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HomeMy WebLinkAboutPushcart Cafe, Inc. - 12/31/2020=ta; FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name S�:I<'r Establishment Address Q Establishment Mailing Address (if different) Establishment Telephone No -- Applicant Name & Title: Applicant Address ,w � �/+ i f n C'. F /'�: ("'. . �, t, x. t I, ';, Applicant Telephone No.: 24 Hour Emergency No.: Applicant Email i"ci f 10(l Y' f 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 L7 An Association partner. N> I A corporation Nae Title Address 00 �An Individual (aunty CCd)oray- ba 4CrlrnerA01— —1 _ M0 O A Partnership 6�k JJYj-, U Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title. (j �,tA r{�. (( P G� j j{t;f.. (Y)!` } yl Address: Telephone No: 24 Hour Emergency No: FAX: 1 ,C`C7!jr'-`�(✓ E-mail: A C}�) 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: SEWAGE DISPOSAL: v) `T" DEP Public Water Supply No: If applicable) pPY ( pp ) No. of Food Employees: f DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: ,�.,1 Name of Person(s) In Charge Certified in Allergen Awareness Training i Name of pest control company routinely inspecting the premises for evidence of pests fid- VJ If there is seating for 25 peopIe or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. &rYes Does this establishment require a FOG permit? ! A !' => If yes, please attach the FOG permit application. Length of Permit: Establishment Type: : Annuat Q Retail Food $125.00 Q Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream El Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 El Pushcart $50.00 # of Pushcarts: Temporary Time: E] Supermarkets $400 Q Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF-Potentially hazardous food (tlma4amperature controls required) (Check all that apply): Non•PHF's- non-poten0ally hazardous food(no f1mellemperature controls required) RTE - reedy -to -eat foods /Ex. sandwiches, salads, muffins which need no further processing) E] Sale of Commercially Pre -Packaged Non-PHFs 16HFCooked To Order [] Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer E] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand E] 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 EJ Offers Raw Or Undercooked Food Of E] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale El Vacuum Packaging /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 will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to oblgin;coples of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: ' (,A,(J ,t`=r'.( ,`T(''� ('� -f, /4"� Pursuant to MGL Ch.52C, 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: (1 f ( LA 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 "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\Scolt's 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 Please Print Legibly Business/Organization Name: Address: d ; . 4f 1 i' ti' i t Are you an employer? Check the appropriate box: L. 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] 31-1 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.] Phone Business Type (required): 5. ® Retail 6. E3ilastaurantBar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ®Non-profit 9. ❑Entertainment 10,® Manufacturing 1 L® Health Care 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 # t. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: �CaOU City/State/Zip: S� h Policy # or Self -ins. Lic. # t666 /4C'(PL// Expiration Date: U c cs v 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 Ilse pains and penalties of perjury that the information provided above is true and correct. Signature: 1 C t V t F. (c_ Date: ( 2.2 / t" v Phone #: . rf c i 2 ��- 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 #: vwwsnass.gowma Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT ., •�r.. .,., a ,. Business/ Food Establishment Name: Pk ��.�'� t- p Address: I'Af,i A Mailing Address: Phone/Fax Number: Email: „j { ( 11 ( { (/4 Cl C Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly {c F t y 1r'J a 7? ( � - I) ` <� 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 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. Date (`, ') ') / r/ Print Name 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): 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 r. t5 3 compartment sink r' Handwashing sink Commercial Dishwasher Bar sink "4i✓ 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? 7 V� Yes No Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? i External Grease Traps Does this establishment have an outdoor Grease 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: Please list fixtures attached to each grease trap Grease Trap l Grease Trap 2 i 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 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: 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 DATE (MM/DDIMY) p� t� CERTIFICATE OF LIABILITY INSURANCE 11/18/2019 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 be endorsed. If SUBROGATIONIS 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 CONTACT NAME: AUTOMATIC DATA PROCESSING INS AGCY 76250717 COMMERCIAL GENERAL LIABILITY PHONE (800) 524-7024 (AIC, No, Ext): FAX (800) 524-4013 (AIC, No): 71 HANOVER ROAD FLORHAM PARK NJ 07932 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICp EACH OCCURRENCE $1,000,000 INSURER A: Twin City Fire Insurance Company 29459 INSURED INSURERS: Hartford Accident and Indemnity Company 22357 PUSHKART CAFE INSURER C: 219 N MAIN ST MANSFIELD MA 02048-2211 INSURERD: INSURER E: MED EXP (Any one person) $10,000 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 RESPECT TO 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICCY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMASETO RENTED $1,000,000 MED EXP (Any one person) $10,000 X General Liability A 76 SEW BG2554 10/10/2019 10/10/2020 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY E]PRO- JECT Fx_1 LOC PRODUCTS - COMP/OP AGO $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT u e ROD ILY INJU RV (Per person) ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) PROPERTY DAMAGE HIRED NON -OWNED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS- MADE ED I RETENTION $ WORKERS COMPENSATION PER X OTH- AND EMPLOYERS' LIABILITY STATUTE ER E.L. EACH ACCIDENT $500,000 ANY YIN B PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A 76 WEG AE4B4N 10/10/2019 10/10/2020 E.L. DISEASE -EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 (Mandatory in and It yes, It yes, describe under ESCRIPTION OF OPERATIONS below A EMPLOYMENT PRACTICES LIABILITY 76 SBW BG2554 I 10/10/2019 i 10/10/2020 Each Claim Limit $10,000 i Aggregate Limit $10,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached i( more space is required) Those usual to the Insured's Operations, ccmrtcrr^ATE HOLDER CANCFI_LATInN The Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 6 Park Row BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Mansfield MA 02048 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _I Ael� 15if C�t_z,� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD THE' HARTFORD THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 The Town of Mansfield 6 Park Row Mansfield MA 02048 Account Information: Policy Holder Details : PushKart Cafe November 18, 2019 vQ Contact Us Business Service Center Business Hours: Monday Friday (7AM - 7PM Central Standard Time) Phone: (877) 287-1316 Fax: (888) 443-6112 Email: agency. servicesothehartford.com Website: httos:Hbusiness.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 V z r--4 z z w w = N N 04 N C G H N L 0E 0 z N f;L O z a o ami ,Q o o 0 Qi p , � =- EQ � ♦ V L x W d 0 0 z f0 0 0 a o V� C w v O 0 w v O tl bq n� C .p ti v N N o I M+