HomeMy WebLinkAboutVillage at Willow Crossing - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued ou1
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(Application must be submitted at least 30 days before the planned opening date)
Establishment Name The Village at Willow Crossings
Establishment Address 25 Cobb Street, Mansfield, MA 03048-4505
Establishment Mailing Address (if different) c/o Benchmark Senior Living LLC
201 Jones Road, 3rd Floor West
Waltham, MA 02451
Establishment Telephone No 508-261-1333
Applicant Name & Title: Lynda Maryanski, Vice President and Assistant Secretary
Applicant Address 201 Jones Road, 3rd Floor West, Waltham, MA 02451
Applicant Telephone No.: 781-489-2825 24 Hour Emergency No.: 978-944-4902
Applicant Email compliance@benchmarkquality.com
Owner Name & Title (If different from applicant) KRE Husky Willow Crossings Licensee LLC
Owner Address 201 Jones Road, 3rd Floor West, Waltham, MA 02451
Owner telephone number (781) 489-2825
Owner email: compliance@benchmarkquality.com
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
El An Association
partner.
El A Corporation
Name Title Address
El An Individual
N/A
El A Partnership
C�Other legal Entity LLC
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: Florence Botti, Senior Director of Dining Services
Address: 25 Cobb Street, Mansfield, MA 02048-4505
Telephone No: 508-261-1333 24 Hour Emergency No: 978-944-4902
FAX:
E-mail: compliance@benchmarkquality.com
Alt E -Mail:
District Or Regional Supervisor (if applicable)
Name & Title: James Hourihan, Regional Director of Dining Services
Address: 201 Jones Road, 3rd Floor West, Waltham, MA 02451
Telephone No: 781-489-7100 24 Hour Emergency No: 978-944-4902
FAX: 781-235-01368
E-mail: compliance@benchmarkquality.com
Food Establishment Information
WATER SOURCE: No change
SEWAGE DISPOSAL:
No change
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
5
DAYS/HOURS: No Change
Name of Person(s) In Charge Certified in Food Protection Management:
Florence Bottii, Jean Faulkner, Thomas Sroka, Erik LeBlanc, Chad Bunger
Name of Person(s) In Charge Certified in Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests VA'A" n, P@S 614*
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. E] Yes
Does this establishment require a FOG permit?ems_ If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
❑x Annual
❑ Retail Food $125.00
[] Mobile Food Consession
Temporary
Q Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
Ei Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
E] Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400
E] Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
❑ Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(lime/lemperature controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required)
RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs n PHFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs [] Preparation of PHFs For Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer
E] Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
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 ❑ Ice Manufactured and Packaged for
control)
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
❑ Prepares Food/Single Meals for
El 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 obtain copies of, 10e5 CMR 590.000 and the federal Food Code.
Signature of Applicant:
` A 1N;V?nski, Vice Pre d a d s istapt S cr It
r,7
to MGL Ch.62C; seca.(� certify under a erilties o per)uryethaef r, Cryo my best knowledge and belief, have fled all state tax returns
and paid state taxes requi ed }/niter law.
Social Security Number or Federal ID: 84-1955974
Signature of Individual or Corporate Name: KRE Husky Willow Crossings Licensee LLC
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.
KRE Husky Willow Crossings Licensee LLC
Signature of Individual or Corporate Name
84-1955974
**Social Security No. (Voluntary) or Federal
Identification Number
L.
y: orporate Ofrc(nndatony, ifynda Maryice President and Assistant
Secretary
*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.
Q\Users\sleite\Desktop\Scott's Documents\Food Eslablislunents- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
o Boston, MA 02111
wwminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: KRE Husky Willow Crossings Licensee LLC d/b/a The Village at Willow Crossings
25 Cobb Street
City/State/Zip: Mansfield, MA 02048-4505 Phone #: 508-261-1333
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with 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' comp. 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.]
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
11.❑ Health Care
12.❑ Other Assisted living and memory care facility
*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 Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. # 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 hereby certlfry, under the pains and penalties ofperjury that the information provided above is true 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:
www.mass.gov/dia
Phone
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: KRE Husky Willow Crossings Licensee LLC d/b/a The Village at Willow Crossings
Address: 25 Cobb Street, Mansfield, MA 02048-4505
Mailing Address: 201 Jones Road, 3rd Floor West, Waltham, MA 02451
Phone/Fax Number: 508-261-1333(t) 781-235-01368(f)
Email: compliance@benchmarkquality.com
Contact Person/Title for Grease Traps: Daniel Corvelo, Director of Plant Services
Name of Company scheduled to pump internal grease trap(s) monthly: Wind River Envrionmental
Name of Company scheduled to pump external grease trap quarterly: Wind River Envrionmental
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.
Date Iz -.S-- I
Print Name Ihnda MaryanslQi, vice President and Assistant
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): 150
Seating Capacity (Actual Count): 130
Normal Hours of Food Preparation/Service:
Monday 6 a.m. - 7 p.m.
Thursday 6 a.m. - 7 p.m.
Sunday 6 a.m. - 7 p.m.
Tuesday 6 a.m. - 7 p.m. Wednesday 6 a.m. - 7 p.m.
Friday 6 a.m. - 7 p.m. Saturday 6 a.m. - 7 p.m.
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
1
Y
3 compartment sink
1
Y
Handwashingsink
1
Y
Commercial Dishwasher
1
N
Bar sink
1
Mop Sink
0
N/A
Garbage Disposal
1
Y
Ice Making Machines
1
N
Fryolators
3
N
Grills or Ovens
1
N
Exhaust Hoods
4
Y
I Floor drains
Other:
How are hood vents cleaned? (Le., in three (3) bay sink, off site by private company):
cleand by outside vendors
Is dinnerware pre -rinsed before being washed? x Yes No
If yes, at what station/sink? Dish rinse station
2
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site? 1
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
X Yes No Size 2,000 gallons
Where is the existing outdoor GRU located? Main Entrance (Northwest)
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? Yes
Where is the grease storage unit located? Located in dumpster area
How often is this grease storage unit emptied? Quarterly
Please list the vendor who removes the waste: Bakeus Commodity
3
Please list fixtures attached to each grease trap
Grease Trap 1
3 Bay Sink
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)?
X Yes No Size 2,000 gallons
Where is the existing outdoor GRU located? Main Entrance (Northwest)
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? Yes
Where is the grease storage unit located? Located in dumpster area
How often is this grease storage unit emptied? Quarterly
Please list the vendor who removes the waste: Bakeus Commodity
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