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HomeMy WebLinkAboutBuffalo Wild Wings - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION . (Application must be submitted at least 30 days before the planned opening date) y<f Establishment Name Buff6j^®` Loll W(6#4e)2 Establishment Address 323 ,r , 111 Establishment Mailing Address (if different) wm� ull= CSAWV _ Mstai�� � (t31�d�✓Si-d�"2,ca0 MI nn-eo�lis,MNG,&4Itn sta ishmen selephonte��N��o Applicant Name & Title: amin Wt�� wcC Applicant Address -V) VeQ (a -Te '1lo,tC OZA� 9 �&MMM Applicant Telephone No.:QW—SiiQ-ia)nS 24 Hour Emergency No.:QJ2'3_�3.C('QI,!,� Applicant Email Owner Name & Title (If different from applicant) Owner Address &a"\Q -) Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El Association partner. ,� ,{A�n 1�Corporation Name Title Address 1-1 An Individualu_V El A Partnership 11 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title:U"1) 1 tat Address: `SCJ_)) `� 00 Telephone No: Z5i • t 4 24 Hour Emergency No. FAX: E-mail: oGC1�1?�tY1�S.CA9rY1 CJ Alt E -Mail: oSjnsvruafz�% Cum District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE ,--t-p �` �n SEWAGE DISPOSAL DER Public Water Supply lNloJ(If vapplicable) t �� �n,�No V7-n' off Food Employees' (c r)' DAYS/HOURStSIj Y).- I y )� I I (kM ",JW.1. ,JM'j tom Name of Person(s) In Charge Certified in Food Protection Management: ('�mnle# �� i r c i►e Name of Person(s) In Charge Certified in Allergen Awareness Training �' tck DriUZ. G - Name of pest control company routinely Inspecting the premises for evidence of pests C(7PC. SA /� --�Ip�MA✓' If there is seating for 25 pg�opple 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?j CS If yes, please attach the FOG permit application. Length of Permit: Annual [I Temporary Temporary Start Date Temporary End Date: Temporary Time. Rain Date Food Operations'. (Check all that apply): Establishment Type: ( ) Retail Food $125,00 [.1 Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Dessertslice Cream (-) Food Service up to 101 -200 $250.00 $25.00/1'reezer jNfood Service up to 201 + $300.00 1I Pushcart $.50.00 # of Pushcarts' [..] Supermarkets $400 (I Residential Kitchen $100.00 ir{ Milk & Cream $10.00. _.. 1 Caterer $35.00 Definitions: PHF - Potentially hazardous rood ruch4e rperalum cereals required) Non PHP'S - non-poeeneially hazardous fondles fima/lsmpenuum controls required) RTF - ready-lo-eal foods (Ex, sendANches, salads, muffins vhich need no further processing) (.] Sale of Commercially Pre -Packaged Non-PHFs PI IFCocked To Order [.] Sale of Commerclary Pro -Packaged PHFs (.. ] Preparation of PHFs For Hot And Cold Holding For Single Meal Service (.1 Delivery of Packaged PHFs f._J Sale of Raw Animal Foods Intended [ I Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours [ j Customer Self-Service j J Customer Sell -Service of Non PIIF and Non- Perishable Foods Only _ (] Ice Manufactured and Packaged for Retail Sale [.J Preparation of Non-PHFs (J Juice Manufactured and Packaged for Other Food Operations Retail Sale I, the undersigned, attest to the establishment operation will con board or health on how topbtain Signature of Applicant: Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out Of -Date 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) [1 Offers flaw Or Undercooked Food Of Animal Origin (f Vacuum Packaging / Cook Chill �] Prepares Food/Single Meals for Catered Events or Institutional Food Service �of the information provided in this application and affirm that the food 105 CMR 590.000 and all other applicable law I have been instructed by the of 105 CMR 59D,000 and the federal Food Cade. Pursuant to MGL Ch.62C, sec. AA, I certify under the penalties of perju that to My best know/ledge and belief, have riled all state tax returns and paid state taxes required under law. �i `°' Social Security Number or Federal ID'. Signature of Individual or Corporate Name: __-,_ _ _.-_. __I _ __ ____..._. The Cottrntonivealth ofMassachusetts -- Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston, iVA 02111 ti www.inass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lev'"y Business/Organization Address:_ 1 —'t/ )U0 i t c A City/State/lip:, l lsll l� 02-`WJ Phone 9: � �j, t lam` �GJ Are you an employer? Check the appropriate box: I. I am a employer with ALB— 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. INo workers' comp. insurance required]*' 4. n We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] \N 41 MN Business Type (required): 5. F-1 Retail G. F] RestauranUQar/Gating Establishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. F] Entertainment an Manufacturing I Ln Health Care 12.0 Other -- `Any applicant that checks box N 1 must also fill out the section below showing their workers' compensation policy in 16rnmlion. ' * If the corporate officers have exempted themselves, but the corporation hes other employees, a workers' compensation policy is required and such an organization should check box N1. I am an employer that is providdia3workers' compensation insurance for arm employees. Below is the policy information. r �t�K11 CCl 7 Y\SL�i �Ylct'. Insurance Company Nmnc: --- -- _—_-- _— Insurer's City/State/`Lip:—.tnAO, YYSO_�__U l -A a t Policy # or Self -ins. Lic. # '] Expiration Datc: C)"9_Cj 12-C) 0 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 Investigytiens'M-Ihe'D1A for insurance coverage verification I do heWjb certij; andr the pairs and penalties of perjury that the information provider/ above is true and correct. Signature:// Date: 10113 P,O i 5 Phone U, q '^ m Official use only. Do not wrhe In this area, to be completed by eipr or town official. City or Town: Perin it/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.nmss.gov/dia 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. Signat re of Individual or Corporate Name By: Corporate Officer (Mandatory, If Applicable) "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\Nsers\s 6e6Desklop\Scon's Documc uVoW Felabhshmems- "Temp\TAX CERTIFICATION FORM clot I H4 v / O z w C O N O N N W al v .P ❑ o ❑ ❑ 0 0 s y W V e / p �( M 4 0 o / \ \ \ / \ R \ R q ( E\R\ \ , & ( 7 \\§} \ ®®§ƒ % { )@�{ |)o j (® r a�z \ / p �( M 4 0 o / \ \ \ / \ R \ R q K \ , & ( 7 )@�{ |)o j (® r a�z \ / p !x M 4 0 o / \ \ \ / \ R \ R q K \ & \ WE ► �Mmi � � z � z 0 ?� Ww � � ® AC" o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YVYY) nn&12o1s 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 endorsement(s). PRODUCER MARSH USA, INC. TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 CONTACT NAME: PHCNN Ext: we No: EMAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC# INSURER A: ACE American Insurance Company 22557 040876-BWW-G_AWUP-19-20 482 INSURED Buffalo Wind Wings, Inc. Three Gienlake Parkway INSURER B: ACE Pro eqA Casualtylnsurance Compan 20699 INSURER C; The Continental Insurance Company__ INSURER D: Employers lnsUranCe DOmpanY Of WBUSSU 21458 Atlanta, GA 30338 INSURER E: ACE Fire Underwriters Insurance Company _ 20702 MED EXP(Any one" men) $ EXCLUDED INSURER F: X SIR: $750,000 COVERAGES CERTIFICATE NUMBER: ATL -004823928-11 REVISION NUMBER: 6 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 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 LT TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DOY EYYY MMd EXP LIMITS A X COMMERCIAL GENERAL LIABILITY XSL G71566481 06/29/2019 06129/2020 EACH OCCURRENCE $ 2,250,000 Cl-AIMSCl-AIMS-MADEurrence Cl -AIMS -MADE OCCUR LIQpOf Llabl ly: PREMISES Ea occ $ 1,000,000 MED EXP(Any one" men) $ EXCLUDED X SIR: $750,000 $2,250,000 each common cause X Liquor liability PERSONAL&ADV INJURY $ 2,250,000 $4,000,000 aggregate $750,000 SIR GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,250,000 PRODUCTS -COMP/OPAGG $ 2,250,000 PRO - X POLICY JECT PRO- [I LOC $ OTHER: A AUTOMOBILE LIABILITY CAL H25296394 06/29/2019 06129/2020 COMBINED SINGLE LIMIT $ 2,000,000 Ea accident BODILY INJURY (Per person) $ X ANY AUTO OWNEDSCHEDULED AUTOS ONLY __ AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BODILY INJURY (Par scddent) $ PROPERTY DAMAGE $ Per accident X UMBRELLA LIAR X OCCUR XOO G7114799A 002($15M) 05/29/2019 06/29/2020 EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 X EXCESS LIAB CLAIMS -MADE 6072498765($IBM XS $15M) 06129/2019 0612912020 OED I IRETENTIONS $ A E A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANVPROPRIETORIPARTNERIEXECUTIVE OFFICEWMEMBEREXCLUDED9 (Mandanny In NH) NIA WLR C6589404A(AOS)Ded $$500k SCF 065894087 WI RETRO ( ) WCU C65894129 OH On ( Orgy) 0612912019 06/2912019 I9202O 06/2912020 06/2912020 X STATUTE ORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, descdba under DESCRIPTION OF OPERATIONS below D Property YAO1-91-469147-019 06/2912019 0612912020 Limit 100,000,000 Othr Ded may apply per tens & cond Deductible 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may ba attachad If more space is required) Re: Location: Buffalo Wild Wings #482,321 School Street, Suite At 10, Mansfield, MA 02048 Liquor Liability policy is continuous until canceled. Palin is included. Certificate Holder is/are included as additional insured with respect to the above -referenced general liability insurance for liability arising out of the operations of the referenced unit as required by writer; contract. CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ISSUING COMPANY Workers' Compensation ACE AMERICAN INSURANCE COMPANY NCCI CARRIER CODE and Employers Liability 12165 Insurance Policy Information Page POLICY NUMBER ❑ New ❑X Renewal ❑ Rewrite Symbol: WLR Number: C6 5B 94 04 A PREVIOUS POLICY NO. ❑ Individual Partnership Association Symbol: WLR Number: C65228361 Corporation ❑ Joint Venture ❑ Other Legal Entity Item 1. INSPIRE BRANDS, INC. Inter/Intrastate ID No.: 910016903 Named THREE GLENLAKE PARKWAY NE Insured ATLANTA GA 30328 Federal Employer ID No.: 452485293 Mailing Address L Employer's ID No.: PIC CODE: 5812 For other named insured see Extension of Information Page — Schedule of Named Insured, WC 99 99 99 A For other workplaces see Extension of Information Page — Schedule of Other Workplaces, WC 99 99 99 B Item 2. Policy period: From 06-29-2019 To 06-29-2020 12:01 A.M., standard time at the named insured's mailing address. Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: AL,AR,AZ,CA,CO,CT,DC, D E,FL,GA, Hl, IA, ID,IL,IN,KS,KY, LA,MA, MD, MI, M N,MO,MS,NC NE, NJ,NM,NV,NY,PA,RI,SC,TN,TX, UT,VA, W V Item 3B. Employers Liability Insurance: Part Two of the policy applies to work in each stale listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee Item 3C. Other States Insurance: Part Three of the policy applies to the stales, if any, listed here: ALL STATES EXCEPT ND,OH,WA,WY, AND STATES DESIGNATED IN ITEM 3.A Item 3D. This Policy includes these endorsements and schedules: See schedule of Forms and Endorsements WC999999D Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE—CLASSIFICATIONS If indicated here, interim a,dd'J''u,slments of premium will be made: Minimum Premium collected in CA $ 1000. ❑ Quarterly ❑ Monthly Total Estimated Premium $ 2197559. Deposit Premium $ PRODUCER NAME AND MAILING ADDRESS MARSH USA INC 3560 LENOX ROAD SUITE 2400 ATLANTA GA 30326 PRODUCER CODE: 244022 36-1436000 ATU _ MARKETING OFFICE: ATLANTA BRANCH L_ 61 ISSUE DATE: 07/16/2019`f `+ Authorized Representative WC 00 00 01A (05/88) Copyright 1987 National Council on Compensation Insurance INSURED COPY AGENCY CUSTOMER ID: 040876 LOC #: Atlanta Ac R ® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY MARSH USA, INC. NAMED INSURED Buffalo Wild Wings, Inc. Three Glenlake Parkway Atlanta, GA 30338 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Special Conditions: Property Coverage Includes Equipment Breakdown, Building, Improvements 8 Betterments, Contents and Business Interruption Earthquake Limit / Earthquake Deductible (par occunence): $501000,0001$100,000 $10,000,000 California 15% or $250,000 $25,000,000 New Madrid/ Pacific NW 12% or $100,000 $25,000,000 Nevada 12% or $100,000 Deductible Named Windstorm (per occurrence): $100,000 Florida, Hawaii, Puerto Riw: 5% subject to $250,000 All Other Tier One: 21k, Subject to $100,000 Flood Unit I Flood deductible (per occurrence) $100,000 Flood SFHA (100 Year) Zones: $5,000,000 limit subject to $500,000 deductible Other deductibles may apply per policy terms and conditions. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD FXTFNSION OF INFORMATION PAGE Named Insured Endorsement Number INSPIRE BRANDS, INC. Policy Number Symbol: WLRNumber: C6589404A THREE GLENLAKE PARKWAY NE ATLANTA GA 30328 Policy Period Effective Date of Endorsement 06-29-2019 TO 06-29-2020 06-29-2019 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. SCHEDULE OF NAMED INSURED ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: NAMED INSURED FEIN INSPIRE BRANDS, INC. AFA SERVICE CORPORATION ARBY'S INTERNATIONAL, INC. ARBY'S RESAURANT, LLC ARBY'S RESTAURANT GROUP, INC. EXTENSION: ARBY'S LLC FRANCHISE ASSOCIATES, LLC RTM ALABAMA, LLC RTM GEORGIA, LLC RTM GULF COAST, LLC RTM INDIANAPOLIS, LLC RTM PARTNERS, LLC RTM SAVANNAH, LLC RTM WEST, LLC RTM, LLC RTMSC, LLC ARG IH LLC For the state of CA refer to state specific endorsement. 452485293 341113644 814682426 710898730 133760393 452485214 Authorized Representative WC 99 99 99 A (10/06) Page 1 of 4 FXTFNSION OF INFORMATION PAGE Named Insured Endorsement Number INSPIRE BRANDS, INC. 452488026 Policy Number Symbol: WLRNumber: C6589404A THREE GLENLAKE PARKWAY NE ATLANTA GA 30328 Policy Period Effective Date of Endorsement 06-29-2019 TO 06-29-2020 06-29-2019 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the olicy. SCHEDULE OF NAMED INSURED ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: NAMED INSURED FEIN ARG INVESTMENT CORPORATION 452488026 ARG RESOURCES, LLC 261476024 ARG SERVICES, INC. 205728240 BLAZIN WINGS, INC. 411957107 DOING BUSINESS AS: B—DUBS EXPRESS BUFFALO WILD WINGS INTERNATIONAL, INC. 311347419 BUFFALO WILD WINGS, INC. 311455915 BWW JERSEY WINGS, INC. 273208748 BWW LEX PARK, LLC 451219677 BWW RESOURCES, LLC 832194340 REAL WING, INC. 431830114 RIM ACQUISITION COMPANY, L.L.C. 582307207 RTM MID—AMERICA, LLC 261552741 RTM OPERATING COMPANY, LLC 261552790 For the state of CA refer to state specific endorsement. Authorized Representative WC 99 99 99 A (10/06) Page 2 of 4 EXTENSION OF INFORMATION PAGE Named Insured Endorsement Number INSPIRE BRANDS, INC. Policy Number THREE GLENLAKE PARKWAY NE ATLANTA GA 30328 Symbol: WLRNumber: C6589404A Policy Period Effective Date of Endorsement 06-29-2019 TO 06-29-2020 06-29-2019 Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. SCHEDULE OF NAMED INSURED ITEM 1., NAMED INSURED, OF THE INFORMATION PAGE IS EXTENDED AS FOLLOWS: NAMED INSURED SYBRA, LLC For the state of CA refer to state specific endorsement. 9w 261552833 Authorized Representative WC 99 99 99 A (10/06) Page 3 of 4 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT aseo "S' RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Buffil o 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 Arlrirccr c_ Z- � �cy-)c �< Each grease interceptor/trap over 3 Mailing Phone/Fax Number. Email: Bww a CQ-rY-'WiQ Ens 0 1 vt k8 vv-ty b CjYn I-4�2 G� V)a- to wt O vv W -C S Ctrn Contact Person/Title for Grease Traps: �.:%� �t(j' l '`�� !^1" Z• I G -M Name of Company scheduled to pump internal grease trap(s) monthly: y Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: J • 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 cons exon of a granting of the permit, the undersigned agrees to the conditions of the permit and actawledges t at the information submitted in these documents is true, accurate and complete. Date I Z/i'3/2bt Print Name `1) (i ik- Cl�) 0m Im 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 Department Regulation): a5t) Seating Capacity (Actual Count): QCro— Normal Hours of Food Preparation/Service: Monday I la'1yy_ Thursday -PAM Sunday )- ", Tuesday llam-12 Wednesday Vt - Friday ham -1041), Saturday I W&__((x) 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 2— 3 compartment sink Handwashing sink Commercial Dishwasher CT Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators 2 Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): S V_�' S�m Q6Ck' Is dinnerware pre -rinsed before being washed? (� X Yes No If yes, at what station/sink? p1 &S )b1 < Grease Trans 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)? X Yes No Size gallons Where is the existing outdoor GRU located? a �,{Ac L 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: 3 Please list fixtures attached to each grease trap GreaseTrapl 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 gallons Where is the existing outdoor GRU located? a �,{Ac L 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: 3