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HomeMy WebLinkAboutGeno's Restaurant - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued V 1 G 2( OD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) EstablishmentName QC—v)cj� t��'sTR�t�4iy� Establishment Address "t CFZ t/lc atW tti' 4V'j :5,(— Establishment Mailing Address (if different) Establishment Telephone No S O P,' 3 3 c' g �7 L Applicant Name & Title: _4e� rt'^ 5 tP1<-2C b Applicant Address -15/+_I-^ C Applicant Telephone No.: 5 ODE2 `f( -32--Z`f 24 Hour Emergency No.: Applicant Email isG—✓tGS 0c) x'904-- `C_db "y 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 An Association partner. 11 A Corporation Name Title Address Individual A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 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: into, —t `? ` f ; a :M c -A -I " >s j _ "" t �. ..� ti Ga rtn " %a ,M f.. ) , Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training 5 Gf1 1 Name of control company routinely inspecting the for evidence of ` 10 54('/1 k d-1 pest premises 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? t/ If yes, please attach the FOG permit application. Length of Permit: I Establishment Type: r -Annual rail Food $125.00 Mobile Food Consession Temporary 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 E] Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: EJ Food Service up to 201 + $300.00 ❑Pushcart $50.00 it of Pushcarts: Temporary Time: Supermarkets $400 E] Residential Kitchen $100.00 Rain Date: 'Milk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous rood(time/temperature controls required) (Check all that apply): Non-PHFs -non-potenlfally hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs 6Z PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hol Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service ILS Y 9 [•_.l P Delivery of Packaged PHFs Cold Holding For Single Meal Service E] 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 and/or HACCP Plan (including bare hand U 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) 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 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 obtain copies of 105 CM3 590.000_�no the fe l Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, lertif/r/tit and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns %7'( * vCa 8 21f "P 5'� the Coutnionweattu oftvlassacttusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwtv.inass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information n Please Print Legibly Business/Organization Name: Ge4c) Address: 40,11 �/ 04>/z'f t,( 04y q m 5 f City/State/Zip: VI G 1-115 t `eyo /44 61041tihone t S e5a ^ 3 37— 8 7`7, Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with �2 employees (full and/ 5. ❑ Retail or part-time).* 6. urant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑ 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 c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 110 Health Care with no employees. [No workers' comp. insurance req.] 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. Into an employer that is providing ivorkers'compensation insuranceformy employees. Below is the policy information. Insurance Company Name: �Lai P— e Insurer's Address: .7 Z� 1� ty —"2, 10,41a City/State/Zip: Policy # or Self -ins. Lic. # W CA 9 COO -75 7 Expiration 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. I do hereby certify, un the ains an collides `oof perjury that the information provided above is true and correct. Signature: q Date: l I L C� t Phone #: 5 — 3 2.Z / Official use only. Do not write in this area, to be completed by city at- 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. 4a�� Sign A of Individual rCor late Name 'l,�jC � a ct 7- 73 6Z 7C t;'o (4 5C) 43 "Social Security No. (Voluntary) or Federal Identification Nuteber By: Corporate Officer (Mandatory, if Applicable) *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:\Uscts\sleite\Desktop\Scolrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Town of Mansfield Health Department �'6 91141Irelln 1 11 , ) , 4-jkvill Business/ Food Establishment Name: C� Tm S p cwel� "u� Address: +0�t d naa-i t- M4P,44 f��i 57F— Mailing Address: �"° 4 Phone/Fax Number: u oa - 3,5 Z ~ 9 77 Email: GEvilo5 :3b 4t 1-k,(-. Contact Person/Title for Grease Traps: -� C> i-Lt.1 5P(C2-( C7 Name of Company scheduled to pump internal grease trap(s) monthly: I -„L fcK?e-ts""l 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 vi�Z' Date 41�C /or Print Name 'Ae3 (-1 A .5' To / C`Z-( O Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or snore of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' workers' compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia 4orm Revised 5-26-05 Nd ity 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): 6b -I Std Seating Capacity (Actual Count): 56 T 5� Normal Hours of Food Preparation/Service: Monday tI- ICD "7koA`rfuesday Thursday Sunday Friday 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 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators 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): 19u- `i�SK6 V& It CLC -A [ g L Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? FA Yes No Grease Trans and Grease Remy 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 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? rlZ�, Where is the grease storage unit located? k-c-t't e --VN, How often is this grease storage unit emptied? UK* Please list the vendor who removes the waste: `e- LC IjC C is 9&vI c0A &LC>5 Please list fixtures attached to each grease trap Grease Trap 1 ri C-4 "It «`� r 14C'(— 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 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? rlZ�, Where is the grease storage unit located? k-c-t't e --VN, How often is this grease storage unit emptied? UK* Please list the vendor who removes the waste: `e- LC IjC C is 9&vI c0A &LC>5 i WF N C w O; gg "C w ui N fix., O N�. 9 O N C O; CD "C w o O O 2 � \ LW \ � � � (/ 7 / 2 i© o /N m2 � \ LW \ � � ntiold t ric El"kh I P'.St. X l western The L,,—Is m Peal COWmI BOSTON PEST,30 POND PARK RD,MA,02043-4340 99,(800)649-7228 0000,(781) 331-8321 Servicing Branch 4047 Customer GENOS RESTAURANT & LOUNGE 407 N MIAN ST MANSFIELD MA 02048-1945 44-20059 Contract Number Premise Number Visit Type Visit Date 013736905 SERVICE MAINTENANCE 07/17/2019 Order Number Status Service Date Report Description _ 48070991000 Completed 07/17/2019 COMMERCIAL PEST GENERAL MAINTENANCE SERVICE Materials Used No preparations used during this service Treatment Notes Service performed 7 17 19 at 700 am. Unable to scan location as device not working, Time In Time Out Customer Signature Unavailable technician Signature 07/17/2019 02:45 PM 07/17/2019 02:47 PM Key Account 07-17-2019 l 4:47:38 with thanks, STEPHEN LEVESQUE Rontokil Steritech Eh'kh I Oresto X I Western Th,, E......1, In f"', COnV01 BOSTON PEST,30 POND PARK RD,MA,02043-4340 99,(800)649-7228 0000,(781) 331-8321 Servicing Branch 4047 Customer GENOS RESTAURANT & LOUNGE 407 N MIAN ST MANSFIELD MA 02048-1945 44-20059 Contract Number Premise Number Visit Type Visit Date 013736905 SERVICE MAINTENANCE 09/18/2019 Order Number Status Service Date Report Description 49046577000 Completed 09/18/2019 COMMERCIAL PEST GENERAL MAINTENANCE SERVICE Device Summary Device type With activity Without activity Unserviceable Total inspected Worksite Inspection Point 0 1 0 1 Materials Used _Material Used epa lot # Dilution % Concentrate Quantity Unit Method Target Maxforce Fly Spot Bait 432-1455 10.0 8.0 8.0 oz Spot Miscellaneous i flies, Miscellaneous -night flying Device: Insp. Pt. Kitchen Hardware: Aerosol Active Ingredient: Imidacloprid Treatment Notes Inspection of Kitchen, Bar and Basement areas. Replaced Monitors throughout the Facility. Please keep areas clean to help prevent Pests. Time In Time Out Customer Signature Unavailable technician Signature 09/18/2019 06:53 AM 09/18/2019 07:19 AM Key Account 09-18-2019 07:18:27 with thanks, STEPHEN LEVESQUE Rentokil Steritech EhOlch i Pfe5t0.X i Western The Ee11111 in Pest Conlrul site BUILDING, MAIN, FOOD PREP Detailed Inspection Results Device Time Pest I Am Quantity Infestation Level Insp. Pt. 07:04 AM No activity found Kitchen Customer INFO Name Address City, ST Zip TRAP CONDITIONS: GASKET: FO FaT-Wk llfecyclerenewables C� PO BOX 1144, MARBLEHEAD, MA 01945 888-461-98311 service@lifecyclerenewables.com I lifecyclerenewables.com GREASE TRAP SERVICE TICKET SERVICE DATE: TECHNICIAN:; GOOD DEPTH in INCHES: DEPTH in INCHES: ( ' ) SITE INFO Name: Address: City, ST Zip: Contact: Phone Phone NEEDS REPLACEMENT SUTIL0 SOLIDS DEPTH in INCHES: GALLONS GPM TRAP MANUFACTURER TRAP CLEANING: SCRAPE SIDES CLEAR INLET REMOVE BAFFLES CLEAR OUTLET SCRAPE BAFFLES REPLACE BAFFLES( LEAKS (Y) (N) LOG COMPLETE I PROPER FLOW: TEST( RUST (LIGHT) (MED) (HEAVY) SECURE LID ------------------------------------------------------------------- ----------------------- NOTES: x ��'V- 09 CUSTOMER SIGNATURE / DATE > 3 CL Q [ ` p f / 3 CL 7 0 \ « E (ri / / .\ (« :ƒ - t \ r �—k\\ -,o ol mZc \D r�£ ©km # (ƒM � 2 \ > 3 CL Q [ ` p f / 3 CL 7 0 \ « E (ri