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HomeMy WebLinkAboutCousin's Pizza - 12/31/202050 q0 - FOR BOARD OF HEALTH USE ONLY Permit #ls§u( FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name ,,'�� �2P U, 1j, A A I Establishment Address ji'M J Establishment Mailing Address (if different) 1Vz 2, fir` W0 Establishment Telephone No 'fj Applicant Name & Title: Applicant Address J' �j Applicant Telephone No.: 24 Hour Emergency No,: Applicant Email ("J,A t I 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. A Corporation Name, Title 11 Address '7 r ' El An Individual 13 s, <i �11 El A Partnership 1-1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name& Title: i, 4 Address: A j A H It L�V' Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone Na 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: r '( y/ ; SEWAGE DISPOSAL: L t JUs ' I No. of Food Employees: DEP Public Water Supply No: (If applicable) ° DAYS/HOURS: 1 P10 Name of Person(s) In Charge Certified in Food Protection Management: iQ U Name of Person(s) In Charge Certified in Allergen Awareness Training " � I I, i Name of pest control company routinely inspecting the premises for evidence of pests " 11 r iIn- there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times If' food is being prepared. O Yes Does this establishment require a FOG permit? j ti ( If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ❑ Retail Food $125.00 Mobile Food Consession ❑�femporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/lce 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 E] Pushcart $50.00 # of Pushcarts: Temporary Time: El Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 E] Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(6mertemperature controls required) (Check all that apply): Non-PHFs -iron-polentialy hazardousfood(rro Uniahemperatuc controls required) RTE- ready-l"at foods (Ex. sandwiches, salads, ins which needno Nrtherpnxessing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs E]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 Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours 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 ❑ 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 El Vacuum Packaging I Cook Chill Offers RTE PHF in Bulk Quantities ❑ 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 vrill 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.62Cisec. 49A, I certify under the pe a tias'6f 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 f J` 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. 91gnature of Individu off' r Corporate Name 0q-M-1Yo "*Social Security No. (Voluntanj) or Federal Identscation 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:\Uscrs\sleile\Desktop\Scott's DocumenN\Food Estabbstnneals- Temp\TAS CERTIFICATION FORM.doc The Cotnrnonweafth of Massachusetts Department of Industrial Accidents Office of Investigations k1wi 600 Washington Street Boston, MA 02111 rvtvw. nmss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: L 11 V t.itv/Ctnta/Zin aVl(�fP,(i�l 111770 dad J411 Jac Phone Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Rpldf 2. ❑ or part-time).* I a have 6. Restaurant/Bar/Eating Establishment ant sole proprietor or partnership and no 7• ❑ Office and/or Sales (incl. real estate, auto, etc.) er3rp byres working forme in any capacity. 8• ❑Non-profit workers' comp. insurance required] ��(x�o 3. We are a corporation and its officers have exercised 9. []Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit by 111] Health Care organization, staffed volunteers , 12.❑ Other with no employees. fNo workers' comp. insurance req.] *Any applicant that checks box MI must also fill out the section below showhrgareir workers' compensation policy infommtion. "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 am an employer that is providi flg workers' CoiVgsation- hystil ance (oroy eipployees. Below is the policy information. Insurance Company Name: / 1 1 1llIL "UWu Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. 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 of perjury that the information provided above is trur and correct. Official use only. Do not mite in this area, to be completed by city or torn 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 #: Utiu�S www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE DATEfML11aoYYYYl 10/29/2019 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PaooucER C° TACT Debra Gemaughty NAME: C& S Insurance Agency, Ino.PHONE (608)339-2951 aC Na: (500)339-0811 mak Debbie@cands'ms.com 190 Chauncy Str° AIRC, Box 400 INSURERISIAFFORDINGGOVERAGE Nl11ci Mansfield MA 02040 INSURERA: Twin Cey Fire Insurance Co 29459 INSURED INSURER 6: Commerce Insurance Co 34754 INSURER c: NorGUARD Insurance Company 31470 Cousins Pizza and Subs Inc. 44 Cannon Forge Of INSURER 0: INSURER E: Foxboro MA 02035 INSURER F: COVERAGES CERTIFICATE NUMBER: 2019 COI REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOFINSURANCE I SD = POLICYNUMMER CY MSIR MN am Umms COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 2.000,000 CINMS-MADE © OCCUR 1,000,000 EMIS S ppmeenm $ MEDEXPAmy Onepasom $ 5.000 PERSONALSAOVlwuRY f 2,000,000 A DOSBAAC0155 04/26/2019 04/25/2020 GENLAGGREGATE UMITAPPUES PER: GENERALAGGREGATE S 4.000,000 POLICY El ,£' El LOC PRODUCTS-COMP/OPAGG $ 4.000,000 BIEXE s 10.ODD OTHER: AUTOMOBILEMINUTY COMBINEDSINGLEUMIT $ 1000000 Rla."Idml) WDILYIWURY(PapmsaM $ ANYAUTO g OWNED SCHEDULED AUTOS ONLY AUTOS SBDBBB 10/21/2019 10/21/2020 BODILY 1NuRY Per eusawn S HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ ,,*Wde S UMBRELtALiAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS W1B CINMS.MADE DED I I RETENTION.f $ C WORKERS COMPENSAFIGN ANDEMPLOY VLIABILITY ANY PftOPRIEioRPARTNER/FJECUTIVE Y� OEFICERIMEMBER EXCLUDED? pannotayln Nm NIA COWC046115 06/01/2019 08/01/2020 PER 0TH STAtUTE EL EACHACCIDENT $ 500.000 E.L. DISEASE -EAEMPLOYEE S 500000 Ifyes, des tribe under DESCRIPTIONOFOPERATIONSbabw ELDISEASE-POLICYLIMIT S 500,000 DEWRIPDON OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe aaachad N more space is ma uiled) CERTIFICATE HOLDER CANCELLATION ®1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 2 Park Row AURIORMED REPRESENTATNE Mansfield MA 02048 al, G. h ®1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Finail• ��J �'IJ ��I.���V��I.Il U1�l'RY�� Contact Person/Title for Grease U ( - Name of Company scheduled to pump internal grease trap(s) monthly: (�i k k.W Uhf Name of Company scheduled to pump external grease trap quarterly: tb 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 /nd cc pllete. Date I b IV �`/d � t 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 Departmentgulation): IIVI Seating Capacity (Actual Count): 14 Normal Hours of)jFood `'Prepanrnation/Service: 60 my Monday IOI Thursday U U Sunday Tuesday to Friday Wednesday I D -- 156 a Saturday o ", 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 /may Exhaust Hoods K) Floor drains Other: How are hood verAs cleaned? Is dinnerware pre -rinsed before If yes, at what station/sink? bay sink, off site by In Yes No 2 t�rz�rr�� Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this/gstablishment have an outdoor Grease emoval Unit (GRU/Interceptor)? Yes No Size gallons �.G Where is the existing outdoor GRU located? C)� If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: r Property Owner's Name: u1iF ="' 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? eimil,, t Please list the vendor who removes the waste: i,61 i A Please list fixtures attached to each grease trap Grease Trap l a J i, [l4 ? 4'C 140[a Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this/gstablishment have an outdoor Grease emoval Unit (GRU/Interceptor)? Yes No Size gallons �.G Where is the existing outdoor GRU located? C)� If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: r Property Owner's Name: u1iF ="' 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? eimil,, t Please list the vendor who removes the waste: i,61 i A Name of Recipient: FRAwmnomrs Certificate Nornber: ^ Date of Completion: FIs Date of Expiration: a+3rso21 Du nboam• +nunvd pnrwr is /rete! y issud Jris wrth nh• %avongJ:�Arg un idle Grrr n:mw•eam tariuingproga+m r,.o�niuxl by ihr 84aae.bnsrtlr 1hpirmiew q% Pnldir ArnAG in nnmrl rm-e wide /OS CLUB S9UD09(G)(3)(:). Ibis evi! wle evil/!;, rr/irl Ja frrrnr 15) v+'urs ('om rl mr gj'rompl viou. 1.<n«ivy: �. nit+,: , •.j AUR ir.SOCI kr nzsoc_Ircnov, ION A•I:14i1.'I\OSttIS IZC5I:111lPnr A61OC1:lIMn 90U.7G5.2122 333'fi.g4W Road• Suite 102 wv.rnxmamnemg Swnbbu:vugl:,A'IA 01772 509-303-9905 n w.xnuraumrumtta.anry 0 D m r•0 m X ti T H A D 1 m �1 ° m W �oN oN." Wim\ fE��'� z� 2n T x N ! o. moo. �a �fl o. r Q� N _ l � m N � N G 0 = O N 2 � c � � o x ^ o' m = = 3 m^ Q m m 0 d n m v 3 O n o O = n3a. 0 o' _ 0 D m r•0 m X ti T H A D 1 m �1