Loading...
HomeMy WebLinkAboutSubway - 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) Establishment Name v10'>)W' Establishment Address ''L( CjhdIe,,4 Dt<. /"4- 02-DL(Y Establishment Mailing Address (if different) Establishment Telephone No D j'2� �(� pyo Applicant Name & Title: l��ec Y IGS ✓^ I�) t 04JNe", Applicant Address Sl7AY� OLL D%. /l6 . �C �GVd MA D & '/a v Applicant Telephone No.: ` y 3W / 24 Hour Emergency No.: j j`_ 2.5q- 3Y6 Applicant Email Ch UC -"A04 3 (Pnour 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 I a' An Association partner. ' 'A Corporation Name Title Address SM & ,I l An Individual V {� _S W A Partnership — A.). l� d p} Z� W Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: C (,,r l-Gf SP` 10`- G v'✓ ex -t Address: I Z� ®GjL k-A)vll .tom. ( N. A41ebffO, Telephone No: t/ Z$-�/ 3yG� 24 Hour Emergency No: Zs -L( -3q6 FAX: E-mail: L��G�SvLlrn Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 I -lour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE:SEWAGE DISPOSAL: M enrra�'n (cQ Ude. �yJ � — _- DEP Public Water Supply No: (If applicable) NO. Of Food Employees: DAYS/HOURS:--:\ 4, _Y yv1_ 2j0_ �f t _ �J-k SUtti _ 11" 6"f _ _ < • d�{�✓� i Name of Person(s)In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training clotar(45 Sr.K''`/— S_� _ k00i0i c —b-zcc Name of pest control company routinely inspecting the premises for evidence of pests_r_4�MV_G5 av'�� 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. J Yes Does this establishment require a FOG permit? LYA-_ If yes, please attach the FOG permit application Length of Permit: Establishment Type: RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherproressing) Annual lidi Hot PHF Cooked and Cooled or Hot Held I Retail Food $125.00 JA Mobile Food Consession (]I Temporary U PHF and RTE Foods Prepared For Highly ice up to too INCLUDING ood ServFOOD NO PHF PREPARED ON SITE $100.00 Temporary Start Date: Use of Process Requiring di Variance TRUCKS $175.00 ' x Manufacture Frozen Desserts/ice Cream Perishable Foods Only -01 Ice Manufactured and Packaged for control) M4 Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Animal Origin IN Food Service up to 201 + $300.00 ] Pushcart $50.00 It of Pushcarts: Temporary Time: Lk,l Vacuum Packaging /Cook Chill ] Supermarkets $400 1.1 Residential Kitchen $100.00 Rain Date: IX Milk 8 Cream $10.00 '.;fei Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food parie/temperatum controls required) (Check all that apply): Non-PHFs- non -potentially hazardous income time/lempemiure controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherproressing) Sale of Commercially Pre -Packaged Non-PHFs A PHFCooked To Order lidi Hot PHF Cooked and Cooled or Hot Held '.,]I Sale of Commercially Pre -Packaged PHFs ml Preparation of PHFs For Hat And for More Than a Single Meal Service 0] Delivery of Packaged PHFs Cold Holding For Single Meal Service U PHF and RTE Foods Prepared For Highly !uAl Sale of Raw Animal Foods Intended i,f,r Reheating of Commercially Susceptible Population Facility to be Prepared 6 Consumer Processed Foods for Service Within 4 Hours P y Use of Process Requiring di Variance ti Customer Self -Service 01 Customer Self -Service of Non PHF and Nan- and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only -01 Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale P l€"J Offers Raw Or Undercooked Food Of ]i Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Lk,l Vacuum Packaging /Cook Chill A Offers RTE PHF in Bulk Quantities [Yd] 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 obtai Ragie of 105 CMR 590.000 and the federal Food Code. &Kim Signature of Applicant: /1 C ' 5��---/11b--' Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have tiled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Z 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: Jy Mailing Address: '/4jt(STi"Z& 01A &Z'&Y' Phone/Fax Number: 5-0 —3:32-0e 6= Emai Contact Person/Title for Grease Traps: ( ,a/n oc L si-41 3oL Name of Company scheduled to pump internal grease trap(s) monthly: �. %�ivc� /�r ✓o t 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. Print Name( V` 0/ les Date // V 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 YA"" — c%.3DPk4 Tuesday gpN1 Wednesday Thursday Y&A 4 3/J /7M Friday Saturday JJ PA4 Sunday qkA-- :3o Pk" 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 Z Handwashing sink Commercial Dishwasher © C7 Bar sink Mop Sink 6 © Garbage Disposal © Ice Making Machines h (l v Fryolators 0 D Grills or Ovens 7 Exhaust Hoods D Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): 1 h 4-0 r-4W'0'jc, lgdyj_�- -6 nr t [,✓P�cO v �:�j. Is dinnerware pre -rinsed before being washed? �j'%k Yes No If yes, at what station/sink? 2 Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes V 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? N Where is the grease storage unit located? M1' / A How often is this grease storage unit emptied? /,)/ /nn_ Please list the vendor who removes the waste: A/ Please list fixtures attached to each grease trap Grease Trap I A) 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)? Yes V 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? N Where is the grease storage unit located? M1' / A How often is this grease storage unit emptied? /,)/ /nn_ Please list the vendor who removes the waste: A/ 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. 0J� e- 5_�� a��f le�; ce�)�Je, Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 24— / e// Y3Y-;?— "*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 Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Insurance Company of the Midwest ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 20605 Company Code: G Suffix LARSLARS RENEWAL C�— POLICY NUMBER: 76 WEG �GC0709Previous Policy Number: 76 WEG 0709 1. Named Insured and Mailing Address: CSS SUB INC (No., Street, Town, State, Zip Code) 74 TAUNTON AVE SEEKONK MA 02771 FEIN Number: 27-1418387 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 2. Policy Period: From 12/09/19 To 12/09/20 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: COMPLETE BENEFIT SOLUTIONS/PAC ONE CARANDO DRIVE SUITE 1 SPRINGFIELD MA 01104 Producer's Code: 76250837 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 287-1316 Total Estimated Annual Premium: $1,865 Deposit Premium: Rmnimum Premium- $215 MA _...._. Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by -F Com ' 10/30/19 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 10/30/19 Policy Expiration Date: 12/09/20 The Commonwealth of Massachusetts ,Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mays.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address 17—( l , City/State/Zip Phone #: 0 �2 i 0 � 3 9'J 4) 6 0 Are on an employer? Check the appropriate box: Business Type (required): L I am a employer with �— employees (full and/ 5. ❑ Retail or part-time).* 6. V❑Restaurant/Bar/EatingEstablishment 2. ❑ 1 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] S. ❑ 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]* 4. ❑ We are a non-profit organization, staffed by surance volunteers, 1 IE] Health Care with no employees. [No workers' comp. inreq.] 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 Insurer's Address: Z(006 1.5_(��C//h '7 �( . City/State/Zip: sae) // i � C7z_ �l Policy # or Self -ins. Lia # Y� 1.0 r_;5& t4- b t6 c, Expiration Date: 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 herebyce�hfyy] _utpfer the pains and penalties of perjury that the information provided above is true and correct. / j' / \ I / l h 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 www.mass.gov/dia Phone 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 burn 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. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia corm Revised 5-26-05 m OWNN I CD CD C� ^G W CD CD cn Ct) C v ((D CD 3= civ