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Home My WebLink AboutMedtronic - 12/31/2020J O r FOR BOARD OF HEALTH USE ONLY Permit # Issued - — - — ", - FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name �W(-On lc_ i Establishment Address Im yo-mvgily � b� Establishment Mailing Address (if different) (-PAL goltt�(i Co.l �yL . �l�o ill�a�Sr• p�� oltoa.�� • Dtn�� Establishment Telephone No Applicant Name &Title: Mu,na Lqr Applicant Address pa '�1461 ckz l�l ht r w / Applicant Telephone No.: 7W -o"W -U a-3 f 24 Hour Emergency No.: r%r%y"o -tP dz?/ Applicant Email f0 fY Al 1 �pyvl • 1Ll -CUM Owner Name & Title (If different from applicant) "�t p Owner Address' ao rJetJbvh hice '�`�5'^ '"�j�nS4 Su t4,Q ��r QeuMy)r �+� W� /' Owner telephone number J Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. VA h Corporation ame t_ Title pAddress 1 An Individualvvr>hdo _ufphy CFo_- rJO(�ahli- A Partnership 1� 17 Other legal Entity p@' - p " 4�hr K4 0[74 -- tiv d �t �-li��Soo� Lett 0 (ftldiN.S+, I � liaNNd-OI Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: lax Ow&\ IbU�her� y fit' ,{�pC V6S0� Address Telephone No:24 Hour Emergency No: I ly -01W-(0;�-3[ FAX: - 2'l -3'1 I i E-mail: `A�YI+CIOtAghe4� ylkoy,�c , uovo Alt E-Mail: hi ft�( �J1jI p�h�1l , com District Or Regional Supervisor (if applicable) Name & Title: Address: Jvf'C Telephone No: n—q(po-,qfJd-o FAX: (� E-mail:�(y�� `Pm�1Cti Com 24HourEmergencyNo: CjtJ-q(0o-1qO.0 Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) - No. of Food Employees: DAYS/HOURS: Name of Person(s)OIn Charge Certif ed in ood Protection Management ,Name of Person(s) In Charge Certified in Allergen Awareness Training v T_Y6W_\ C6A9h'e I Name of pest control company routinely inspecting the premises for evidence of pests eccola'b 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 MYes Does this establishment require a FOG permit? `%(� S If yes, please attach the FOG permit application. ! Length of Permit: Annual Temporary Temporary Start Dale'. Temporary End Date: Temporary Time: Rain Date: Establishment Type: L,J Retail Food $125.00 Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 x Food Service up to 101 -200 $250,00 Food Service up to 201 + $300.00 f] Supermarkets $400 ,}(j, Milk & Cream $10.00 i_[I Mobile Food Consession NO PHF PREPARED ON SITE $100,00 -,i Manufacture Frozen Desserts/Ice Cream -",I $25.00/freezer [1 Pushcart $50.00 # of Pushcarts: Residential Kitchen $100,00 Caterer $35,00 Food Operations: Defimlmns: PHF � Potentially hazardous food fhmellemperalure controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no tlmellemperalum conlrols required) RTE - ready-to-eal foods (Ex, sandwiches, salads, muffins which need no ludherprocessing) Sale of Commercially Pre -Packaged Non-PHFs i'.: Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs L11+1. Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only j Preparation of Non-PHFs Other Food Operations KPI IFCooked To Order Preparation of PHFs For Hot And old Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer "I( -Customer Self -Service Ice Manufactured and Packaged for Retail Sale 'T9 Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service -J PHF and RTE Foods Prepared For Highly Susceptible Population Facility Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ', Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for --- Animal Origin Retail Sale _'1 Vacuum Packaging /Cook Chill i Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for f 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 arid all other applicable law. I have been Instructed by the board of health on how Iq.aFl n-topes gj�f15 c90 00^d 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 stale taxes required under law. Social Security Number or Federal to: N14"If— �� I ff11 Signature of Individual or Corporate Name: � (1ui OhP s119 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. PA 4�" CD 1 Signature of Individual r Corporate Name By: C rporate Of i er (Mandatmy, if Applicable) 6 as 1 a0 *'Social Security No. (Volmtlnry) or Fedeml ldeillification 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 islet 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 tinder the authority of Massachusetts General Law Chapter 62C, section 49A. C\I kenV�Icite\Desktop\Seo(I's DocumenIslpnod GsIt, blislilt enle- IcmpCI A CRR I IHCA'HON 17ORM.dm Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name:` cwear) Address:19�i ti(ptM()c1�11(e lit �1 Mailing Address: tO0ih�r,2S4I(1 Phone/Fax Number: Contact Person/Title for Grease Traps: If(� lanas Name of Company scheduled to pump internal grease trap(s) monthly: Qn-6 0\'lhQ r 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 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 inforrrLation submitted in these documents is true, accurate and complete, signed f� Date Print Name A sy` m koolrw 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 Im — 3Q Thursday _ ;3a Sunday CLUM Tuesday 7am.)r Friday _�klo t_— Wednesday Saturday_ 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 VY� Commercial Dishwasher Bar sink Mop Sink 00 Garbage Disposal ou Ice Making Machines Fryolators Yk7 Grills or Ovens r10 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? 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 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 Owner's Address: Property Owner's 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?_ Please list the vendor who removes the waste: The Coonnonwealth gjAl rssuetinsetts UV'- Department ofIndustrial Aecirfents O(fiee of'Investigations 600 Washington Street Boston, AIA 02111 vtvw, rnass.gov/afro Wortcers' Compensation Insurance Affidavit: General Businesses Business/Organization Manic: Address_ City/state/zip: Ut Phonelt: ?'7�-ftj-0(¢(Q0 Are voan cnydoycr? Check the appropriate hnz: business Type (required): I .faun a emMoyer with 7� employees trill and/ 5. ❑ Retail or part -tune)' 6. ❑ RestaLit all t/BadF.ating Establishment 2. ❑ 1 am a sole proprietor or partnership and have n° 7. ❑ Office and/or Sales (incl. read estate, auto, etc.) employees working for tie in any capacity. S. ❑ Non-profit (No workers' comp. insurance required] 3.❑ Wo are a corporation and its officers have exercised 9. ❑ Entertainment their right of c.xnaptkin per c. 152, § 1(4), and we have 10.❑ Manufacturing TEI no employees [No woikels comp. insurance miIcgwmgl We am a no1plolh by I I❑ Hcahh (:are orbzardom staffed volUNeetS, I IZ.0 4- wdh no employees. [No st owes* comp utsurancu feq.] vnc�t - — -K44------- �:Anc applicant that check.. hos I71 n M&, NO svod:ors' compatsation pulicv inlivnunion. '" lI the corpmrnle offiaas linc cecngned themselves. but the aorporrtion has other employees, a workeremapensvuon poliq is icquired and such an mgmai/aLion should check hoe tll. t ant an enrphiller thal is providing worAers' contlynsalion insuranceJbr nap employees. Below is the police information. Insurance Company Name:_ CMS - is_E.#.R.I CkQ-i'�e&.A_''S Co[C- C.-NoQ-10 ZAJC Insurer's Address: clty,State/zip. A71 &Pjy.. .I.y- -__ J.,&Dj __.. Policy Il of Self ins. I icli 4 0 0 lspiial ion Date _J" Attach a copy of the workers' compensation policy doelaration page (showing the policy number and expiration daie). Failum to secure coverage as required under Section 25A of MGT- c. 152 can Lad to the imposition of criminal portables of a line up to S 1,50t1.00 and/or one-year imprisonment, as well as civil pmmH&s in the form ortt STOP WORK ORDER and a fine of up to S2%MD a day against the violator. Be advised that a copy, of this statement tray be fmtivardcd to the Office of Investigations orthe DIA lot insurance coverage verification. / do hereby cerItf.i% under the pains and penallies ol'peijm;y that the injornlafion provided above istrue and correct. I'hunc lt: Q11icial use only. Do not write in this area, to he completed h1' city or town a/,Brio!. City or Town: PermidUcense 11 Issuing Authority (circle (tne): L Board of Health 2. Building Deparnucnt 3. City/Town Cicrk 4. Licensing Board 5, Selecbnen's Office I Other Contact Person: Phone#: ,co,e.nuus V wAlia A� " CERTIFICATE OF LIABILITY INSURANCE DATE IYYYY) 12/03/2003/2019 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 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 endomement(s). PRODUCER CONTACT NAME: Elise FIano Roger Keith & Sons Insurance Agency Inc (508) 583-1106 PAXA/Not: (508) 583-8478 PAIC HONEo C NExt: 1575 Main Street E-MAIL e8anogurogerkeith.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAICN INSURERA: The Charter Oak Fire Insurance Company 25615 Brockton MA 02301 INSURED INSURER B: Travelers Property Casualty Company of America 25674 LPM Holding Co. Inc. INSURER C: Federal Insurance Company 20281 24 Main Street INSURER D: MA Retail Merchants WC Group Inc. INSURER E: Association Members WCT Maynard MA 01754 INSURERF: COVERAGES CERTIFICATE NUMBER: 2019 LPM HOLDING REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMEDABOVE 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. NSR LTR rypE OFADOLSLION INSD D POLICYNUMBER POLICYEFF MMIDD POLICY EXP MWDDNM LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 1,000,000 MEDEXP(Anycneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 A 630-6C830447 01/01/2019 01/01/2020 GEN'LAGGREGATE UMITAPPLIES PER: POLICY ❑ PRO- ❑ JECT LOC GENERALAGGREGATE $ 3,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 LIQUOR LIABILITY $ 1,000,000 OTHER: I AUTOMOBILE LIABILITY COINED SINGLE MIT Ea acMBcidLIMIT ent $ 1,000,000 X BODILY INJURY (Per person) $ ANYAUTO q OWNED SCHEDULED AUTOS ONLY AUTOS 810-7C399675 01/01/2019 01/01/2020 BODILY INJURY (Per a0den0 $ PROPERTY DAMAGE Per accident $ HIRED NON�OWNED AUTOS ONLY AUTOS ONLY X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 B EXCESS LIAB CLAIMS -MADE ZUP-91M48908 01/01/2019 01/01/2020 DED RETENTION $ C: EXCESS $ 35,000,000 A WORKERS COMPENSATION ANDEMPLOYERS' LIABIUry Y ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ R/ OFFICEMEMBER EXCLUDED? IMandatory In NH) NIA UB-91-1942545 01/01/2019 01/01/2020 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 EL DISEASE - EAEMPLOYEE $ 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT g 1,000,000 WORKERS COMP & EMP LIAR BI by Accident /Accident $1,000,000 D MASSACHUSETTS ONLY 014000502016119 01/01/2019 01/01/2020 BI by Disease Policy Limi $1,000,000 BI by Disease /Employee $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tat, Additlonal Remarks Schedule, may be attached B more apace is required) E: WORKERS COMP NH ONLY, 030009100240119, 1/1/2019-11112020,$1,000,0001$1,000,000/$1,000,000 POLICY LIMITS IN EFFECTAT POLICY INCEPTION. SHOULDANY 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 AUTHORIZED REPRESENTATIVE/^�\\ MANSFIELD MA 02048 [(/L}� V 19UB-2015 ACORD CUKPUNATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 0 •E a. u� c c o U D V o c =o rn o v I I I < Q % w \ § / \� \ U / / \ \ \ � [ i)t® \ \(2\ § � ,»® 5|\\ \ / : ! 'to % 4ƒ�k \ /