HomeMy WebLinkAboutNY Pizza - 12/31/2020r
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATIONr
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name N V PNL2a
/� 1
Establishment Address 2,1 Al Mal" MAv151 1e'd M a ®io4,7
Establishment Mailing Address (if different) 2; w�
Establishment Telephone No
Applicant Name & Title: Ma kw I
Applicant Address 3-7 .Q SA0611MaY'e of 12@4/eY�e %�A O-210
Applicant Telephone No.: G I7-S � 2 - 3 9 3,0 24 Hour Emergency No.:
Applicant Email op f4 f c,A. 4, vf- eb t_ 4 w o, I - Crar^
U
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
10 An Association
partner.
W-A Corporation
Name Title /I Address qq
An Individual
t4/ eJ✓ +q7 9 S re Y
jzty.dA)5 f
I APartnership
�)114
E Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 1�► pdQE�p %� A SS cn�
Address: !�
Telephone No: 6 0 U 24 Hour Emergency No:
FAX:
E-mail: 6-0 :514 1 i/P'✓� (1 Q tv a � � . Ca r^^
Y
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: �awh
SEWAGE DISPOSAL: TO W
No. of Food Employees: b
DEP Public Water Supply No: (if applicable)
DAYS/HOURS: /'gyp r,dey -�e Sa 4 rJ0+J '1 to _ lov- SIA✓C6!, (^2pti 9p W,
_ — —
Name of Person(s) In Charge Certified in Food Protection Management: ne l a vo-ftl apsee�//
Name of Person(s) In Charge Certified in Allergen Awareness Training /his pW--gat t % A SS'GG/ i
Name of pest control company routinely inspecting the premises for evidence of pests F A-.d Ia.✓
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. IN Yes
Does this establishment require a FOG permit?_ If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
WLAnnual
Retail Food $125.00 ® Mobile Food Consession
Rfl Temporary
QC Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
z $25.00/freezer
Food Service up to 101 -200 $250.00
Temporary End Date:
❑"L Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Q Supermarkets $400 H Residential Kitchen $100.00
Rain Date:
"Yvlilk &Cream $10.00 [A Caterer $35.00
Food Operations: Definitions:PHF-Potentially hazardous food dimeRemperature controls required)
(Check all that apply): Non-PHFs -non-potentally hazardous food(no tlme/tempemture controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
4a Sale of Commercially Pre -Packaged Non-PHFs .KL PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs I2g Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
of
Sale of Raw Animal Foods Intended Susceptible Population Facility
G7 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
0 Customer Self
-Service Customer Self -Service of Non PHF and Non- contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for control)
G;[ Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Q Vacuum Packaging /Cook Chill
0 Offers RTE PHF in Bulk Quantities 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 690.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62 sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns
and paid state taxes required under law. 2t 1,p 9��y
Social Security Number or Federal ID: -- _!— ( —1 1,9 `^'/f tJ� Signature of Individual or Corporate Name: —
Town of Mansfield Health Department
APPLICATION FOR FATS, OILS, and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
Address:_,-'Z"2 rI e /tA ( 0 S 0 JA Y1/—'I - 1 fl 1 t i ' AA jz t`7T2
Mailing Address: ,r� m Cf A''vl S" I i'.1, -) i- J ti oX V 2
Phone/Fax Number: I 'Q Lf — 33 q — -S7570 n7
Email:
Contact Person/Title for Grease Traps: &Lam e ( Vj sS-4 0 I
Name of Company scheduled to pump internal grease trap(s) monthly: ,Q IV _4!21l /S BL S e-' I ')IA �1 C
Name of Company scheduled to pump external grease trap quarterly: ay ( I 42('�
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.
Date ,.
Print Name � /;) laMn ( 1.4 a S ! 7'"/
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 ,' PYN Tuesday //am y Wednesday //at,, — %`
Thursday �Lc _�IUAK' Friday H0104 Saturday
Sunday
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
i 16
Handwashing sink
d
Commercial Dishwasher
Bar sink
D
Mop Sink
Garbage Disposal
O
Ice Making Machines
vG
NU
Fryolators
2
A16
Grills or Ovens
%/U
Exhaust Hoods
U
1VV
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? t% Yes No
If yes, at what station/sink?
6
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 l
D'1u 'r�z�''-4- z'11,C`
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 V No Size n 4" 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 Addres
Property Owner's Telephone Number: r7 j i - 9 9 R - X<Q
Yellow Grease Waste
Do you store yellow grease waste from fryolators? V P h 7
Where is the grease storage unit located? RtAA'/ v h C 'ii'ke �h ( t i t h e V\ P_
How often is this grease storage unit emptied? LAt-& 0 1416 J"/ �+ L1
Please list the vendor who removes the waste: ect, f I I �1 r! VI C
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses,
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leaibly
Business/Organization Name: p n� O 1M I TVI C:_—
Address: ,2 Z I Y\1'4'r M A ( P1 s, (—
City/State/Zip:_14& o S r'i'� li 40 ? DUphone #: 2,013
Are you an employer? Check the appropriate box:
I M-1 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.]
Business Type (required):
5. ❑ Retail
6. ❑Restaurant/Bar/EatingEstablishment
7. ❑ Office and/or Sales (Incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
1 I.❑ Health Care
1213 Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
'"Irthe corporate often have exempted themselves. but the corporation has other employees, a workers' compensation pot icy is required and such an
arganimion should check box 01.
I am an employer that is providing workers' compensatton insurance for my employees. Below is the policy Information.
Insurance Company
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. 0 Expiration Date:
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
Investigations of the DIA for insurance coverage verification.
do hereby certify, unnder the
of perjury that
OfJIctal use only. Do not write In this area, to be completed by city or town ofnclat.
City or Town:
Permit/License
above is true and correct.
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:
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.
Signa ure of individual or Corporate Name By: Corporate Officer (Mandatory, IF Applicable)
'9�-A�94�a42.
Social Security Number (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.
p�_N
4COFz� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YVYY)
�'- 11/27/19
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, 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 endomement(s).
PRODUCER
NAME:
Robert M. Zagami Insurance Agency
555 Bridge Street
Weymouth, MA 02191
PNCN o e.t ; 781.337-0033 FAX Not: 781.337-4103
E-MAIL
ADDREsS: bzagaml@rmzinsurance.com
INSURERS AFFORDING COVERAGE
NAIC0
INSURERA : AM Guard I NorGuard
INSURED
INSURER B :
_
INSURERC:
Ram! Inc
dba NY Pizza
221 North main St
INSURER D:
INSURER E :
Mansfield, MA 02048
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. NOTWTHSTANDING 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.
LTR
TYPE OF INSURANCE
INSD
MD
POLICY NUMBER
MM/DD/YYYYI
IMMIDDIYYYYILIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE 7 OCCUR
EACH OCCURRENCE
5
ET6RERrE
PREMISES Ea occunenw)
$
MEDEXP An me emon
$
PERSONAL&ADV INJURY
8
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ J.�T LOC
OTHER:
GENERAL AGGREGATE
$
PRODUCTS -COMP/OPAGG
$
$
AUTOMOBILE
LIABILITY
ANY AUTO
EDULED
OWNED AUTOS ONLY SCAUTHOS
HIRED NON -OWNED
AUTOS ONLY At/TOS ONLY
COMBINED SINGLE LIMIT
Ea acGtlent
$
BODI LY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPER D
Per accident
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEC) I
I RETENTION$
$
A
WORKERS COMPENSATION
ANDEMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER
(Mandatory in NH)
ifya5 describe under
DESCRIPTION OF
VIN
EXCLUDED? �
OPERATIONS below
NIA
RAWC087023
11114/19
11/14/20
PER OTH-
X STATUTE ER
E.L. EACH ACCIDENT
$ 100,000
E.L. DISEASE -EA EMPLOYEE
$ 100,DDD
E.L. DISEASE -POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional RemarksSchedule, maybe attached if more space Is required)
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.
01988-2016 ACORD CORPORATION. %11 rjdhts reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
MOHAMED HASSANI
PROMETRIC
0
Exam 6702 Recognized By Conference For Food Protection
Certificate No: 2078485
Exam Date: 11/17/19
Ryan McMillian, Client Services Manager Test Code: 6203046702
Expires on: 11117/24
Pfhmetr?G t 7941 Corporate Drive, Nottingham, MD 21236 1 800.624.2736
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F?VAW
PEST CONTROL
Commercial Pest Management - Service Agreement
Agreement #18-4560
Prepared For
Prepared By
New York Pizza
F&W Pest Control - Wrentham
Youssef Hassan!
Michael Harris
221 N Main St
190 Industrial Road
Mansfield, MA 02048-2214
Wrentham, MA 02093
bostonlivery@gmail.com
michael.harris@fwpest.com
(401)369-2537
774-847-5004
Service Location: 221 N Main St, Mansfield, MA, 02048-2214
Item
Qty
Frequency
Initial
Recurring
Extended
COM (Commercial IPM Service)
1
12
$95.00
$50.00
$645.00
Initial Total $95.00
Recurring Total $550.00
Extended Total $645.00
Pest Coverage Service Frequency Scheduled Months
Ants, Mice, Rats, Roaches, Silverfish Monthly (12) Jan, Feb, Mar, Apr, May, Jun, Jul,
Aug, Sept, Oct, Nov, Dec
Square Footage
700
Page 1 of 3
Commercial. Service - General Terms and Conditions
PAYMENT
In consideration for service to be provided by F&W, the Customer agrees to pay to F&W, Inc., its successors or assigns, as
outlined above per service location. Payment shall be due upon receipt of invoice.
OFFER EXPIRATION
F&W's offer to perform these services in accordance with the terms, conditions and price stated in this Agreement shall
expire if not accepted within 30 days.
F&W's MONEY -BACK GUARANTEE
If, during the regularly scheduled visits, the Customer is not satisfied with the results, F&W will return to treat the area again
at no extra charge. Such service visits shall be made promptly when requested by the Customer. Should the problem
persist, F&W will continue to work to solve the problem to the Customer's satisfaction or F&W will refund the Customer's
last monthly payment.
CUSTOMER COOPERATION
The Customer agrees to cooperate fully with F&W to insure effective results from the Pest Control service. In order to
qualify for the Money -Back Guarantee, the Customer agrees to maintain its premises as recommended by F&W in the
Housekeeping and Maintenance Survey Report originally provided to Customer and as recommended by F&W in its Pest
Control Inspection Reports. The Customer agrees that F&W may withhold any and all refunds until its recommendations
have been accomplished.
PEST DAMAGE
The Customer agrees that F&W is not responsible for insect or rodent damage or disruption to its operation, premises or its
contents, and the Customer specifically releases F&W from liability for any such claims.
DOCUMENTATION
Upon request, F&W shall furnish to the Customer a certificate of insurance coverage in effect and any Safety Data Sheets
(SDS's) or Labels requested.
MATERIALS
The materials used to control pests in and around Customer's premises shall conform to Federal, State, and local laws and
regulations, and shall be used with all due precautions to avoid the possibility of accident to humans, domestic animals and
pets.
TERM OF AGREEMENT
This agreement shall be effective for an original period of on year, Thereafter, this agreement shall renew itself from month
to month until terminated by either party upon sixty days' written notice.
Massachusetts - Consumer Information Bulletin For Indoor Applications
The Massachusetts "Regulations Relative to the Commercial Application of Pesticides to Indoor Setting" (333 CMR 13.10)
requires you to receive this notice before performing a pesticide application.
https://www mass gov/files/documents/2016/08/nu/cib-indoor pdf
X41
Initial
Notes
Monthly IPM program, initial service is Wednesday 11/6 between 8-10am. Customer will pay at time of each service. Thank
you
Page 2 of 3
Initial Payment Due: $95.00
Recurring Payment: $50.00
Approved By
10/31/2019
Youssef Hassan! Date
Approved By
MUM (¢ems 10/31/2019
Michael Harris Date
F&W Pest Control - Wrentham
Page 3 of 3
Ru;ycGn0 L
oa
SERVICE AGREEMENT FOR JAMAICAN RESTAURANT
The agreement is made by and between DJV OIL RECYCLING INC. and NY Pizza hereby referred to as
"ESTABLISHMENT".
General: DJV OIL RECYCLING INC. Agrees to collect the used cooking oil from the establishment in the amount
written below. THE ESTABLISHMENT agrees to keep the container of DJV OIL RECYCLING INC. on their premises
and pour into them only waste vegetable oil (used cooking oil) free of other liquids, water, food waste, grease
from traps etc. THE ESTABLISHMENT will also not allow anybody else to collect waste vegetable oil from its
premises for the term of this AGREEMENT.
SERVICE PROVIDED BY DJV OIL RECYCLING INC.: DJV OIL RECYCLING INC. agrees to clean grease
trap/interceptor, and collect the waste vegetable oil from the NY Pizza . NY Pizza agrees to provide
unobstructed access to the containers and keep them safe.
TERM OF THE AGREEMENT: This agreement is on an open term, beginning in the date written below, unless
either party gives oral or written notice to the other to terminate the AGREEMENT effective thirty (30) days prior.
This agreement will continue in full effect otherwise.
A EXCLUSIVE RIGHTS AND PROPERTY OF DJV OIL RECYCLING INC: NY Pizza agrees that DJV OIL RECYCLING INC.
is its exclusive oil collection provider. NY Pizza acknowledges and agrees that DJV OIL RECYCLING INC is providing
the services in return for obtaining the exclusive rights in and possession of the used oil generated by NY Pizza
identified herein during the term of this agreement.
COLLECTION SCHEDULE: Every _3_ weeks as needed, the ESTABLISHMENT can contact D1V OIL RECYCLING
INC. at (774) 578-2409 especially if collection container(s) become full and need immediate pick-up. DJV OIL
RECYCLING INC. will collect the oil within 24/48 hours after such notice.
PAYMENT: DJV OIL RECYCLING INC. agrees to only charge 25,00 dollars instead of full payment. Cooking oil
payment collected from NY Pizza will be waived. NY Pizza and its employees will be mindful to not put water,
food waste, grease from traps, soap, or any other substance that is not used cooking oil in the containers of DJV
OIL RECYCLING INC. Please note that DJV OIL RECYCLING INC. pays for the used cooking oil only and not for other
contaminants which may be inside the containers.
Restaurant's Owner/Manager: Name6 40 k? )P (i / a S seil
Restaurant Owner/Manager Signature:_ / e ^%
DJV OIL RECYCLING INC. Representative. —Elvis A
GREASE TRAP/INTERCEPTOR MAINTENANCE LOG
PROVIDER NAME: DJV Oil Recycling INC.
ADDRESS: 61 Fremont st Worcester, MA 01603
PHONE NO.: 774-578-2409 FAX:774-530-6020
TYPE OF
GREASE UNIT (S): GREASE TRAP GREASE INTERCEPTOR BOTH
DEPTH OF WATER IN UNIT (inches):
DATE
PERFORMED
DESCRIPTION OF WORK
DEPT OF
GREASE
REMOVED
(inches)
DEPTH OF SOLIDS
REMOVED
(inches)
MANAGER'S
INITIALS
11/819
Grease traps clean up
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