HomeMy WebLinkAboutHangar 12 - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit#Issued I,
FOOD ESTABLISHMENT PERMIT APPLICATION-,
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name I? —
Establishment Address 2(c,5 F&U i'>- 57Y2eeY M h NSFi Clp M A- C9 20 4 U �,
Establishment Mailing Address (if different)
Establishment Telephone No -7 7 (4 d 28 `{ 41 °m Z
Applicant Name & Title: M PCNAa, 6i-55R071
Applicant Address 23 MOOsE �+iLA, Sr 51+A4_Cw1 MA- 02061
Applicant Telephone No.: 1pf7 S29 31g4 24 Hour Emergency No.: 5AME
Applicant Email MJCj+AeL_Ifni S5AN6 @ &eKAri- . COM
Owner Name & Title (If different from applicant) SAME.
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
11 An Association
partner.
1�tA Corporation
0 An Individual
Name Title Address
A CHAP 615S&uT 23 Moos, Mic. Sr 514AkW 02
Wer(> F%P60-i61
APartnership
0 Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: RAWV 1-AevvIOVLb✓IG
Address: 23 M005E Vt�U- Sr 5f+tM0"J MA- 62-CLI
Telephone No: 61l $325$2S' 24 Hour Emergency No: toll o32SoZ6
FAX: reps
E-mail: kj5J✓6ISSAt1M 6> 67VKAs L . Coo w\
Alt E-Mail: N/04
District Or Regional Supervisor (if applicable) NIA
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
E
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
AAIWP►':J— t5►SSAnrT t��NJ C, vJb�lt�a�1K
Name of Person(s) In Charge Certified in Allergen Awareness Training
M✓�►lct+ cam Ax�SSANJ i / fLCNJ le4rIt ovc ►'�llc
Name of pest control company routinely inspecting the premises for evidence of pest<:�L\�- °n
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. XYes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
❑ Retail Food $125.00 J Mobile Food Consession
Temporary
[ ( Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00 0 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 E] Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 EJ Residential Kitchen $100.00
Rain Date:
[Milk &Cream $10.00 El Caterer $35.00
Food Operations: Definitions :PHF - Potentially hazardous foodflimeRemperature controls required)
(Check all that apply): Non-PHF's-non-polantially hazardous(nod(no tlme4emperature controls required)
RTE - ready -to -eat fads (Ex. sandwiches, salads, muffins which need no furtherprccessing)
E] Sale of Commercially Pre -Packaged Non-PHFs O<PHFCooked To Order El Hot PHF Cooked and Cooled or Hot Held
0, Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And for More Than a Single Meal Service
El Delivery of Packaged PHFs Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly
E] Sale of Raw Animal Foods Intended Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer Self -Service
contact alternative, time as a public health
Customer Self -Service of Non PHF and Non-
❑ g control
Perishable Foods Only Ice Manufactured and Packaged for )
Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of
EJ Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging lCook 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 cQQqq��ply with 105 CMR 590.000 and all other applicable law. 1 have been instructed by the
board of health on how to obt9i ,2oviewbf 105 CMR 590.000ancl the federal Food Code.
Signature of Applicant:; , 1 q (/V—L'�`
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 I D: y�A,, t!'
Signature of Individual or Corporate Name: S f kVt� /2, 74
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.
H hoc-7&gI V- 11-C.- (M mjj.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
U-S i mLrgsL7
*"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:\Usem\sleite\De 1dop\8con's 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 Leeibly
Business/Organization Name: 4JN PJ (AY2_ 12 Lt—C—
Address: VvS
City/State/Zip:
�Lvrr sr
A-tJSFtEA-b nAP.- (OZ04SPhone #:"-
AZ�o
Are you an employer? Check the appropriate box: Business Type (required):
1N I am a employer with employees (full and/ 5. E] Retail
or part-time). * 6. ORestaurantBar/EatingEstablishment
2. ❑ I am a sole proprietor or partnership and have no 7. Office and/or Sales (met. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑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.QManufacturing
no employees. [No workers' comp. insurance required]*
4. We are a non-profit organization, staffed by volunteers, 1 LQ Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box #I 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: HAoFcolep ►I.1S CD
Insurer's Address: 90 QOX 5(DOO
City/State/Zip: 0faZTIFPy1-0 CT 0b 102,
o Policy # or Self -ins. Lic. # loSIOD U 6 ' I 42� '- Z ' � 1 9 Expiration Date: 3 '� �20
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct
\'I"
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
19
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 permitAicense 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 Sheet
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-N ASSAFE
Form Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: Gf>`i'y&AVL i'Z
Address: 2j,05 Fh MITT 020 y a
Mailing Address: Sf%vnn%'f-
Phone/Fax Number: -7"7`i " -"(A " kA-7'007-
Email: �N11C(I r'�C—(1j15SRN1r� C�NIAI �. • &Ovv \
Contact Person/Title for Grease Traps: PAd 16l`hc.VN/ IOI./L10U l<
Name of Company scheduled to pump internal grease trap(s) monthly:
� Dveko�t
Name of Company scheduled to pump external grease trap quarterly: CIFEUTW ' FAeaNW 9
p�r~rin9
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 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the information submitted in these documents is true, accurate and complete.
SignedDate
Print Name MtctfAell 6I5SAt M
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count): 3$
Normal Hours of Food Preparation/Service:
Monday -t- 29
Thursday -1p Ze
Sunday "�^- z
Tuesday l ^ 2�
Friday l — Z.r'
Wednesday -7"- 2 p
Saturday -7�-2110
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`I
I7
3 compartment sink
Handwashing sink
yCommercial
Dishwasher
Bar sink
/
Mop Sink
d
N
Garbage Disposal
Ice Making Machines
Z
Fryolators
tJ
Grills or Ovens
Exhaust Hoods
2
y
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
gy I ,LI V Ar 1Z AA f ArW`-t
Is dinnerware pre -rinsed before beingwashed?
If yes, at what station/sink? ws 6uC46T
Yes No
0Yz_ ,o VV
Pa
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site? 10 NE
Please list fixtures attached to each grease trap
Grease Trap 1
51 r�3 KS , I eE M AC!-WN E., D rSli w AS HCe,
Grease Trap 2
Grease Trap 3
Grease Trap 4
Grease Trap S
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
V Yes No Size )SO% gallons
Where is the existing outdoor GRU located? S IDE. OF I&J t %—br tJ (—
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: -Mat`I 1)F KA SF�E--10
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolatoq? Yh
Where is the grease storage unit located? :51nE or —
How often is this grease storage unit emptied? 18\1151 `( Of1'}ccMOA1714
Please list the vendor who removes the waste: �✓� K� �""� "o n s riGS
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P.O.Box
Norton,02766
508-285-7783
Bill TO
Hangar 12 Re:.tanrant
Wilde Federici
26:5 Fruit 81,
Awiansfield, INLx
Invoice
E Date nvoice#
ll?019
P.O, Number
Terms
Rep
Ship
Via
17,03,
Project
I1/21l201.9
Due on receipt
III
11e21/2019
Quantity
Item Code
Description
Price Each
Amount
I
Interior Oreas,..
Monrh1v Pump of interior t reasc Trap 111121/1 9
120.00
120.00
Next sehWuled seMce- December
Water to grease ratio; 90120
Heavy flock grease- NvIll pump In 3 cviceks to
check status
Thank youfor vow, hu$inesst
Please make G1tceks payable to Dumont Purnpingt
S 120.00