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HomeMy WebLinkAboutMooyah Burgers |& Fries - 12/31/2020_7 FOR BOARD OF HEALTH USE ONLY Permit # Issued I I FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name Kooyh" ROr�wS �Yfcs-SVnak� w Establishment Address 3a1 5e i,&o c SV. S U,, .4 1 Ho M P_m,.A 1 n S MA. (7 Establishment Mailing Address (if different) Establishment Telephone No 50$ & I$ _ 3 p q 5 Applicant Name & Title: �7fl F t p 91 FA t O W N t Applicant Address y gtvck Sl- So. eAs-roa1 Min. 0a3 kS Applicant Telephone No.: 5o $ -a9 y- "� V 24 Hour Emergency No.: ��y- �t 5 -0003 Applicant Email r_ A n ' n 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. VA Corporation El An Individual ❑A Partnership Other legal EntityEl Name Title t Address FAef r, Qi FA r _erLsV�eNt �( �W�A 6l. Se. QiSTUN,ha. 13 }1 .6;3" ,21a'y Ar in�Hc 2tio�ah._..__ 'rY sv✓ a '31 010.._Cot6W14 V rwh{;i�".ah✓ It.WA Zeid Lei- OW JJE%JL 341 &Jh e:. ' ra,h r NA Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: M hetvAt.I Za i Anti Address: q Telephone No: 611--$35-HASq 24 Hour Emergency No: ol- FAX: E-mail: 1 AltE-Mail: %1ZGAav\ com District Or Regional Supervisor (if applicable) S hkj� ;5 PcQoUa Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail Food Establishment Information WATER SOURCE: TO SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: l_g� DAYS/HOURS: nrpA - 14Urt SpA WoD-9:oo F4PA-5i4TV10R /�;✓.- ) Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training µ tF- wFAt - AN7b/Nv' 2rA AN - MAkW14/-1 Pelel Aw/ Name of pest control company routinely inspecting the premises for evidence of pests D R K I hl 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. MYes Does this establishment require a FOG permit? yl�_ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual �'{1j`Ietail Food $125.00 E] Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 [:1 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: [] 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: El Supermarkets $400 E]Residential Kitchen $100.00 Rain Date: Milk &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 ((EfEx. sandwiches, salads, muffins which need no further processing) ('Sale of Commercially Pre -Packaged Non-PHFs I)'F.PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ii❑�_'' Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And -. for More Than a Single Meal Service Cold Holding For Single Meal Service E]PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service contact alternative, time as a public health Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Ice Manufactured and Packaged for control) E] Preparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities E] 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 co r 10 OIR�590.00And all other applicable law. I have been instructed by the board of health on how to ob m copies of C kk 590.O,�tjj�� 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. Social Security Number or Federal ID: a L� � Signature of Individual or Corporate Name: O 1 7 3 (oi1 t7 o-Aree__r. BOa" i Z7✓C 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. Three- (;mJ Cdys aK _ Signature of Individual or Corporate Name By: oipo •ate Officer (Mandatory, if Applicable) $1-Y3(4I4oyo **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. Ci\lJsers\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassacliusetts Department of Industrial Accidents x b I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDlicant Information Please Print Legibly Business/Organization Name: M © o YAH TN Qse Ge),, u y5 rw C Address: 3d.1 SCR-ooL 51, ;Ijl] #Iy6 #: 5 --6101-3095, Are ygu an employer? Check the appropriate box: Business Type (required): 1. � 1 am a employer with is employees (full and/ 5• ❑ Retail orpart-time).* 2. ❑ 1 6. ®Restaurant/Bar/EatingEstablishment am a sole proprietor or partnership and have no y, n Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. $• ❑ 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 no employees. (No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. INo workers' comp, insurance reg.l 12.0 Other 'Any applicant that checks box #1 must also fill out the section below showing Weir workers' compensation policy information. "'Ifthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box NI. 1 am an employer that is providhtg workers' compensation insurance for nsy employees. Below is the policy Information. Insurance Company Insurer's Address: kAQTF02h &AZA City/State/zip: Ha i f xts l GT Z>(.155- Policy 615SPolicy 4 or Self -ins. Lie. K t 10 WE Ar— 6- VZ M Expiration Date: &/— 0 —.26 A O 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. 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 swvw.massacw/ain Phone Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Irl o 0 yff H 1 Three— Ca s o 0 U V45 3/'G Address: 2111 S&"t 45cii6 -4lLi0 br'nNSr�'t!1 F,nA 0o)a�0 Mailing Address: 7CLyne/. p Phone/Fax Number: SY/�— i? )d 3 O 1 5 Ema Contact Person/Title for Grease Traps: VATkF D^7 [/MONT &M Pit44 50ZV1Ci Name of Company scheduled to pump internal grease trap(s) monthly: DuM oNi" 1' m P." aa /hlenliWla� Name of Company scheduled to pump external grease trap quarterly: 10!'A , b� �Ar/n�oR 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 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Signed Date P Print Name FAQIA RI FA 1 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): S� Seating Capacity (Actual Count): —may Normal Hours of Food Preparation/Service: Monday LI neo — 9,'012 C'N Thursday Sunday Il , o o _ Cj ao Tuesday lj %Vo _ cl loo Friday /I -$a — `n;tt .p , Wednesday Saturday 011"A' 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 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): A=1fAr-&V G1, IQ M6iJ7*G% 11e/ PP-IVOVr C4MOA-n/Y Is dinnerware pre -rinsed before being washed? yes RE If yes, at what station/sink? MIbDILE 51n14, ml 2 CernPar6,tACh4 06j�, %I Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this es blishment have an outdoor Grease Removal Unit (GRU/Interceptor)? La ft4 L�Ordl _ Yes No Size gallons Where is the existing outdoor GRU located? Qta r , 1A%L 6Ji C jos q 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: MAKmFiat,-A CouNrjl� 5Q,LLe— Property Owner's Address: 'f 8U 2LInlGTO0 wnc(1- Dr. BVR-L4,44T-ew .o A, /V3 Property Owner's Telephone Number: M- 1 7 3 - 4,555" Yellow Grease Waste Do you store yellow grease waste from fryolators? yIFS l Where is the grease storage unit located? QPar s bJ �� ���e veY lb T4u AAV' -Jtr How often is this grease storage unit emptied? Please list the vendor who removes the waste: 1J C W '?br1 I o` i 55e L Yo l -8y 6) Please list fixtures attached to each grease trap Grease Trap 1 C 0M V Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this es blishment have an outdoor Grease Removal Unit (GRU/Interceptor)? La ft4 L�Ordl _ Yes No Size gallons Where is the existing outdoor GRU located? Qta r , 1A%L 6Ji C jos q 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: MAKmFiat,-A CouNrjl� 5Q,LLe— Property Owner's Address: 'f 8U 2LInlGTO0 wnc(1- Dr. BVR-L4,44T-ew .o A, /V3 Property Owner's Telephone Number: M- 1 7 3 - 4,555" Yellow Grease Waste Do you store yellow grease waste from fryolators? yIFS l Where is the grease storage unit located? QPar s bJ �� ���e veY lb T4u AAV' -Jtr How often is this grease storage unit emptied? 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