HomeMy WebLinkAboutMansfield House of Pizza - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit# Issued
` FOODESTABLISHMENTPERMIT APPLICATION
(9pplion must be submitted at least 30 days before the planned opening date)
Establishment Name rA (AY-t5 F I e w 5e °` rZAA
1
Establishment Address 175 fv 0' ("(A t -) � 1 • MDI n s F` i e l c)) M IR -
Establishment Mailing Address (if different)
Establishment Telephone No 5 J3 Bf _ ,� Lf 0 t7
Applicant Name & Title: [ ?-'.A T
Applicant Address of q LCI i r_G1 S V"'re-
Applicant Telephone No.: % g -,3,3q - 17 &.0 24 Hour Emergency No.: Y--o?(p 9 - 4 3,3
Applicant Email C_ ZZ"t ro c h U r (CV �A 0o � GO do
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
O An Association
partner.
'5(A Corporation
O An Individual
Name !! Title L Address
F7?f�} lA YI �iJ eo�51(/) i' Ytl �` �� (CA cce x)
❑`O A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, erson in charge, supervisor, manager etc.)
Name & Title: zz-6) z01 41 Gl r/ i �St
Address: 11 t( t0j n Zjo S j i4-e. Dr. ,Mon 5 pl'e' IJI f 01
Telephone No: 5-03-33 24 Hour Emergency No: 4133
FAX:
nn
E-mail: C-ZZnJr�et16kCkrl6D/
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title: J'7
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
—F-O LJ n '
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS: -DqS I —
Name of Person(s) In Charge Certified in Food Protection Management:
'
Name of Person(s) In Charge Certified in Allergen Awareness Training
FZZOT 0- 7PPkHAny
Name of pest control company routinely inspecting the premises for evidence of pests V-11fln
NA
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
[a Retail Food $125.00
Mobile Food Consession
`d Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
-❑j Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
l Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
❑""r Pushcart $50.00 # of Pushcarts:
Temporary Time:
0 Supermarkets $400
Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
Q Caterer $35.00
Food Operations: Definitions:PHF- Potentially hazardous food(lime/fempemture controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required)
RTE - ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs E PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
reparation of PHFs For Hot And
Sale of Commercially Pre -Packaged PHFs Preparation
for More Than a Single Meal Service
old Holding For Single Meal Service
Delivery of Packaged PHFs
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
® Sale of Raw Animal Foods Intended
Reheatingof Commercially
Y to be Prepared by Consumer
Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Q 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 I] Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
i] Offers Raw Or Undercooked Food Of
I] 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 comply with 105 CMR 590.000 d all other applicable law. I have been instructed by the
board of health on how to ogtam copies of 105 CMR 590.OQ1and the federal Food Code.
Signature of Applicant: '
Pursuant to MGL Ch.62C, s , 9A, I certify under
and paid state taxes required under law.
Social Security Number or Federal ID: M�
Signature of Individual or Corporate Name: a! v
of perjury that I, to my best knowledge and belief, have filed all state tax returns
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Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name:;wn
y i5 ) eld
)•-j1 u s e- o En
Address: 610, njol1
n
ST ^
/y:
MO) ,Z) P)
Mailing Address:
Phone/Fax Number: TQ Y _ 5 3 "/ — 0ZJ 0 0'
Contact Person/Title for Grease Traps: r=7 20 t- Zi V li�1 / TY'e—_C od-e o+
Name of Company scheduled to pump internal grease trap(s) monthly: �' r LYVC e,
Name of Company scheduled to pump external grease trap quarterly: 16/.114
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.
Date ) ) ) Y- ) of
Print Na
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 q Tuesday j j — U( Wednesday
Thursday 1 —q Friday C i — (® Saturday
Sunday I�
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):
Is dinnerware pre -rinsed before being washed? Yes No
If yes, at what station/sink?
2
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
C�)Afr l e—*4 6yKik
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)? J '
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 Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators? V r —5
Where is the grease storage unit located? S L° b l'✓1� ` Vl t? JIA U 1 I d 01`) :
How often is this grease storage unit emptied? & L-i e-r l< S Please list the vendor who removes the waste: ejt<.p.r 5 C-00 1 /Y100111
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26 HILLSIDE AVE. • .REHOBOTH, MA 02769
SOB-2S2-4668, S08-336.7024 FAx S08.252-5144
croorniesai tatori@comcast.net
COMPLETE PUMPING SERVICE SMWEROOTCER SERVICE
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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.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable)
I�e97
**Social Security No. (Voluntanj) 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:\UserAsleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: t)1 (A Y-) 5 F) '2 1 d k \A,5 f_ Of P I '-U ZCn '
Address: j 7 S f1%D Pj 1' Y1 1
#: 512K-35 l -19'0 n l%
Are you an employer? Check the appropriate box:
1.X I am a employer with_ employees (full f�land/
Business Type (required):
5. ❑ Retail
or part-time).*
6. CgRestaurant/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.
8• ❑Non-profit
[No workers' comp. insurance required]
30 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
12.❑
with no employees. [No workers' comp. insurance req.]
Other
*Any applicant that checks box 91 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 N 1.
I mu mi employer that is providing workers' contpensatimi insurance for my employees. Bel is the policy information.
Insurance Company Name: /\/Qa� `� �,o _( (Z ;,Co
g C iA
Insurer's Address: ,'�,y`Z�
City/State/Zip: p e m h a m t/l fl-
Policy # or Self -ins. Lic. # WE7 11&e.2 9 0 - Expiration Date: 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, under the pains and peipldes ofperjury that the information provided above is trite and correct.
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.mass.gov/dia
:WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY ---- INFORMATION PAGE
INSURER: POLICY NO: WE172629A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE.COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 04-3291697
r
ITEMI. NAMED INSURED AND MAILING rAlibkgsl. AGENT NAME AND ADDRESS:
MANSFIELD HOUSE OF PIZZA,,INC SALHANEY INSURANCE AGENCY
175 N MAIN STREET 5264 WASHINGTON ST
MANSFIELD, MA 02048 WEST ROXBURY, MA 02132
AGENT NO.: , 20121060
LEGALENTITY: CORPORATION.,,
OTHER WORKPLACES NOT SHOWN AP0VE; L (See Workers Compensation ClzssifiCation Schedule)
,r
ITEM 2. POLICY PERIOD: From: 11/05/2019 TP:`. '11/05/2020
Effective 12:01 A.M. Standard Time at theInsureds, mailing address,
ITEM 3. COVERAGE:
A, Workers Compensation Insurance, Pact One of the policy applie's to the Workers Compensation Law of the
states listed here:'
MA
B. Employers' Liability Insurance: Part Two of the policy applies to wo1rk in each state listed in Item 3.A. The limits
of liability under Part Uo are:
Bodily Injury by Accident:' $. 5'00 , 000 each accident
Bodily Injury by`Disease . $, 500 , 000 policy limit
Bodily Injury by Disease: % 500, 000 each employee
C. Other States Insurance Part Three of the:policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC;;;`20 03"0:6 B
D. This Policy includes these Endorsements, and Sohedulesr
See Schedule of Forms and Eridorsemants
ITEM 4. PREMIUM: The premium for.this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule Is subject to
verification and change by audit;
Total Estimated
Minimum Premium: $ 215 Annual Premium: $ ` 1,078
Audit Period: ANNUAL Additional:/ RetUrn Premium:'
Comments:
Issued At:
Date: 09/26/201'9 Gouhtersigned by
WC 00 00 01 A Copyrl'ght,OP7 Natipnal Council on Compensation Insurance
Ma4RED COPY -