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HomeMy WebLinkAboutCatman Cafe - 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) n Establishment Name QC'AVV'Wl Establishment Address WOO 60 V%K 4 Establishment Mailing Address (if different) Establishment Telephone No j'(�1� �jlj `� 003 ,2 Applicant Name & Title: comAto Applicant Address (q Wcavn(10nti P �%0�'t4"V 01?Ub Applicant Telephone No.: 5V i3 M Old 3 -1 24 Hour Emergency No.: 3,()-? 3 eU ^ ctt 3 ;) Applicant Email 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 Ed An Association partner. WA Corporation Name Title Address O An Individual O A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: -r C'ewl1Q Address: L R w "y'^90 w^ 90 (UO Cr o•j Telephone No: a� 34 �� 3 �( 24 Hour Emergency No: IM 3P® q13', FAX: E-mail: k G-@W u 0 Lcl r^GhS'f c 1JF 'T" 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: U SEWAGE DISPOSAL: TO No. of Food Employees:. `- DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: '54 69�`th 3 Q"J 11L0 Name of Person(s) In Charge Certified in Allergen Awareness Training 4ktPWA, a tlo —C Name of pest control company routinely inspecting the premises for evidence of pests 1ev vvi� he K If there is seating for 25 peo a or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. YYes Does this establishment require a FOG permit? \ If yes, please attach the FOG permit application. of Permit: Establishment Type: ,,��Le��ngth WAnnual [ Retail Food $125.00 0 Mobile Food Consession Q Temporary Mood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Dale: Q Food Service up to 201 + $300.00 FqT] Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: ..Milk &Cream $10.00 EJ Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(timedemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous fcod(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) F1] Sale of Commercially Pre -Packaged Non-PHFs M,/�,�PPHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHF[y s 'Preparation of PHFs For Hot And for More Than a Single Meal Service :❑-�. Delivery of Packaged PHFs Cold Holding For Single Meal Service i] PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended SWPeheating Commercially Susceptible Population Facility of to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours [.3 Customer Self -Service and/or HACCP Plan (including bare hand to Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) [= Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of 0 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging / Cook Chill ❑-', Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for [71 Retail Sale of Salvage, Out -Of -Dale 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 105 CMR 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: �> f +y f Signature of Individual or Corporate Name: �.4J ` QL(3 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 (Mandaton/, if Applicable) 5 4 U 3cIv "Social Security No. (Voluntanj) or Federal Identification Nuinber *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 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: �Cclw 1� e Address: k 01-y� VOkowtq Mailing Address: Rt 01-0 0�D yi4 (AAq Phone/Fax Number: '5-02 3 �A (9 u 3 y Email: % Ce rU u0 0. C.{1 MCAs t- o N r Contact Person/Title for Grease Traps: 5keyP \@y) (oru 0o Name of Company scheduled to pump internal grease trap(s) monthly: 'PA+rto t SeNIt 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 $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. Signed A)Zw'- n Cam' Datez - Ci'- ZC9 Print Name ` ktp)'ty-\ X Le -,AO 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): qR GN 1? ctyLy Seating Capacity (Actual Count): (� Normal Hours of Food Preparation/Service: Monday W 7 Ip Thursday 1 2,0 — Ll Sunday 0a'a � Lt Tuesday 433- 11 Friday 613J'- tl Wednesday 11 ail 3 ay Saturday L6 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): C.. e O k ve' l Vro LA A-LoVA eL.Ce V-� Is dinnerware pre -rinsed before being washed? ✓ Yes No If yes, at what station/sink? 3 B A -A 511v1t- 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 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? J e5 Where is the grease storage unit located? NEY+ +Lj dQ q,+<✓ How often is this grease storage unit emptied? cc�li bNcn wy �r c1 is ��.i .11 Please list the vendor who removes the waste: �3 okL t ^ C_s9 vh o by tir s 1 m Ac"ROP CERTIFICATE OF LIABILITY INSURANCE �.-�"' DATE (MM/DD/YYYY) 11 /22119 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(ies) 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 NAME: MUTIeI Studley Barrows Insurance Agency, Inc. AICNNo n: 508-339-7260 ac No: 508339.9524 EMAIL ADDRESS: info@barrowsins.com 215 North Main Street Mansfield, MA 02048 INSURERIS) AFFORDING COVERAGE NAIC // INSURER A: Hospitality Mutual Ins CO INSURED INSURER B : INSURERC: Chamberlain Avenue Enterprises Inc dba Catman Cafe 19 Wampum Road Norton, MA 02766 INSURER D : INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 INSD WVD POLICY NUMBER MM/DI[bYYYY MM/DDYIYYYV LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE100,000 PREMISES Ea occurrence $ MED EXP (Any oneperson) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A 00101170GL 04/16/19 04/16/20 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑PRO- JECT LOC PRODUCTS - COMP/OP AGO $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ i i AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNEWEXECUTIVE❑ E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDEDY NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below I Per Occurrence $500,000 A Liquor Liability 00101171LL 04/16/19 04/16/20 Aggregate $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row—"'�"�`� AUTHORIZEDq P SENTATIVE­'_ Mansfield, MA 02048 © 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ?D#: XXX-xx- 1 ScaledTestScore:78 rasa "`, STEPIESCEAUI C3 Candidate Status: Pass Test Date: April 15, 2019 �2xav�mn �fr i9eiCr�a 2 9(kni[u RLJ?621 � r" sWYrwwx7 ' ➢hgf {90r$ap3ve3b, tl Cer45ram No 23572438 Issue Dam April 15, 2019 -1:uz+UttaSrbeq - v�kNRrSP"an6 .:. Expiration Date: April 15, 2024 Congratulations! Attached is your certificate and wallet card. Please notify STEPHEN J CERULLO the National Registry of name or address changes at the address below. 19 WAMPUM RD NORTON, MA 02766 Preventing Contamination and Cross Contamination (Competent) Ensuring Personal Hygiene and Employee Health (Competent) Actively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) Ensuring Product Time and Temperature (Needs review) Conducting Cleaning and Sanitizing (Mastered) Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Needs review) National Registry of Food Safery Prot'essionalsr9 1 6751 Forum Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352,3830 1 Fax: 407.352,3603 %§2 § 6}\[ J \R$} ( |eF�: ){\E[a-up ^ \§G^E $ 3 ;§( I The Commonwealth ofMassaehusetis 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 /y Please Print Legibly Business/Organization Name: ccarmckjol Ct<fc Address: lCa ()LD Cp �Owti j City/State/Zip: Lz Phone #: i-08 339 QO�, `7 Are you an employer? Check the appropriate box: Business Type (required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. [3<estaurant/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 3.0 [No workers' comp. insurance required] 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 4. ❑ no employees. [No workers' comp. insurance required]* We non-profit organization, staffed by volunteers, I Ln Health Care are a 12.❑ Other with no employees. [No workers' comp. insurance req.] *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 ant an employer that is providing workers' compensation insurance for my employees. Beloip is the policy information. Insurance Company Insurer's Address: 3 Lt 00 W'tS e win P, L V V) City/State/Zip: -i,?2y l Policy # or Self -ins. Lic. # -1 (e lots:: G 3W t N 5'I0 Expiration Date: 'I I Z I Zl? Z a 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, tinder /`-cK the pains ainss anJd penahies ofperjury that the information provided above is true and correct. Signature: . II,' l 'I. Date: IA— 7r R0 I f/ Phone #: 1' b q `I 3 i U (E 3 W 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 0 Contact www.mass.gov/dia Phone THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 Chamberline Avenue Enterprises Catman Cafe 16 Old Colony Rd Manfield MA 02048 Account Information: Policy Holder Details : Chamberline Avenue Enterprises DBA Catman Cafe November 18, 2019 vQ Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (877) 287-1312 Fax: (888) 443-6112 Email: agency.services(a)thehartford.com Website: https:Hbusiness.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 A CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/Yl'1'Y) 11 (18/2019 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(ies) must be endorsed. If SUBROGATIONIS 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: PAYCHEX INSURANCE AGENCY INC 7621070$ 150 SAWGRASS DRIVE ROCHESTER NY 14620 PHONE (877) 266-6850 (AIC, No, Ext): FAX (585) 389-7894 (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Hartford Accident and Indemnity Company 22357 INSURED INSURER B : CHAMBERLINE AVENUE ENTERPRISES DBA INSURER C: CATMAN CAFE INSURER D: 16 OLD COLONY RD INSURER E: MANSFIELD MA 02048-2113 INSURER F : COVERAGES CERTIFICATE NUMBER: 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. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR MID POLICY NUMBER POLICY EFF MM/D(MMIDDIYYYYJ POLICYEXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES (ER rm MED EXP (Any one person) PERSONAL B ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRO - PRO- P POLICY ❑ ❑ LOCJECT PRODUCTS-COMP/OP AGO OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaa dent BODILY INJURY (Per person) ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED H PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS - MADE AGGREGATE ED I RETENTION $ WORKERS COMPENSATION ANDEMPLOYERVLIABILM PER X STATUTE OTH- ER E.L. EACH ACCIDENT $1,000,000 ANY YIN A PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMSER EXCLUDED? NIA 76 WEG AD1N56 04/02/2019 04/02/2020 E.L. DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) Those usual to the Insured's Operations. Catman Cafe 16 Old Colony Rd Manfield MA 02048 ACORD 25 (2016103) BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 9)1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD