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HomeMy WebLinkAboutGreat Woods Pizza - 12/21/2020V FOR BOARD OF HEALTH USE ONLY Permit# Issued Cnnn C(2TAW IQL1KACAIT DCDKAIT ADDI lrATlr)Kl ^ 9 (Application must be submitted at least 30 days before the planned opening date) Establishment Name 6r� \pj 00d S [ZZL+, Establishment Address 42.16 Elim S' ' Establishment Mailing Address (if different) Establishment Telephone No 1 _ , Q 11 Applicant Name& Title: VVV-rwi-C is(n'ygkL i_S C)w�� -' Applicant Address 2'Tl��� aV, �, eaStbt� AA Da, Yrj Applicant Telephone No.: 24 Hour Emergency No.: 1 01-6 14L1 (-H Applicant Email Grtfk+v,jvoQ 3i^l\-Ctt� , CD �o Owner Name & Title (if different from applicant) chy %SA-DS Owner Address Owner telephone number jr_Df3-gqLALA Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or r An Association KA Corporation partner. Name Title Address t4 f--h 4bu An Individual `, .. � t2��� 1 7aw V1� t� -a ' r ❑9 APartnership �11 �125' Cu � OVyvvcV �. Iulk� r 10 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Kak1.C_Y)n<- �S( av'a.ut S Address: Telephone No: 24 Hour Emergency No: J-08 ,C( b-f y , L4. Lq--/ `P FAX: E-mail: C-)YeLI� W i_ ct s' � CZlc--� cC3 � t tiSA 11 r COVY� 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: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: �� . �r ✓ A P 1�. CQ �J(� !} — (u�'�H " ��� Si) IAA — Name of Person(s) In Charge Certified in Food Protection Management: 41\Cy I,ots f - - 6( CLY\_ L a" y 1 tA&_ ILL 40LL Name of Person(s) In Charge Certified in Allergen Awareness Training Y_cx�\ 1 vu I G Y S Name of pest control company routinely inspecting the premises for evidence of pests A�-Got_S 1 r)S 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? __Z___ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ##Retail Food $125.00 [,],1 Mobile Food Consession Temporary X Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer [I Food Service up to 101 -200 $250.00 Temporary End Date: (] Food Service up to 201 + $300.00 Pushcart $50,00 # of Pushcarts: Temporary Time: 0 Supermarkets $400 Residential Kitchen $100.00 Rain Date: ,Milk &Cream $10.00 [ Caterer $35.00 Food Operations: Definitions.,PHF - Potentially hazardous food(tlmeAemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no fine4emperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins; which need no further processing) %a Sale of Commercially Pre -Packaged Non-PHFs XPHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs [f Preparation of PHFs For Hot And for More Than a Single Meal Service 0 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 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 ID Ice Manufactured and Packaged for control) a Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of ❑B Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 0 Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities EM] Prepares Food/Single Meals for 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 gbtain copies of 1055,103 590.000 and the federal Food Code. Signature of 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: , ` 7A — il� , O q � Lo Signature of Individual or Corporate Name: (� E. Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name Arldracs.l�Ty - � JX AM Mailing Address: Phone/Fax Number: ���1 1 C) Contact Person/Title for Grease Traps: 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 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Signed �kL��Date Print Name a�Yl.i �S 1C4 Facility Onerational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire DepartmentRegulation): s Seating Capacity (Actual Count): C5 Normal Hours of Food Preparation/Service: (� Monday Cie Tuesday C(J , O q Wednesday V30ry �P Thursday •?j�F}' P Friday VWN— 10SaturdayV®A- — I Op Sunday 1\ �(� Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU I 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines �7 l� Fryolators ZGrills or Ovens 2 Exhaust Hoods 2 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): lr \ v rxA-A�_' (`Pm-\m,y)A Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? �j, CDIM Q. S � Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 S C . S Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? T Yes No Size gallons Where is the existing outdoor GRU located? � , bA'( Wi h q If the owner is responsible for external trap pumping, provide the Name, Address an Tell$ ephone Number of the property owner below: 1(� _ Q Property Owner's Name: 1t 6ny — \ t-C�l:>i-��C Property Owner's Address: Property Owner's Telephone Number: `fob, qf�Q.CJj-�'g Yellow Grease Waste Do you store yellow grease waste from I Where is the grease storage unit locates How often is this grease storage unit err Please list the vendor who removes the fecyclerrenewables GREASE TRAP SERVICE LOG 1,110of-olffell gallm service@lifecyclerenewables.com '"' ;f s� ,�.•�rNf..m�,,�,�-�' " hoc "r � .� r „�' P° 1,,,. Ugm 0-0 .� �'r in / =WA=KIM 0 EMERGENCY GREASE TRAP + DRAIN LINE SERVICE S 61 m X D n m 7v T n O z i i ■ T n O Z c Department of Industrial Accidents Office of Investigations s 600 Washington Street Boston, MA 02111 ° www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ 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] 3,0 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.] Phone #: 11LA' :�q -00-4 Business Type (required): 5. ❑ Retail 6._E�RestauramBarBating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other *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 thepolicy information. Insurance Company Name: hid \�u� � Powco 1 W L f\)(`i Cww1 Umnioo ` Insurer's Address: \ 5 Q bY 1 V City/State/Zip: cd '&, A1C,.Y` DNA H (opn Policy # or Self -ins. Lic. #� )1� —10 Expiration Date: 10-1 1 I i 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 Investieations of the DIA for insurance coverage verification. I do herebyNferft 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: Phone www.mass.gov/dia 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 (Mandatory, if Applicable) 'Al -u1V 100(.V **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:\Users\sleite\Desktop\Scou's Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc a' z, a w z r LO LO o 0 _.. 3: N � , N X 04 N N �- N •4 4-4 UA �♦ a o �zQ u Q p U Q Lq A d - CERTIFICATE OF LIABILITY INSURANCE 12/01/2019 IYYYY) 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 endorsements . PRODUCER CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE PHONE , 877-266-6850 FAX • 585-389-7426 E-MAILSS. Certs@paychex.com ROCHESTER, NY 14620 INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: NorGUARD Insurance Company 31470 INSURER B: GREAT WOODS PIZZA CORP 428 ELM STREET INSURER C: WRENTHAM, MA 02070 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 CONTRACTOR 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 TYPE OF INSURANCE DDL INSR UBR D POLICY NUMBER POLICY EFF (MMIDO/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS-MADE[:::—]3CCUR $ ' MED ESP (Any one person) PERSONAL &ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: POLICY = PROJECTO LOG PRODUCTS - COMP/OPAGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea socldenl) $ ANYAUTO ALLOWNEO SCHEDULED AUTOS AUTOS NONDWNED HIRED AUTOS AUTOS P BODILY INJURY (Per (Per person) BODILY INJURY (PeraCGdent) $ PROPERTY DAMAGE (Peraccld.m) $ $ UMBRELLA LIAR = OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR =CLAIMS -MADE $ DED RETENTION $ WORKERS COMPENSATION AND WORKE EMPLOYERS' LIABILITY GRWC046598 12/05/2019 12/05/2020 X WC STATW OTH- E.L. EACH ACCIDENT $ 100.000.00 ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBEREXCWDEDi YIN (Mandatory In NH) N N/A E.L. DISEASE - EA EMPLOYEE $ 100,000.00 E.L. DISEASE -POLICY LIMIT $ 500,000.00 If vaa, aescnlro unda, DESCRIPTION OF OPERATIONS LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION Proof of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD