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Home My WebLink AboutWhite's Bakery - 12/31/2020_% DV V V FOR BOARD OF HEALTH USE ONLY Permit # Issued IJ FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening J 2019 Establishment Name White's Bakery Establishment Address 321 School St. Mansfield, MA 02048 Establishment Mailing Address (if different) 1041 Pearl St. Brockton, MA 02301 Establishment Telephone No 508-339-8230 Applicant Name & Title: David White / President Applicant Address: 1041 Pearl St. Brockton, MA 02301 24 Hour Emergency No.: 508-269-5809 Applicant Telephone No.: 508-584-5100 Applicant Email: dawhite24@hotmail.com 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. O A Corporation Name Title Address An Individual David White President 90 Barnabas Rd Falmouth, MA O A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'Tracy Carifa / Manager Address: 321 School St Mansfield, MA 02048 Telephone No: 508-339-8230 24 Hour Emergency No: 774-297-0687 FAX: E-mail: mansfieldmanager@whitesbakeryandcafe.com 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: Town of Mansfield SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Mon thru Fri 7:00am-7:00pm, Sat 7:30am-7:00pm, Sun 7:30am-6:00pm Name of Person(s) In Charge Certified in Food Protection Management: Tracy carifa Name of Person(s) In Charge Certified in Allergen Awareness Training Tracy carifa Name of pest control company routinely inspecting the premises for evidence of pests Braman 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. U Yes Does this establishment require a FOG permit? yes If yes, please attach the FOG permit application. Length of Permit: Establishment Type: I* Annual Fel Retail Food $125.00 Q Mobile Food consession 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 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definifions:PHF - Potentially hazardous food(fime/temperature controls required) Check all that a ( Non-PHFs- non-potenfially hazardous /ood(no fimeRemperature controls required) ( PP Y) RTE - ready4o-eat foods (Ex. sandwiches, salads, muffins which need no rurfher processing) Q Sale of Commercially Pre -Packaged Non-PHFs ❑Q PHFCooked To Order Fil 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 Cold Holding For Single Meal Service ❑3 PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility RA Sale of Raw Animal Foods Intended Reheatingof Commercially Y 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 contact alternative, time as a public health I Customer Self -Service of Non PHF and Non - Perishable Foods Only 1:- Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale 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 Iii 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: Pursuant to MGL Ch.621ff sec. 49A, I certify undev r 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: 04-3056801 Signature of Individual or Corporate Name: 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. 02!2u L�iLeeru� ature of Individ al or Corporate Name 04-3056801 "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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 19 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: White's Pastry Shop, Inc (dba White's Bakery) Address: 1041 Pearl St City/State/Zip: Brockton,MA 02301 Phone#: 508-584-5100 Are you an employer? Check the appropriate box: Business Type (required): 1.5�x I am a employer with _ 160 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, §I(4), and we have 10 F1 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 *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. lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ace American Insurance Company Insurer's Address: 436 Walnut St / PO Box 1000 City/State/Zip: Philadelphia, PA 19106-3703 Policy #or Self -ins. Lie. # C6681760A Expiration Date: 10/01/2020 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 thepains and penalties ofperjury that the information provided above is true and correct. n.+, 10/17/2019 100 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: White' s Bake 321 School St., Mansfield, MA 02048 Mailing Address: 1041 Pearl St., Brockton, MA 02301 Phone/Fax Number: 508-339-8230 Email: mansfieldmanager@whitesbakeryandcafe.com or dawhite24@hotmail.com Contact Person/Title for Grease Traps: Tracy Carifa / Manager Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: Patriot Services 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 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 information submitted in these documents is true, accurate and complete. Print Name Jamie Chung 1 Date 10/17/2019 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): n/a Seating Capacity (Actual Count): 10 Normal Hours of Food Preparation/Service: Monday 7am — 7pm Thursday 7am — 7pm Sunday 7am — 6pm Tuesday 7am — Friday 7am — Wednesday 7am — 7pm Saturday 7am — 7:30pm 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 S 3 compartment sink Handwashing sink n (j 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? wash s 2 rZT5 M 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 No Size L)aUr gallons Where is the existing outdoor GRU located? o n 5()Y C 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: 0 10 1— loci (+ e Property Owner's Address: W Property Owner's Telephone Number: V '( 6M "' Yellow Grease Waste Do you store yellow grease waste from fryolators? no Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: 3 Please list fixtures attached to each grease trap Grease Trap 1 3 M C OL'(1 1 Y S I rL 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 L)aUr gallons Where is the existing outdoor GRU located? o n 5()Y C 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: 0 10 1— loci (+ e Property Owner's Address: W Property Owner's Telephone Number: V '( 6M "' Yellow Grease Waste Do you store yellow grease waste from fryolators? no Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: 3 EXTENSION OF INFORMATION PAGE Named Insured Endorsement Number INSPERITY, INC. Policy Number Symbol: RWCNumber: C6681760A 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Policy Period Effective Date of Endorsement 10-01-2019 TO 10-01-2020 10-01-2019 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be com leted on1v when this endorsement is issued subsequent to the preparation of the policy. SCHEDULE OF NAMED INSURED ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: NAMED INSURED INSPERITY, INC. WHITE'S PASTRY SHOP, INC. For the state of CA refer to state specific endorsement. FEIN 760979695 093056801 Authorized Representative WC 99 99 99 A (10/06) Page 1 of 2 EXTENSION OF INFORMATION PAGE Named Insured Endorsement Number INSPERITY, INC. Policy Number Symbol: RWCNumber: C6681760A 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Policy Period Effective Date of Endorsement 10-01-2019 TO 10-01-2020 10-01-2019 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the Rolicy. SCHEDULE OF NAMED INSURED ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: NAMEDINSURED For the state of CA refer to state specific endorsement. FEIN Authorized Representative WC 99 99 99 A (10106) Page 2 of 2 EXTENSION OF INFORMATION PAGE Named Insured Endorsement Number INSPERITY, INC. Policy Number 19001 CRESCENT SPRINGS DRIVE KINGWOOD TX 77339 Symbol: RWC Number: C6681760A Policy Period Effective Date of Endorsement 10-01-2019 TO 10-01-2020 10-01-2019 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. SCHEDULE OF OTHER WORKPLACES ITEM 1., OTHER WORKPLACES, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: OTHER WORKPLACES INSPERITY, INC. 19001 CRESCENT SPRINGS DRIVE KINGWOOD, TX 77339 WHITE'S PASTRY SHOP, INC. 1041 PEARL ST BROCKTON, MA 023015400 98 DERBY ST HINGHAM, MA 020434225 321 SCHOOL ST MANSFIELD, MA 020481853 380 WASHINGTON ST WELLESLEY, MA 024816205 For the state of CA refer to state specific endorsement. This endorsement is not applicable in NJ. FEIN 760479645 043056801 Authorized Agent WC 99 99 99 B (10/06) Page 1 of 2 1 i C O C ^ A c e V �s 60 W f LA g Z � n. C O LL O D Z �a O w � a o8 S OLs mi 1 i A c e V �s 60 W f LA 1 i C7 z z a ozv 0 hi 4 �q M Ct A� 1w