HomeMy WebLinkAboutPrimrose School - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date) ,
01?019
Establishment Name ?fIm U So 9Cv4e0t~ OF MANS FrELb
Establishment Address 201 (oPfcAND 'DL MANSfiab, µA 0u1 g�
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title: N 611 A QA1EL O W N6L-
ApplicantAddress It Wttt.ow QAtr_, I,)Ett.eSWf, NA 0-2001 OLotrf
Applicant Telephone No.: 61'7- S t S - 4 5 P r 24 Hour Emergency No.:
Applicant Email n para (q f ri'mtoJe • ca,v+
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.
El A Corporation
Name Title Address
1,1 An Individual
Pok, 0WA4U 11 W luau QMGIC. Gn21A;
-9th -4
Pwa� ?AW OWAU t
�APartnership
EJ Other legal Entity
Sa#AY ,r 146µa(, iAk O WA V 3 NQsfi' rb flAV{A' H
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: oe)A^ PAki O WAu
Address: 1$ WILLOW PACk. r I tQuES teY� tafi oU,B
Telephone No: (01 I ^ 11$-4't 24 Hour Emergency No:
FAX:
E-mail: A f ak l P�HIO�e.W,t. �d'el� toe"
Alt E -Mail: p CtiC l A:I, t4 M
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
`CC3.
�P
Food Establishment Information
WATER SOURCE: *rOWW 0 f jeA
SEWAGE DISPOSAL:
011' N q M)Pi C40
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS: _ 7 0 6L�4 — 6 30/0.
t
Name of Person(s) In Charge Certified in Food Protection Management:
?v4.R,r (�, rad btu
Name of Person(s) In Chargee Certified in Allergen Awareness Training
VJ i+4 Ri y AGQ.%tti/�
Name of pest control company routinelyinspectingthe premises for evidence of pests ht Pia �h�
If there is seating for 25 peop or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. t es
Does this establishment require a FOG permit? iA ? If yes, please attach the FOG permit application.
th of Permit:
Establishment Type:
7len
-::. AnnualI❑
Retail Food $125.00
0 Mobile Food Consession
I❑ Temporary
5J<d 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:
l� Food Service up to 201 + $300.00
Pushcart $50.00 If of Pushcarts:
Temporary Time:
€❑ Supermarkets $400i❑
Residential Kitchen $100.00
Rain Date:
[g -Milk &Cream $10.00t❑
Caterer $35.00
Food Operations: Definitions.PHF - Potentially hazardous food (11me/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, muHlns which need no
furtherprocessing)
i❑ Sale of Commercially Pre -Packaged Non-PHFs To Order
r` of PHF Cooked and Cooled or Hot Held
W/Preparation
0 Sale of Commercially Pre -Packaged PHFs L✓ Preparation of PHFs For Hot And
for More Than a Single Meal Service
Q Delivery Packaged PHFs Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
of
Sale Raw Animal Foods Intended
Susceptible Population Facility
of
K] Reheating of Commercially to be Prepared by Consumer
❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
0 Customer Self
and/or HACCP Plan (including bare hand
-Service
I❑ Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for
control)
i❑ Preparation of Non-PHFs Retail Sale
Offers Raw Or Undercooked Food Of
0 Juice Manufactured and Packaged for
Animal Origin .
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Q Offers RTE PHF in Bulk Quantities
0 Prepares Food/Single Meals for
I❑ 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 o(N105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 494, 1 certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: 12.- 191
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.
&leu'DY ScG�l Ma�s�ruA
Signature of Individual or Corporate Name By: Corporate Fficer (Mandatory, if Applicable)
2,.29Ib52,�'
"Social Security No. (Voluntary) or Federal
Identification 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:\Users\sleite\Desktop\Scott's Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
UT www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: INSQI/jt9loNal, mi4oi t-t.L 'D 6A PewMe-ot S Cot<oe- or
NANS>< of
Address: Z 0I tio h LA,4 n b t
City/State/Zip:
sfttt) , M
Phone #: 5 0]5 - 3 6 q- L 143
Are ypu an employer? Check the appropriate box:
Business Type (required):
1.
I am a employer with 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.
8• ❑ Non-profit
[No workers' comp. insurance required]
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 organization, staffed by
11.❑ Health Care
volunteers,
12.DOther k 4 t0k(GA UAW
nce
with no employees. [No workers' comp. insurareq.]
*My 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 #1.
I ant an employer that is providing workers' conepensation insurance for my employees. Below is the policy information.
Insurance Company Name: May get
Insurer's Address: 'CZE Pakwa.n Por4tA t �y
City/State/Zip: � ey i ,w , I L 6 0 o t S
Policy # or Self ins. Lie. #__14 ii1 t d 14 � 7- 5-7 - 0 1 Expiration Date: (1410 t' `7.o 7-0
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
fore 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 fore
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 ofperjury that the information provided above is true and correct.
Signature: _4 ^A Date: t t I 1 I 1 q
Phone #:
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,inass.gov/dia
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 bum 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 us 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
Fenn Revised 5-26-05
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: ?k 1H 1436 SC41.bi, OF km'14F(F0
Address: 201 C.oPCLgAND 'Dj- , Iu�\NSf eLb,kA oz4R/
Mailing Address: I r
Phone/Fax Number: 50 8 - 3i, 9. 01 3
Email: ndRA (Al Cor"
Contact Person/Title for Grease Traps: n r pjG u
Name of Company scheduled to pump internal grease trap(s) monthly: PaJ j S Pd 14
Name of Company scheduled to pump external grease trap quarterly: 6w D to f `6a1
sas 144'
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 and complete.
Date 1 I 1 1 I
Print Name #36MA Q6taElr
• •- - �l. �
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): ) 9 9
Normal Hours of Food Preparation/Service:
Monday I' Coat. 6:lot" Tuesday I! to a,, , 6,'3 f^ Wednesday `(: r
Thursday T.tNaf, 6:3^fm Friday J,Iroo,. 6: o fm Saturday
Sunday l
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
fCommercial
Dishwasher
Bar sink
Mop Sink
Garbage Disposal
/
X//
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):
V1A-
Is dinnerware pre -rinsed before being washed? � Yes No
If yes, at what station/sink? ja4k
2
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
M
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
L/ Yes No Size O-LrO gallons
Where is the existing outdoor GRU located? f2pt p -'A I—V4-
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?
Please list fixtures attached to each grease trap
Grease Trap 1
U„/
Grease Trap 2
How often is this grease storage unit emptied?
Grease Trap 3
Please list the vendor who removes the waste:
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
L/ Yes No Size O-LrO gallons
Where is the existing outdoor GRU located? f2pt p -'A I—V4-
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?
PIA
Where is the grease storage unit located?
N1.4
How often is this grease storage unit emptied?
fil A
Please list the vendor who removes the waste:
^r( A
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Original Printing issued March 29, 2019 Standard
NCCI Carrier Code:22616
Type: Stock
Markel Insurance Company
Ten Parkway North
Deerfield, It, 60015
1. The btsureWs Name and Melting address:
Inspirational Minds, LLC
18 Willow Park
Wellesley, MA 02481-5609
6178184111
Policy Number.
MWC0146257-01
Renewal of Policy:
Rewrite of Policy:
Fain # / Risk ID #:
822916525/
DBA Name: Primrose School of Mansfield
SIC CODE: 8351
Other work place not shown above -See Attached Location Schedule Type of Limited Liability Company
entity:
2. The policy period is from owir2o19 to 04/012020 (12.01 AM standard Tmmej at the insured§ waiting address.
3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers
Compensation Law of the states listed here: MASSACHUSETTS
B. Employers liability Insurance. Part Two of this polity applies to work in each state Gated in Item 3A -
The Emits of or habiEty under Part Two are:
Bodily Injury by AaSdent: $1,000,000 each accident
Bodily Injury by Disease: $1,000,000 policy limit
Bodily Injury by Disease: $1,000,000 each employee
C. Other States Inslrance: Pad Three of this policy applies to the states, If any, listed here
Ali states except those fisted in Item 3A of the Information Page and the following states or territories: District of Columbia, ID,
MT, NY, NO, OH, OR, WA, WY, Puerto Rico and US Virgin islands.
1 + MIJJT
Other State Endorsements and Schedules:
MDWCIOOL MWC 1201, WCOOOOOOC, WC000308, WC000406A, WC000414A, WC000422B, WC000425, WC 2003 01, WC 2003 02 A, WC
20 03 03 D, WC 2004 01, WC 20 04 05, WC 20 06 Ol A, WC 2006 04, M)WCI000, MIL 1214, MPIL 1083, MPIL 1007
4. The premium for ihs poky viol be determined by our Manual of Russ, Classifications, Rates and Raft Plans. AN Information wired is subject
to verification and change by audit.
Minimum Premium: 258.00 Deposit Premium:$437.00
Pmduoer:DMS Insurance Agency Of Texas LLC Countersigned By:
12400 Cont Road, Suite 1100 972-419-7568 D
Dallas, TX 75251 Data: 03/29/2019
Servicing office. Markel Service, Inc., (888) 500-3344
Central Park Plaza, 222 South 15th Street, Suite 15ODN
Omaha, NE 68102-1680
(See extension of information page for class code, rate and premium detail)
Total Estimated Annual Premium:$2,803.00
Pay pian: 10 -Pay- 1546
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
ENDORSEMENTS. IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY
1uINIM4 PI 11.907
1 of 28
998012,01 3 72256Da32na19 MV"146257-01
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
MARKED
Original Printing Issued March 29, 2019 Standard
NCCI Carrier Code:22616
Type: Stock
Markel Insurance Company
Ten Parkway North
Deerfield, IL 60015
1. The Insured's Name and Mailing address:
Inspirational Minds, LLC
18 Willow Park
Wellesley, MA 02481-5609
6178184111
Policy Number
IMWC0146257-01
Renewal of Policy:
Rewrite of Policy:
Fein # / Risk ID #:
822916525/
DBA Name: Primrose School of Mansfield
SIC CODE: 8351
Other work place not shown above:See Attached Location Schedule Type of Limited Liability Company
entity:
2. The policy period is from 04/01/2019 to 04/01/2020 112.01 AM Standard Time] at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers
Compensation Law of the states listed here: MASSACHUSETTS
B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A.
The limits of our liability under Part Two are:
Bodily Injury by Accident: $1,000,000 each accident
Bodily Injury by Disease: $1,000,000 policy limit
Bodily Injury by Disease: $1,000,000 each employee
C. Other States Insurance: Part Three of this policy applies to the states, if any, listed here
All states except those listed in Item 3A of the Information Page and the following states or territories: District of Columbia, ID,
MT, NY, ND, OH, OR, WA, WY, Puerto Rico and US Virgin Islands.
D. California Endorsements and Schedules
Other State Endorsements and Schedules:
MDWCf001, MWC 1201, WCOOOOOOC, WC000308, WC000406A, WC000414A, WC000422B, WC000425, WC 2003 01, WC2003 02 A, WC
20 03 03 D, WC 20 04 01, WC 20 04 05, WC 20 06 Ol A, WC 20 06 04, MJ W C 1000, MIL 1214, MPIL 1083, MPIL 1007
4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information required is subject
to verification and change by audit.
Minimum Premium: 258.00 Deposit Premium:$437.00 Total Estimated Annual Premium: $2,803.00
Pay plan: 10 -Pay- 15%
Producer:DMS Insurance Agency Of Texas LLC Countersigned By:
12400 Coit Road, Suite 1180 972-419-7568 Date:
Dallas, TX 75251 03/29/2019
Servicing office: Markel Service, Inc., (888) 500-3344
Central Park Plaza, 222 South 15th Street, Suite 150ON
Omaha, NE 68102-1680
(See extension of information page for class code, rate and premium detail)
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY
MDWC 1001 05 10
IIIIIIIIII111111III11111111111111111111111111111111111111111111111111111111111 1 of 26
008012-013396-44722540-03292019 MWC01462.57-01
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