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HomeMy WebLinkAboutMedtronic - 12/31/2020 (2)q(9oaa- l✓305, 10 FOR HOARD OF HEALTH USE ONLY Permit # Issued j FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name Establishment Address �rr-E Establishment Mailing , dress (if different) kipm EVok&6v�4 11-0`, I G • �0 © &W1p j CSS Establishment Telephone No Ei�1p`0c gj-0tou0 Applicant Name & Title: K65Aevl V6'r ba` PJ.YiOL e'i � Q3-1,ApplicantAddress'70L&r, C66OV)I �'A orN`7 Applicant Telephone No.: rpq q _a0o-u ij 24 Hour Emergency No.:" r "doo-u'n Applicant Email KV _ &'0mhCt. Owner Name & Title (if different from applicant) 4W, v' f Owner Address IWp NeuyfVA Pla•.c.,�5 WoWkn3 tlM 5',' a}kt 3(30r UeW40y,l HA_ 69!-45P' Owner telephone number �OM Owner email. Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. �QA Corporation Name Title_ Address � . J An Individual -`v"G' `" `�rp�` - _ �� b% v ko1 f)_as _ I I A Partnership j&l.k-'0V)l KA 1OtherlegalEntity Wrtf r �xtSOW 0 W4DIoju 01140 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Vr�thn 1�((af\y_04 ``Ki ,r� Q jr Address: IJL t7UY� qa, �`�t ICY 001 Telephone No: I ly_ow -UO, 3� 24 Hour Emergency No: �l`70--dW'(Qd-3` i E-mail: ��C r Alt E -Mail fie! Gia Pale al yyk�OY��C �aM - District Or Regional Supervisor (if applicable) Name & Title: J �� (� 7��(� Address: Telephone No: T -)g_ 1 + _ e��a� 24 Hour Emergency No,:'TV7r_q (D o 10a0 FAX: E-mail: ����m Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No (If applicable) I No. of Food Employees: _ ? DAYS/HOURS.�- Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests eeoia_b If there is seating for 25 pe ple or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. fy Yes Does this establishment require a FOG permit? le -c'— If yes, please attach the FOG permit application. Length of Permit: I `�-, Annual '.. I_ I Temporary Temporary Start Date. Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Establishment Type: [_ Retail Food $125.00 IV Food Service up to 100 INCLUDING OOD TRUCKS $175.00 Mobile Food Consession NO PFIF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream [_. I Food Service up to 101 -200 $250.00 _-- $25.009reezer [j Food Service up to 201 + $300.00 [ _i Pushcart 550.00 # of Pushcarts: ����❑....tttt Supermarkets $400 [__J Residential Kitchen $100.00 X'Mllk & Cream $10.00 U Caterer $35.00 OenmhonsPHF - Potentially hazardous food (Gme/lemperature controls required) Nor/-PHF's - non -potentially hazardous Jacopo lime/(enperalure controls required) RTE - ready -to -eat roads (Exsandiviches, salads, naJ/Ins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order i,j Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs �I�,{j Preparation of PHFs Por Hot And for More Than a Single Meal Service iDelivery of Packaged PHFs 7 Cold Holding For Single Meal Service _r] PHF and RTE foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended r : 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 1 Customer Self -Service of Non PHF and Non- Customer self -Service contact alternative, time as a public health Perishable Foods Only [!,I Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging ! Cook Chill Offers RTE PHF in Bulk Quantities '".I Prepares Food/Single Meals for _S 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 94a)ycopie4 of 105c54R 590.000 apifl the federal Food Code. Signature of Applicant:/[ _ �'-"�---- I //l,( a 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 lax returns and paid state taxes required under law. Social Security Number or Federal ID -3\ 17 ' 1 3'00 /�` Signature of Individual or Corporate Name: __�_�. ,'/tC„g� 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 late. Signature of Individual or :orporate Name By: Cor }orate Of- ei (Mmrdalmy, If Applicable) da,g3 �fa6 "Social Security No. (Voltndnry) or Federal liferrlificnlioi 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: AUsershleiICADesktopASco1I's DocumenlsToud Fsmblishmeims Icm[IN l'rAx C'EIYI IFICAIION FORMAuc The Contrnoniveitlth of Men.vochms-etts u,p Department of Industrial Accidents Offlce of /nvestigations 600 Washington Street Boston, MA 02111 wwm ina.ys.go vIdia Workers' Compensation Insurance Affida,i*: General Businesses Business/Organization Address: I 1 city/state/Zi ik kcUlCo., soC-b OR I. S 4- Phone t!:_ Are you an employer? Check the appropriate box: Business Type (required): I.� I mn a employer with t?)z —employees (full and/ 5. ❑ Relail or part-time). 6. ❑ Rcstawant/BarlE:ating Establishment 2.F_1 I 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] R. ❑ Non-profit 3.❑ We are it corporation and its of ficels have exercised 9. ❑ Entertainment their right of exemption per c. 152, § ](4), and we have 10 R Manufacturing no employees INo workers' comp. insurance required)*' 4.❑ We are it non plofil organization, staffed by volunteers, 1 I. 1lealth (ver with no employees. [No workers' comp instil -a req.] 12. Other (°�`'t'� ',1nc upplictud that cheeks bus li I mist also 611 out rhe section below O'minit areiI tcorken colli mnsallou policy inlnnmaicor. ° kill (lie corporate ollkers have oreaupred themselves, but the om poration has ollwr employees, it wurkets, compensation policy is required and such an m.iam,al ian should check bins ft 1. I aur cin emplgper that is proviefin warhers conrpensnhno inscmancefor mp enr1/rtorefes. Below is the policy informatirn , Insmance Company N ane __-_-A%------ Kt+a .-'__KrK(z_4VL+Y L_ 1C. t�ROl=-P Insurer's Address: _--. 1 �O.`F 114 Cllytslale/zip. _ RL62ay Policy 11 or Sell' ins. Lie. It p(� �Ot% .�� � _--Expiration Due. 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 ofa fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the Ibrm ofa STOP WORK ORDER and it fine of up to $250.00 it day against the violator. Be advised that it copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do herebp certify, under the pains mid penahim of perjury that the inforination provided above is true and correct. 141P. $gq-ouoo Of ficial rise only. 1)n nut write in ttris area, to be canpleted by city or town nlfrcirrl. City or Town: Perini (A ice Ilse Issuing Authority (circle one): I. Board of Health 2. Building Deparhuenl 3. 0(y/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person www.mars,5.euvfd is Phone #: A� " CERTIFICATE OF LIABILITY INSURANCE DAE103120/Y9 12/03/2019 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 ORODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 CONTACT NAME: Elise Flano Roger Keith & Sons Insurance Agency Inc ac° No Ext). (508) 583-1106 nAc No : (508) 583-8478 180'Nefiano@mgerkeilh.wnn 1575 Main Street INSURER(S) AFFORDING COVERAGE NAICIs Brockton MA 02301 INSURERA; The Charter Oak Fire Insurance Company 25615 INSURED INSURERS: Travelers Property Casualty Company of America 25674 LPM Holding Co. Inc. INSURERC; Federal Insurance Company 20281 24 Main Street INSURER D; MA Retail Merchants WC Group Inc. INSURER E: Association Members WCT Maynard MA 01754 INSURER F: COVERAGES CERTIFICATE NUMBER: 2019 LPM HOLDING 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 RESPECTTO 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. INSRAVOLSUBR LTR TYPE OF INSURANCE INSD WVO POLICYNUMBER IC N1M/OD/YYYY POLI E MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE Fx_] OCCUR PREMISES Ea occunenca $ 1,000,000 MED EXP (My oneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 A 630-6C830447 01/01/2019 01/01/2020 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 3,000,000 POLICY ❑ PRO-❑ JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 LIQUOR LIABILITY $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Eaaccl4enl BODILY INJURY (Per parson) $ X ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS 810-7C399875 01/01/2019 01/01/2020 BODILY INJURY(Peraccidem) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident $ X1 UMBRELLA LIAR 11 XI OCCUR EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 B EXCESS LIAa CLAIMS -MADE ZUP-91M48908 01/01/2019 01/01/2020 DED RETENTION $C: EXCESS $ 35,000,000 A WORKERS COMPENSATION YIN AND EMPLOYERS' LIABILITY ANYCERIM5ETOREXCLUDED? CUTIVE ❑ OFFICER/MEMBER EXCLUDED? entlatoryln NH) NIA UB -9H942545 01/01/2019 01/01/2020 PER OTH- %� STATUTE ER EL. EACH ACCIDENT $ 1,000,000 E.L. DISEASE $ 1,000,000 It yes, D DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 WORKERS COMP & EMP LIAB BI by Accident/Accident $1,000,000 D MASSACHUSETTS ONLY 014000502016119 01/01/2019 01/01/2020 BI by Disease Policy Liml $1,000,000 BI by Disease /Employee $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is mqumd) E: WORKERS COMP NH ONLY, 030009100240119,111/2019 -1/1/2020, $1,000,000/$1,000,000/$1,000,000 POLICY LIMITS IN EFFECTAT POLICY INCEPTION. CERTIFICATE HOLDER CANCELLATION ©1968-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 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 ©1968-2016 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT Business/ Food Establishment Name: Address: C, _ Mailing Address: 1CQ %,W,04ire Phone/FaxNumber:'779-d—oC l,.P03f _ Email: rAc QMV16 •1a 00 Contact Person/Title for Grease Tra Name of Company scheduled to pump internal grease trap(s) monthly: Ot n& &P Ir Name of Company scheduled to pump external grease trap quarterly: Please attach the following clocuments 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 $so 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 Date 1110,50 �) Print Name 1 lk YA —vol ar 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 ky� — 1 Thursday m— .30PO Sunday joLnad Tuesday l4w' i.'3oom Friday fifh- 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 n0 3 compartment sink Handwashing sink Ylp Commercial Dishwasher _ Bar sink nb Mop Sink — -- (� no np Garbage Disposal Ice Making Machines nQ Fryolators y\Q _ Grills or Ovens Y)v 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 If yes, at what station/sink? �ryQA 2 No 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)? Yes K 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? Ck ! 141 Flow often is this grease storage unit emptied? 1�),UO f �\\j Please list the vendor who removes the waste: %V.Pr5 COmMO&I o2� Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 3 _wrrl �/y4QY1� S&nL Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes K 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? Ck ! 141 Flow often is this grease storage unit emptied? 1�),UO f �\\j Please list the vendor who removes the waste: %V.Pr5 COmMO&I o2�