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HomeMy WebLinkAboutCardinal Health - 12/31/2020FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name l P&r3kM, mt % I Establishment Address Establishment Mailing Address (if different) ilc-0��y`i 40 �4G Establishment Telephone No q q $qr[ _OlQlp o Applicant Name & Title: `J t fwi w tµanaQ��YKi Applicant Address �� (�jQY� Grar�ivn, r W QUO t� I Applicant Telephone No.:1 r7q-ow -tp�, 24 Hour Emergency No.: "7711 -Mr WL3I ApplicantEmaii Owner Name & Title (If different from applicant) K�Q Owner Address 7, tea) '9L,�twio\ice, Q14 H30jj Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. C)kA CorporationTitle Address Lamel An Individual }� Vlo_- --- U A Partnership (��a��an Gl-7 C (Other legal Entity fJ1p2Gj �pC� CeU A0pIlya Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: �1 SnoQ K&v1a9Y- Address: &Iq U„yy%py\ A t.My\V iv�tKA Telephone No: 5a0? -U;61 -\'0[9q14 24 Hour Emergency No: SCk'(�3[-t�ia9(p FAX: Ugq-.3liI E-mail:�pa'�q dLzip lft�fpQY1i.COY✓t Alt E-Mail:�Q O�o , com --- --------- - - - - - - - --- - — District Or Regional Supervisor (if applicable) Name & Title.- Address: itle:Address: `, J Telephone No: t"[ Ud r � od-0 24 Hour Emergency No: FAX: E-mail: j�G� �Q�`�JYy�V1Ctr (� Food Establishment Information WATER SOURCE: i DEP Public Water Supply No: (If applicable) DAYS/HOURS UdGll..\CiA Name of Person(s) In Charge Certified in Waym) S Mw SEWAGE DISPOSAL: No. of Food Employees: Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Woa rte 5.1ot,� Name of pest control company routinely inspecting the premises for evidence of pests - - — - - ----- _..- --- - - 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? Length of Permit: i�_, (Innual [) Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type: 0 Retail Food $125.00 If yes, please attach the FOG permit application. Food Service up to 100 INCLUDING ' AOOD TRUCKS $175.00 [,] Food Service up to 101 -200 $250.00 [] Food Service up to 201 + $300.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer [1] Pushcart $50.00 # of Pushcarts: Supermarkets $400 (] Residential Kitchen $100.00 Milk &Cream $10.00 [i Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (dorenernperature controls required) (Check all that apply): Non-PHFs -non-potenfially hazardous leonine tlmeRernperalure controls required) RTE - ready4o-eat foods (Exsandwiches, salads, muffins which need no fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs rLl Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours f` Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations 1 PHFCooked To Order Preparation of PHFs For Hot And old Holding For Single Meal Service I_ ] Sale of Raw Animal Foods Intended to be Prepared by Consumer ffll Customer Self -Service Ice Manufactured and Packaged for Retail Sale (] Juice Manufactured and Packaged for Retail Sale U Offers RTE PHF in Bulk Quantities [] Retail Sale of Salvage, Out -Of -Dale or Reconditioned Food Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 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) itD Offers Raw Or Undercooked Food Of Animal Origin Vacuum Packaging / Cook Chill Prepares Food/Single Meals for Catered Events or Institutional Food Service 1, 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 oblAn copies of 105 CM&W0.000 and the federal Food Code. Signature of Applicant: N/ Ler_,�V_. Pursuant to MOL 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: Signature of Individual or Corporate Name: TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. cc)L�eJ�cf1 Signature of Individill or Corporate Name By: C porate IficerWandatot,y, if Applicable) ouq ,3100 *Social Security No. (Volunla{y) or Federal ldenlifiention 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. C1i DocnmC11tSWood lslnblishmanls-'Pcinp\Tr\X CFRIVICATION PORM,doc The Coinnionwealth oj'Massaehusetts Department of Industrial Accidents u,p Office of In vestigations 600 Washington Street Boston., MA 02/11 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization1Yo6(�6 tib usiness/Organization Name: /.f m, Address: gar) wps City/Staef7ip: I�j_agPhoe: Q1"j pf2lao _ Are y5w an einplover? Check the appropriate box: Business Type (required): I& I am a employer with �+.a'�employees (1`1111 and/ 5. ❑ Retail o• part -lime)." 6. ❑ Restaurant/Bar/Eating Establishment '_. ❑ 1 am it sole proprietor or partnership and have no T ❑ Office and/or Sales (incl, 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 a 152, $1(4), and Nve have 10 El Manufacturing no employees. [No workers' comp, insurance required]*' 4. ❑ We are a non-profit organization, staffed by volunteers. 11.0 Health Care with no employees. [Nn wmkcrs' comp. insurance req.] 12. Ther �'-'�"e�`t X' °Any applica t That checks box N I mast also till out the svelion below showing their workers' eompeasation policy information, a°I rthe corporate officers have exempted themselves, but the corporation has other ennployecs, a workers compensation police is required and such an oromization should check box ill. 1 our an enipla yer that is providing workers' compensation insurance for my enrt{)toyces.�Beloit, ds' the policy Information. InsurmnceCompany Name:----• Y�'t--�'d.t, �(_�•�1�.(��,�S �`G_GIwLJp .1 6.jC.. Insurer's City/State/Zip: __._ _ ___. _ dao Policy.4orSelf-ins.Lic.# 014tco •J'oao Ilio 09 Expiration Date: lIIko Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late). 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 S 1,500.00 and/o' 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 (his statement may be forwarded to the Office of Investigations of Che DIA for insurance coverage verification. 1 do hereby eer4{ti,, under the pains`and(�pen�alttiies ofligim y that the information providerd abofve�ias tare and correct Sienature[ `4) ) - 0b Official use only. Do not write in this area, in be coinpleled by cily or town gfficia l City or Town: Permit/License Issuing Authority (circle one): 1. Bound of f-lealth 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.macc.gos•/dna Phone ACo ®® CERTIFICATE OF LIABILITY INSURANCE °A,E`/0312019 12!0312019 THIS CERTIFICATE IS ISSUED ASA 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(los) 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 Roger Keith & Sons Insurance Agency Inc 1575 Main Street Brockton MA 02301 CONTACT NAME: Elise Flano SON o Eat , (508) 583-1106 plc No : (508) 583-8478 EMAIL eflano@rogerkeilh.mm ADDRESS: INSURERIS) AFFORDING COVERAGE NAICe INSURERA: The Charter Oak Fire Insurance Company 25615 INSURED LPM Holding Co. Inc. 24 Main StreetURERD: Maynard MA 01754 INSURERS: Travelers Property Casualty Company of America 25674 INSURERC: Federal Insurance Company 20281 MA Retail Merchants WC Group Inc. INSU PER RE: Association Members WCT INSURERF: COVERAGES CFRTIFICATE NUMBFR, 2019 LPM MULUINU 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 OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSIR LTR TYPEOFINSURANCE ADDLIWOR INSD WVD POLICYNUM13ER POLIO EFF MMIDD MMIDDNYYY LIMITS X COMMERCIALOENERALLIABILITY EACH OCCURRENTCE $ 1,000,000 CLAIMS -MADE � OCCUR ED PREMISES (Ea occur encs $ 1,000,000 MED EXP (Any one Person)$ 10,000 PERSONALSADV INJURY $ 1,000,000 A 630-SC830447 01/01/2019 01/01/2020 GEN'LAGGREGATE UNIT APPLIES PER: GENERALAGGREGATE $ 3,000,000 PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY ❑ PRI 7 LOC LIQUOR LIABILITY s 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) S X ANYAUTO BODILY INJURY (Per accident) S A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 810-7C399675 01/01/2019 01/01/2020 PROPERTY DAMAGE $ Per eocldenl S x UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 25,000,000 AGGREGATE $ 25,000,000 B EXCESS UAB CLAIMS -MADE ZUP-91M48908 01/01/2019 01/01/2020 DED RETENTION $ C: EXCESS $ 35,000,000 A WORKERS COMPENSATION EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTNE YIN OFRCERIMEMSER EXCLUDED? F—] tMandatory In NH) NIAUB-OH942545 01/01/2019 0110112020 i PER ERN AND -^ E.L. EACH ACCIDENT $ 1,000,000 EJ_ DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY UMIT $ 1,000,000 If yes, describe under DE8 RIPTION OF OPERATIONS below D WORKERS COMP & EMP LIAB MASSACHUSETTS ONLY 014000502016119 01/01/2019 01/01/2020 BI by Accident/Accident $1,000,000 Bl by Disease Policy Limi $1,000,000 81 by Disease /Employee $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 8 more space Is required) E: WORKERS COMP NH ONLY, 030009100240119,1/1/2019-111/2020, $1,000,0001$1,000,000/$1,000,000 POLICY LIMITS IN EFFECTAT POLICY INCEPTION. , CERTIFICATE HOLDER CANCELLATION 0 1988-2015 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 AUTHORIZED REPRESENTATIVE MANSFIELD MA 02048 [//f 1�/� -f- % ©1888.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: rfljel, 6Y) Ram- ip. 1 ar-aloci l Oleo In I Address: T PST % Mailing Address: Saanm Phone/Fax Number: �O- b (n 1 1M Contact Person/Title for Grease Traps: Ian L CA of 0h Name of Company scheduled to pump internal grease trap(s) monthly: 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 $SO ($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 Nl�u` Date PrintName f--0-ri-0-r- 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. y Seating Capacity (per Fire Department Regulation): I �� Seating Capacity (Actual Count): J0 Normal Hours of Food Preparation/Service: Monday 3� Thursday Q, Sunday UFJR W Tuesday Avw- r 3Qpo Friday lm -1,,30 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 1 _ 3 compartment sink AO Handwashing sink e Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens ✓lam 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? F Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes y\1 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: Please list fixtures attached to each grease trap Grease Trap l S Cp VIA ckv%d 81<6)(A$f',Ui 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 y\1 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: