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HomeMy WebLinkAboutDomino's Pizza - 12/31/20201) FOR BOARD OF HEALTH USE ONLY Permit#lssued nt' FOOD ESTABLISHMENT PERMIT APPLICATION! 2 � — (Application must be submitted at least 30 days before the planned opening date) Establishment Name Ovffii'10�5 pkt-",t Establishment Address Establishment Mailing Address (if different) (AA � Establishment Telephone No (5ci- 34 i 1"Z'o Applicant Name &Title: A/v (6"e -i Applicant Address e '600 �'W'1"M C Applicant Telephone No.: 24 Hour Emergency No.: otv Applicant Email L' dU Owner Name & Title (If different from applicant) U > 11" Fjy-k f, ij L Owner Address�, r�, , i i rotnW q Owner telephone number Owner email: 64, Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or FRI f n Association partner. A Corporation Name Title Address 10 An Individual H A Partnership 10 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: o Address: 35 C hew o' (- t Telephone No: 24 Hour Emergency No: FAX: 650e ) CYV E-mail: 4k4 Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: ('nj) 4V �'ndq 04, Address: � Mij i si fevt fa /'PA �J Telephone No.24 Hour Emergency No: FAX: E-mail: r"('kfr> C (At fi Food Establishment Information WATER SOURCE oti,a fa SEWAGE DISPOSAL: y DEP Public Water Supply No: (If applicable) No. of Food Employees: a4 DAYS/HOURS: L:; Fe11"i P„- a t _ ¢ j7, r 'v' v .i8 ei5x`. <.. ts, V4: fi/'{ i�`.3o/kIVI 4 6 Name of Person(s) In Charge Certified in Food Protection Management: ti.'a r Nit, Oclu d Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pestsa 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. O Yes Does this establishment require a FOG permit? ✓ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual WRetall Food $125.00 0 Mobile Food Concession V.1 Temporary 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: 0 Food Service up to 201 + $300.00 [Ed Pushcart $50.00 # of Pushcarts: Temporary Time: n 0 Supermarkets $400 p [a 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/ood(no timo/temperalure controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs [ff`PNFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs a Preparation of PHFs For Hot And for More Than a Single Meal Service W Cold Holding For Single Meal Service ❑M PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility [a Sale of Raw Animal Foods Intended 0 Reheating of Commercially be Prepared Consumer Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours �,sto Lr� Customer Self -Service and/or HACCP Plan (including bare hand er Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only aIce Manufactured and Packaged for control) ,� Ike° Preparation of Non-PHFs Retail Sale IQ Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill 0 Offers RTE PHF in Bulk Quantities IN Prepares Food/Single Meals for IQ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of information provided in this application and affirm that the food establishment operation will comply vd1�j1 MR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtaingopfe5z� QMR 590.000 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. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 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 tmder law. Signature of individuaf or Corporate Name ByrCorporate Officer (Mandatory, if Applicable) "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:Wsecs\sleite\Desktop\ScoU's Docamenls\Food Establishments- Temp\TAX CERTIFICATION FORMdoc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 3` Boston, MA 02111 wrvm niass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: Are you an employer? Check the appropriate box: L ❑TI am a employer with f �~ 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' camp. insurance required] 3.❑ 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.] JS Phone #: ( 6 o) J7 3q 1: o Business Type (required): 5. ❑ Retail 6. ❑`Restaurant/Bar/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 most 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 out an employer that isproviding orkerst' compensation insurance for my employees. Below is the policy information. Insurance Company Name: I (( Lf d °(; f fi 5' ^ itl r i Insurer's Address: 1P It'' YJd City/State/Zip: "i1e t /r? Policy # or Self -ins. Lic. # P :`'.i J q N L '6 l " $ g Expiration Date: i (�> 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 fpr insurance coverage verification. I do hereby certify, y�Vrfflp pains and penalties ofpejmy that the information provided abovg is true and correct. Official use only. Do not write in this area, to be completer) 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.mass.gov/dia z 0 LAW Cie W LMA W-� 0 (M� z � z � � � con � � z � � � � m LU iz: \\ ¢. p" �\!§, �@ }P, §:2 ƒ � ) Q®#% )\{\ \ `�� \ §(} « ƒ+§{ \ $ \ |}\§ my\ ƒ / ) § [ ry E9 h Si 4 ?� S E Vt gLb OR a :At�m LNEm2 SE A�NI EEEo.-aa cN- O!Uww wwDw 9 N CL r O CLLI '. ® c m` « .� � Q eo w L N ?u- t rl4�,LS "` SrF C 5 ia,p. A.p•,,,� y. o tirM i .s (xs ti t N f tt gi 4 c a:54ffi l _V.j E v �a A�,,f O W V M." o cM u. a o u gmimEll N at t 6 i Q Q u G 6� �v a�v QCV �c Q� z *90 z � � W-� W z u � � � � � � z � � � � � On \ 4 3 \: © g ACORO? CERTIFICATE OF LIABILITY INSURANCE �i. DATEIMMoorrrr) 11/0412019 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 pollcy(les) must 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 NAME: Katie FOIE INSURANCE MARKETING AGENCIES INC uOON o E : (508) 471-1120 a Not: 'MAIL k f Imaa EDC .Com ADOREsa. P 9 INSURERS AFFORDING COVERAGE NAIC# 306 MAIN ST INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 WORCESTER MA 0160E INSURED INSURERS: INSURERC: DUFFICY ENTERPRISES INC INSURER D: DBA DOMINOS PIZZA INSURERS: 2 MILL ST INSURER F: FRANKLIN MA 02038 COVERAGES CERTIFICATE NUMBER: 468530 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. ILTR TYPE OF INSURANCE DDL BR POUCYNUMBER MM/OOY� MMIDDYEXP LIMITS COMMERCIAL GENERAL [ABILITY EACHOCCURRENCE $ CLAIMS -MADE ❑ OCCUR PREMISES Me occurrence $ MED EXP (Any one person) $ PERSONALBADV INJURY S N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRCT O- ❑ LOC JE PRODUCTS -COMPlOPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) $ PROPERTYDAMAGE Per coca enl $ NON -OWNED HIREDAUTOS AUTOS UMBRELLALIAB OCCUR EACHOCCURRENCE $ AGGREGATE'-- -'- $ - _. EXCESS LIAB. CLAIMS -MADE -' N/A - -• - DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFCOER/MEM EREXCLU ED ECUTIVE NIA (Mandatory In NN) WA WA 7PJUB4N63389019 10/01/2019 19/01/202D X STATUTE ERH E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 600,000 If as, describe under DESCRIPTION OF OPERATIONS belm E.L. DISEASE -POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS l LOCATIONS/ VEHICLES (ACORD tat, Additional Remarks Schedule, maybe attached If more apace Is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was Issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensatlonfinvestigations/. r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town OP Mansfield ACCORDANCEWITH THE POLICY PROVISIONS. 6 Park Row Mansfield MA 02048 ntel I Daaniel M. 6ropey, CPCU, Vice President —Residual Market —WCRIBMA ©1988.2014 ACORD CORPORATION. All rights resen ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment c Address: 1, s� € T14 Ll rp ; lkA: r t 6 Wflk';T" k r i ":t Mailing Address. Phone/Fax Number: ;, AildE 4!< r°€ a€ L' f , Ema Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly:f"� Name of Company scheduled to pump external grease trap quarterly: I / " 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 AVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGU A IONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In conside ion o th ranting of the permit, the undersigned agrees to the conditions of the permit and ac owledge a e information submitted in these documents is true, accurate and complete. Signe Date it z5r, Z'j Is Print Nam i x't a UAL uV1 r t 11 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: w 1 A Monday is Tuesday ,g:',;e €l- p ko, Thursday t{ 2, %£ - ` arsr'° Friday ,&,zE /aW : c.4 Av-. Sunday Wednesday /" ./e/lap j J r Saturday i�' 3z kv— AYet 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 Barsink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills dr Oven I i 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? 1<1 2 Yes No Grease Traps 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, Gcwv, vv, e S•v��L 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 % 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 Owners Address: Property Owners 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? Y Please list the vendor who removes the waste: ('§