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HomeMy WebLinkAboutCibo Matto Caffe - 12/31/2020jt0, y� fI �S�S ©� 4 spa FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION 10 (c f (Application must be submitted at least 30 days before the planned opening date) Establishment Name C t bo ma+- z CCt � Establishment Address zs i Clnavv L� S� kAo,,)6 N1P_A0 /\4A 03-6LA Ij - Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title Applicant Address U1 t uw�yoll S� Mu'7S�P�c)i Applicant Telephone No.: -) -7 `'( 2 <N y Ce a (o 6 24 Hour Emergency No.: '-I I ` Z t ti " �' `� Q D Applicant Email p e+er Y\,t et. k 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. corporation El An Individual Name Title Address 1 �RRW i (p t ocrvA(o>eII Si" El A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: pvN 1 t I i 5 KLV6 J aA a Address: 'L ti "}'^ S� dVton zl c� (AA 0 - a K "- Telephone No: t a ` 2 Le ce ' u 2 a ti 24 Hour Emergency No: 'I-' Li 2 G Co Li Qjc� i3 FAX: gv b E-mail: Vkue1'44itq�✓vcct\.. Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATERSOURCE: et� W SEWAGE DISPOSAL: N a V) 1+1 S-C"�Jey- No. of Food Employees: U 0 DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training �Iq � rv1 .e w � C ✓� 2 Name of pest control company routinely inspecting the premises for evidence of pests Elsylol 1?R�t' ion If there is seating for 25 people r more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. LJ Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual 0 Retail Food $125.00 E] Mobile Food Consession IJ Temporary E] Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream : 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: 0 Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: Ailk &Cream $10.00 [V]'baterer $35.00 Food Operations: Definitions: PHF - Potentially hazardous food (time/temperature controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no time4emperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [] Sale of Commercially Pre -Packaged Non-PHFs dPHFCooked To Order E] 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 0 Delivery of Packaged PHFs /Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly 1� Sale of Raw Animal Foods Intended Susceptible Population Facility 0 Reheating of Commercially to be Prepared by Consumer l� Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours 0 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 Retail Sale control) [+/Offers Raw Or Undercooked Food Of [ Preparation of Non-PHFs Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities 0 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 conies of 105 CMR 590.000 and the federaYFotO Code Signature of Applicant: Pursuant to MGL Ch.6 and paid state taxes re sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns ad under law. Social Security Number or Federal ID: `�y r �• t'7 p /'.! Signature of Individual or Corporate Name: Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: l .r L" b Al el A� i•.CSP S'( l.�1flu"IaA S( Mailing Address: IV1 a � Phone/Fax Number: Email: 16LA Contact Person/Title for Grease 900co Name of Company scheduled to pump internal grease trap(s) monthly: L i e C,`A LI e S 12 e n e w w Name of Company scheduled to pump external grease trap quarterly: L, 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 thpt the information submitted in these documents is true, accurate and complete. Date O `A 19 i Print Name iP-kA�'- V- 'Q)k5�- Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? l(�jG Please list fixtures attached to each grease trap Grease Trap 1 A )C_ Grease Trap 2�^— e ' Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes C11 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 frvnlatnrc? Where is the grease storage unit loca How often is this grease storage unit Please list the vendor who removes t 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): t '�_ ( Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday p h b Tuesday I a n 1A, b a Wednesday V 6e H- Thursday fo up ✓' Friday - f Saturday c Sunday k r „„ (y nr 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 nn� ``vim 3 compartment sink 6 Handwashing sink commercial Dishwasher lUd Bar sink Mop Sink lfi Garbage Disposal L% Ice Making Machines Fryolators v Grills or Ovens D Exhaust Hoods 6r Floor drains Other: How are hood vents� .cleaned? (i.e., in three (3) bay sink, off site by private company): e/�U° YC _ G---v)W�� Is dinnerware pre -rinsed before being washed? V Yes No If yes, at what station/sink? �lStl� �+�L� •�� 2 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. //ignature 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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street U1V Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information N r r Please Print Legibly Business/Organization Name: C U l A t v b(0 - "3--(- qg()o Are you an employer? Check the appropriate box: Business Type (required): 1.�I am a employer with Co 0 employees (full and/ or 5. ❑ Retail 6. yeestaurant/Bar/Eating Establishment part-time).* 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.E] Manufacturing no employees. [No workers' comp. insurance required]* 1 LQ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12N Other with no employees. [No workers' comp. insurance req.] *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 d 1. I am an employer that is providing ivorkers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: tAb Y S Q @' I lrl C U (0-Y1 C 0 0n [ �1 � { G Insurer's Address: (/V' (1J �)(t) ton ` St City/State/Zip: N 4 4v L a S iD n, MA p?r 3 510 Policy # or Self -ins. Lie. # CA) fin] E> C: (' �-3(J V) -- Expiration Date: 5 I i 2 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 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, m der the , e pains and penrrerjury that the information provided above is true and correct Signature: / /// Date: 1o)3 `] I avY c� U r 1-1q a1(I G2()Co 0 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.mms.gov/dia A� " CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDYVYV) 11/19/2019 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(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. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Karen Forrest NAME: Morse Insurance Agency, Inc. 285 Washington Street PNcNE Ell), (508) 238-0056 AX Ne: (508) 230-8367 nDORILss: karenforrest@morseins.com INSURERIS) AFFORDING COVERAGE NAIC0 INSURER A: Tri-State Insurance Company of Minnesota 31003 North Easton MA 02356 INSURED INSURER B: Hartford Insurance Company of the Midwest 37478 INSURER C: HEYMOHN LLC INSURER D: DBA CIBO MATTO CAFFE INSURER E: 254 CHAUNCY STREET 1 INSURER F: MANSFIELD MA 02048 COVERAGES CERTIFICATE NUMBER: 19-20 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ISEE LTR TYPE OF INSURANCE ADULBUOKYIYYYY I gp POLICY NUMBER MMIDD MM/DDYIYYYV LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEX OCCUR A O E PREMISES Ea occurrcum ence $ 300,000 MEDEXP(Anyonepemon) $ 10,000 PERSONAL SAW INJURY $ 1,000,000 A ADV5412369-10 10/01/2019 10/01/2020 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY ❑ JECTT El LOC GENERALAGGREGATE $ 2,000,600 PRODUCTS -COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per Person) $ ANYAUTO A OWNED X SCHEDULED AUTOSONLY AUTOS HIRED M NON -OWNED ONLY AUTOS ONLY ADA5412370-10 10/01/2019 10/01/2020 BODILY INJURY (Par accident) $ X PROPERTY DAMAGEAUTOS Peraccident 8 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 A EXCESS LIAB CLAIMS -MADE ADV5412369-10 10/01/2019 10/01/2020 DED I X RETENTION $ 0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTWE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) NIA 08WECCF3682 05/15/2079 05/15/2020 X 3EATUTE ERH- E.L. EACH ACCIDENT $ 1,000.000 EL. DISEASE -EA EMPLOYEE 8 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY OMIT 8 1,000,000 each common cause $1,000,000 A Liquor Liability ADV5412369-10 10/01/2019 10/01/2020 aggregate $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, AddKlonal Remarks Schedule, may be attached It more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 0 im 1r. ri I- I I ( \ , m \ \ \ \ s+/ $ y'z ^Z \)§ 2 0 [ ; k ! / I I I \ \ \ \ # \ \ \ \ ( a | I I \ \ ar}\ ƒ \\/\ � � \ «ƒ\2 a \§$5 a ` \ . I M � \ C3 LL. \ E om 0. C) 0 _R 10 C\j 0 q LOu D �: . c Mo Ovi N 14-- 86 (3