 11A 0891 WC 00 03 13 0484 WC 00.04 04 0484 WC 00 04 06 0484 WC 00 04 06A 0895 WC '00 04 1.4 0790 WC 00 04 14A 0119 WC DO 04 19 0101 WC 00-04 21D 0115 WC 00 04 22B 0115 WC 00 00 01 COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE ELI 90-..18840-01 00 191 09-03-2019 Page 003 M CONTINUED ON NEXT PAGE 00600 O1TWORG _-_..-------------------------------------------------------------------------------.. 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. Corporate Chefs, Inc. Signature of Individual or Corporate Name 04-998-1896 "Social Security No. (VoluntanIt) or Federal Identification Number Doli FUM&C 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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc \ � r,� { §dt {\ f \ .y\< (69 . �4 \ \ \ « \ � r,� §dt .y\< (69 . { \ m § \ .� I O 8.0 A m 'n q v = C D W m fD N N (D N fD N N N C C C fF rt fi 0) 01 (D A A A O O O 00 O z z 3 z n n y n N N O N 00 00 !-+ 00 N N 00 N O O A O N N A N Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS r Business/ Food Establishment Name: b�P�Io1 tb0 Address: 130 F 1 -666' AV6 Mailing Phone/Fax Number: S-OK''2-GI'3WO (114A1i4 �hGro C, � Email: C C-P"C P -e rL)R-f--AX l e 501 ( 774—NCP�Gley (V744 Contact Person/Title for Grease h Inc _ Name of Company scheduled to pump internal grease trap(s) monthly: +' �lnt % rVt`"7� VPh tirCJC�� S Name of Company scheduled to pump external grease trap quarterly: All, PC,V rit�l int'1 00, dYEC , t 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 REVIEW ED 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. rC rl Li n C� 1,1A tqA j 6A- -/W s - Iu,7-A, �Aly h1w, Tr" e- Date 2.0 NG'✓ 2.O[ 1 Facility Onerational 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): Li 8 ES r IlgA nA A x 1M ujg1 Normal Hours of Food Preparation/Service: Monday - eyJi Thursday fAVA-13c�A Sunday N(A Tuesday 6, 1,2,t - j� � tvA Friday SAww -- j3: lo Wednesday Saturday P A I 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 GRUii t 3 compartment sink NO Handwashing sink f3 Commercial Dishwasher C) Barsink ii NO Mop Sink N O Garbage Disposal NO Ice Making Machines l'—(O Fryolators No Grills or Ovens t✓ C -7a -c t-�.-�' �7 V �tJ S� NO Exhaust Hoods z-- (`-(O Floor drains 1-fO Other: '1�2C'f i t,4 (Z__ How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): M Is dinnerware pre -rinsed before being washed? V Yes ` No If yes, at what station/sink?12 i5�lYl1� {nia t C -AS \C4ta�� 1C 7d_T- for_FHF-fkew,I �1c, Grease Traps 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 Nlrf" gallons Where is the existing outdoor GRU located? Al 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: /V I A' Property Owner's Address: Al 14 Property Owner's Telephone Number: IJ 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? Ri I Please list the vendor who removes the waste: 3 -iW "j dPS',_�t-,ar7✓n.4'Al-e/VhZ-)jTYtL, Please list fixtures attached to each grease trap Grease Trap 1 - 6A rl )� Grease Trap 2 f4 C) Grease Trap 3 ld 0 Grease Trap 4 0 Grease Trap 5 d External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size Nlrf" gallons Where is the existing outdoor GRU located? Al 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: /V I A' Property Owner's Address: Al 14 Property Owner's Telephone Number: IJ 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? Ri I Please list the vendor who removes the waste: 3 -iW "j dPS',_�t-,ar7✓n.4'Al-e/VhZ-)jTYtL,