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Home My WebLink AboutD'Angelo Sandwiches - 12/31/2020-- FOR BOARD OF HEALTH USE ONLY Permit# Issued OOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name r 7` ` Ur o ` Establishment Address `�� jU�_%Z 1 t1 \J-1— Establishment Mailing Address (if different) 1�QX Q\1 C� (b `3- I Establishment Telephone No kr) R) 3 :�5q Applicant Name & Title: ft c1 OC1 �N�( Applicant Address V o ()'2t X a I Applicant Telephone No.:b-Q,g 24 Hour Emergency No.: � ) Applicant Email ()��f1Y-1 nC , R-4N1 Owner Name & Title (If different from applicant)( [ t y\, (alVj I Owner Address' (o "x Owner telephone numbe�j 0$/" FS d QO Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. N;' Corporation --Me Title Address 11 An Individual f JQ jC 3 �J7 El A Partnership 7 1-1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: V1 �� r® 1 Address: �� _Nf �� c Telephone No<, i'q 24 Hour Emergency No: �ci Fi I FAX: E-mail: IIRS18171IA District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: �o WAG SEE DISPOSAL: o No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: - L'w� Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training M_\A\ 6Y`L S__ 6 n t 0\C Name of pest control company routinely inspecting the premises for evidence of pests .h7W i If there is seating for 25 peo 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? t If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ❑ Retail Food $125.00 Mobile Food Consession 0 Temporary U ood Service up to 1o0 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 upto 201 + $ 300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date:/Milk 6® & Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs I". PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended [J Reheating of Commercially Susceptible Population Facility to be Prepared by Consumer Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand El Customer Self -Service Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of El Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale EJ Vacuum Packaging / Cook Chill El Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to th o racy of the inf mationffpprovided in this application and affirm that the food establishment operation will omplyth 105 CMR0.001)I$nd all other applicable law. I have been instructed by the board of health on how too tam copi s of 105 CMR 90.0 and the federal Food Code. Signature of Applicant: \ s/X.uw' r- I�rv1>✓LL/t,N"�-/ 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: � � \ ��YC�. V �� w N O N r 1 .P `o 0 w A V7 z z Cn W z w P z w P4 wul P a rc y S � w R N � z a o o N z Cd u U O Q w N Q 0 wax a Q � u Yp p y1 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. Signature of Individual or Corporate Name By: Corporate Offer andatory, if Applicable) "Social Security No. (Voluntanj) or Federal Identification Nuinber *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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �n n Please Print Legibly Business/Organization Name: y Address: �0 1�='VX Q 1� nn,n City/State/Zip: i ,NdAeWake,( Upp`1l `0A_�� Phone #: �Mgt %5�� RqCDQO Are yoqdn employer? Check the appropriate box: 1. I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 12.❑ Other *Any applicant that checks box 41 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 am an employer that is providing workers' Insurance Company Name: D t o� Insurer's City/State/Zip: Policy # or Self -ins. Lic. my employees. Below is the policy infornmtion. Expiration 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 fy, under th4ainK and penalties of perjury that the information provided above is true and correct. 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 Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia DANGING-01 MMICIL DATE 01102120190I1/02/ CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A 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(les) 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. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License ff 1780862 3 0 International St eet England Wilmington, MA 01887 NpNTACT PHONE ) FAX No):(978) 988.0038 AIC, No, Ext): (978 687.5100 A&R6SS: INSURERS AFFORDING COVERAGE NAICN INSURER A: Hanover Insurance Company 22292 INSURED INSURER B:Allmerica Financial Benefit Insurance Company 41840 INSURER C: D'Angelo, Inc. _ INSURER D: 323 Manley Street West Bridgewater, MA 02379 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER- 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ILTRNSR TYPE OF INSURANCE ADD $bV VS POLICY NUMBER POLICY/YYYY POLICY EXP ITYWI LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �X OCCUR LBND48487800 01/0112019 01/0112020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTEDnce $ 100,000 MED EXP An one rsan $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER POLICY EPRO- JECT D LOC OTHER: GENERALAGGREGATE $ 2,060,000 PRODUCTS - COMP/OP AGG $ 2,000,110 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED OWNED ONLY AUTOS AUT 030NLY AUOTOS ONLY AWND461185 01101/2019 01/01/2020 EOMaBINED SINGLE LIMIT $ 1�000,000 X BODILY INJURY Perperson) $ BODILY INJURY Per accident S pp PPorr. ddm AMAGE $ A X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE UHND46117400 01/0112019 01/01/2020 EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 DED X RETENTION$ 0 $ A WORKERS COMPENSATION ANO EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN (ManEataryEn NH)CLUDEDP describe under.L. DESIf CRIPTION OF OPERATIONS below NIA WHND442216 12/3112018 12131/2019 PER OTH- STATUTE E.L. EACH ACCIDENT $ 500,000 EDISEASEEAEMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT b 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached If more apace is required) Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Au,vmu La (Le "I aladl U 1 UUU-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: 0 ko brIi "ei \,-,i'nck\A) Ick e-S Address: ---) �� CN(�fkt ttt� W (� p� Mailing Address: `�� kt—' CQ'1_I W 4 V 1��(h 0 ba'JAq Phone/Fax Number: `'s o ) Y6q � d Email: (i('�w�L C1"ek1Y)c - �,,tyi- Contact Person/Title for Grease Traps: T"X Yt MRS s r-) � Ayy_ Name of Company scheduled to pump internal grease trap(s) monthly: ? r \ \ 13y "\ Name of Company scheduled to pump external grease trap quarterly: 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 tQnforrnation submitted in these documents is true, accurate and complete. Date it \q' � -\ Print 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): �")b — � 1�j0 Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday Thursday Sunday Tuesday Friday Wednesday 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 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators / 1 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? Yes No I: Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1) L Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor G ease 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 waste: rJu►1RIV1� Your Grease R Brid (508) 697-9565 ] WWWY Date of Service , Customer Name O +" e r f, c / Address Job Address (if different than customer) _ D �p Pro & Drain ;Specialist P.O. Box 294 ewater, MA 02324 LIKEIn 800) 449-4480 (508) 759-0979 US ON ;riotServicesMa.com Invoice # 6 fl `' Z ' ' � f Phone # City ,'d Zip Apt. # PTION OF WORK 4 Lilt I hereby authorize you to perform the above described services and I agree to pay the amounts indicated to the right. I certify that I am duly authorized to order and approve the work requested. Signature PARTS LABOR 7 Terms: Cash t; 2 " OTHER PO # Bill Out TAX TOTAL This is to acknowledge completion of the above described work DISCOUNT which has been done to my complete satisfaction. TOTAL DUE' 7 }" l , �i Signatura/ Date ' t =i Customer Name