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HomeMy WebLinkAboutMansfield Deli, LLC - 12/31/2020l I FOR BOARD OF HEALTH USE ONLY Permit # Issued , Aj8, "II FOOD ESTABLISHMENT PERMIT APPLICATION ' -�/� (Application must be submitted at le A�* f4E4 e !pprtt pening date)\.` aaa vrx ms A �` Establishment Name A FI L Establishment Address , A 02048 Establishment Mailing Address (if different) Establishment Telephone No goy 3 3 ti-'- I`t'y Applicant Name & Title: — o•x < c � / n Ce t I t 7 Applicant Address 3 (,rovel- Lei')4- F""V 4o. / Applicant Telephone No.: Z-H .r� J -0-41 24 Hour Emergency No.:' i4'J_Z fro (3 Applicant Email "t'e ole;{l-7 '; ) 1.�< 11 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 Atssociation partner. A Corporation ❑ An Individual Name Title / Address _ Z�a�4)�Pi(� �G� $-Ie /hr.l4-,L 3 GNvtl, %IG f7ok6a?a 11 A Partnership 11 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: l_'f /4J' " Address! Telephone No: 24 Hour Emergency No: FAX: E-mail: _T(:1�A ;'h 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: l U SEWAGE DISPOSAL: To y,f DEP Public Water Supply No: (If applicable) No. of Food Employees Fi DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests Acn /ASS 1t 7 1 If there is seating for 25 people 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? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ❑ Retail Food $125.00 Mobile Food Consession Temporary Food Service up to too INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/ice Cream n Food Service up [0 101 -200 $250.00 $25.00/freezer Temporary End Date: ❑ Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 p ❑Residential Kitchen $100.00 Rain Date: !Milk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definifions: PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 2 Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order L:J-Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Pfeparation of PHFs For Hot And for More Than a Single Meal Service f Delivery of Packaged PHFs Cold Holding For Single Meal Service El PHF and RTE Foods Prepared For Highly ��..,,� ElSale of Raw Animal Foods Intended E24eheating of Commercially Susceptible Population Facility to be Prepared b C Processed Foods for Service Within 4 Hours p by Use of Process Requiring di Variance and/or HACCP Plan (including bare hand ,� QCustomer Self -Service 6uslomer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) Piep aration of Non-PHFs Retail Sale �j p ❑Offers Raw Or Undercooked Food Of f-i Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities ©-P-repares 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 copies of 195TMR 690.000 and the federal Food Code. Signature of Applicant: 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. I•t. S/''4 (� Social Security Number or Federal ID: Signature of Individual or Corporate Name: 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 MANS 10. U 4 L C Please Print Legiblv Business/Organization Name: 72 Pun S l CET Address: City/State/Zip:. Phone Are you an employer? Check the appropriate box: Business a (required): 1. ❑ I am a employer with _7 employees (full and/ 5. etail 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. [No workers' comp. insurance required] 8. ❑ Non-profit 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 no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance rep.] 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company L_ Insurer's Address: 01c� U` W1`J 019L, . -3tx5 S. Y7,,,I<- i'l, City/State/Zip: `L t)�,_ Policy # or Self -ins. Lic. # oy wet- T 14 �t 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 certify, under th"atns and penalties of perjury that the information provided above is true and correct. 4 Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 1-zol 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 AC R ® CERTIFICATE OF LIABILITY INSURANCE DATE (M12019 YY) MIO 11/12/2019 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 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 C & S Insurance Agency, Inc. NAME CT Lisa Fonseca PNDNE (508) 339-2951 Alc No): (508) 339-4811 AIC o Ext ADDSo. Lisa@candsins.com 190 Chauncy StreeURO Box 406 INSURER(S) AFFORDING COVERAGE NAICR INSURERA: Employers Mutual Casualty Company 21415 Mansfield MA 02048 INSURED INSURER B; Commerce Insurance CO 34754 INSURERC: Hartford Casualty Insurance Cc 29424 MANSFIELD DELI LLC INSURER D: Hospitality Mutual Insurance Company 72 PRATT ST INSURER E : INSURER F: MANSFIELD MA 02048-1927 rcorrciCATP HLIsewcR• 2019 Cart of Liab REVISION NUMBER: v 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 CONTRACTOR 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. LTR TYPE OF INSURANCE AUDLUUBR INSD D POLICY NUMBER POLICYEFF MMI00� LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED500,000 CLAIMS -MADE � OCCUR PREMISES Ea occurrence $ MED EXP(My one person) $ 5,000 A 5W07628 02/10/2019 02/10/2020 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY ❑ PR� LOC OTHER: COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY Ea accident)$ BODILY INJURY (Pet person) $ ANYAUTO BODILY INJURY (Per accident) $ B OWNED SCHEDULED BBZQWU 02/20/2019 02/20/2020 AUTOS ONLY AUTOS X HIRED X PROPERTY DAMAGE Per accident)$ AUTOS ONLY AUTOS ONLNON-OWNEY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY YIN E.L. EACH ACCIDENT $ 100,000 C ANY PROPRIETOWPARTNER/EXECUTIVE ❑ NIA 08WECTJ 1416 04/24/2019 04/24/2020 E.L. DISEASE -EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED'! (Mandatory In NH) E.L. DISEASE -POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below Per Occurrence 1,000,00D D Liquor Liability 00076SIOLL 02/10/2019 02/10/2020 PerAggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 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. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 1 �_Itc... � do 1eRA-9M5 AC(1Rn r:rTRPORATION_ All rinhfs raeamad ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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. i - Signature of Individual or &rporate Name *"Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatonj, 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:\Usem\sleiw\Desktop\Scotrs Documents\Food Establishments-'temp\TAX CERTIFICATION FORM.doc Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: P . a ^s9- s Address: 72 F KAT STREET u ANS IELD9 A 02048 Mailing Address: Phone/Fax Number: J 0� ^ 3 39^Z q cj y Email: �L Ul{�edL7 S1 �,'h1-5)'1 •nt Contact Person/Title for Grease Traps: e. Name of Company scheduled to pump internal grease trap(s) monthly: (N'mdl 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 the information submitted in these documents is true, accurate and complete. Date It Zd Z Print Name �i 1° "� c I 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): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday Thursday Sunday 3 Tuesday 6-''1 Wednesday G Friday 6. �) Saturday d^1 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 ti Mop Sink Garbage Disposal Ice Making Machines /L 6� Fryolators L 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): -n;,,a N � b/L, Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes A49:_No rj 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 '2 Ao N �/ Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease/Removal Unit (GRU/Interceptor)? v.° hl^ ri•. 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 How often is this grease storage unit emptied? Please list the vendor who removes the waste: / ( a s E\t\ » 2\\} « ®f §ƒ / {}// } w \± I � � 9 e❑ m A ry 0 z m r Patriot Services Inc. Invoice PO Box 294 BRIDGEWATER, MA 02324 Bill To MANSFIELD DELI 72 PRATT STREET MANSFIELD, MA 02048 i Date Invoice r 10/24/2019 G3131024191 P.O. No. Terms Project Net 30 Quantity Description Rate Amount I CLEANED GREASE TRAP AT 3 BAY SINK. TESTED WITH WATER AND IS WORKING WELL. 70.00 70.00 Total $70.00