HomeMy WebLinkAboutTrattoria Romano Pizzeria Bar & Grill - 12/31/2021OONN( evle°v
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FOR BOARD OF HEALTH USE ONLY Permit # Issued
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I FOOD ESTABLISHMENT PERMIT APPLICATION
��� " (Application must be submitted at least 30 days before the planned opening date)
Establishment Name "Tteh+2' t L
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Establishment Address (,,fit 04 � k 9 '-4
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Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title:
Applicant Address a"7 14
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Applicant �' � Y t Telephone No.:Sq/�y
a
24Hour-E��( mergencyNo.:�-,t�. _l
Applicant Email
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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
O An Association
partner.
Ig A Corporation
Name
Title Address
H An Individual
w r° ( f+--
❑t A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations
(owner, person in charge, supervisor, manager etc.)
Name & Title:5C �ft
Address:
Cf
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: (J
24 Hour Emergency No:
FAX:
E-mail:
M
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOU S:
Name of Per on(s) In Charge Certified in Food Protection Management:
Name of Person( In Charge Certified in Allergen Awareness Training
Name of pest control com ny routinely inspecting the premises for a Idence of pests
If there is seating for 25 peop or more, a person trained in manu choke saving procedures will be onsite at all times
food is being prepared. O Ye
Does this establishment require a F permit? f yes, please attach the FOG permit application.
Length of Permit:
stablishment pe:
L7 Annual
F4 etail Food 25.00
M Mobile Food Concession
[1 Temporary
❑L3-- Fee Se ' e up to 100 INCLUDING
NO PHF PREPARED ON SITE $100,00
FOO T UCKS $175.00
O Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
. / Food e e up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Fo Service p to 201 + $300.00
Pushcart $50.00 # of Pushcarts:
Temporary Time:
tsi permarkets $400
Residential Kitchen $100.00
Rain Date:
Milk & Cream $10.0
Caterer $35.00
Food Operations: Definitions: PHF-Potentially azardous food(fimertemperature ntrols roquired)
Check all that a Non-PHFs - no potentially hazardous food(no fime/te nature controls required)
( apply): RTE - ready-t eat foods (Ex. sandwiches, salads, r which need no further processing)
Sale of Commercially Pre -Packaged N n-PHFs Tg PHFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
LI Sale of Commercially Pre -Packaged HFs Preparation of PHFs For Hot An
for More Than a Single Meal Service
Cold Holding For Single Meal Se ice
PHF and RTE Foods Prepared For Highly
s3 Delivery 9 of Packaged PHFs
Susceptible Population Facility
Sale of Raw Animal Foods Intends
Q Reheating of Commercially to be Prepared by Consumer
0 Use of Process Requiring A Variance
Processed Foods for Servile ithin 4 Hours
and/or HACCP Plan (including bare hand
C.❑_' Customer Self -Service
c-7 Customer Self -Service o on PHF and Non-
contact alternative, time as a public health
Perishable Foods Only 0 Ice Manufactured and Packaged for
control)
Q Preparation of Non- HFs Retail Sale
"❑�1" ens Raw Or Undercooked Food Of
0 Juice Manufactured and Packaged for
Ani al Origin
Other Food Op ations Retail Sale
Q Vacuu Packaging /Cook Chill
0 Offers RTE PHF in Bulk Quantities
i09 Prepares ood/Single Meals for
Q Retail Sale of Salvage, Out -Of -Date
Catered Ev is 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 CMR 590.000 and the federal Food Code.
Signature of Applicant: \S
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 stale tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL: Psi i
DEP Publ c Water upply No: (If applicable) No. of Food Employees (�
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Nm')AA"-A Aodl # i�
`
_` FA�'�lut
Name of Person(s) In Charge Certified in Allergen Awareness Training
offlimfh..AUt7L�jP uX
��7A 1 h( '_M 1IIt
Name of pest control company routinely inspecting the premises for evidence of 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. G✓✓Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
,Annual
0 Retail Food $125.00
I Mobile Food Concession
0 Temporary
frj Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
FV�Food Service up to 101 -200 $250.00
Manufacture Frozen Desserts/Ice Cream
❑ $25.00/freezer
Temporary End Date:
[_] Food Service up to 201 + $300.00
❑a Pushcart $50.00 It of Pushcarts:
Temporary Time:
171 Supermarkets $400
I],' Residential Kitchen $100.00
Rain Date:
EJ Milk &Cream $10.00
� Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non PHFs -non-potentially hazardous lood(no fime'remperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
,�/
y Sale of Commercially Pre -Packaged Non-PHFs I' F HFCooked To Order
of PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs reparation of PHFs For Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service
I] PHF and RTE Foods Prepared For Highly
0 Sale of Raw Animal Foods Intended
Reheating of Commercially
Susceptible Population Facility
to be Prepared by Consumer
Processed Foods for Service Within 4 Hours
[ lJ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
..j Customer Self -Service of Non PHF and Non- 0 Customer Self -Service
contact alternative, time as a public health
rishable Foods Only 0 Ice Manufactured and Packaged for
control)
VP
' Pre aration of Non-PHFs Retail Sale
p
0 Offers Raw Or Undercooked Food Of
[] Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
V cuum Packaging / Cook Chill
0 Offers RTE PHF in Bulk Quantities
i epares Food/Single Meals for
0 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 co ply with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obt copie of 1 5 CMR 590.000 and the federal Food Cotle.
Signature of Applicant: _
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:.p ` �� X
Signature of Individual or Corporate Name: Z 2P �lJ
----- ----- - -- --
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name
Establishment Address
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title:
Applicant Address
Applicant Telephone No.:
Applicant Email
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
24 Hour Emergency No.:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
it€} An Association partner.
Iw'I A Corporation Name Title Address
jl An Individual
A Partnership
oLl Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
24 Hour Emergency No:
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 15y: Corporate Officer (Mandaton/, if Applicable)
gV,. m5-%0���
**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:\Usem\sleite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip:
0
Phone #: �6 talc - 1(1,'Z�.
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. �estaurant/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] $• ❑ 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]* 11.❑Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #1 most 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 the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. # 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.
I do hereby ert' y, niter the pains and penalties ofperjury that the information provided above is true and correct
Cionahrre• DntP• -)gggd112.r"Tiw
Phone #: 3'(L-iIfi (/' z! 7 1y✓
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
Information and Instructions
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 more
of the foregoing engaged in ajoint 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 carry 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-NIASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
•..
e hek.,
I W1
Mailing Address:
Phone/Fax�.Nujmber: ' 1oq
Email• LJCd?*F Q �'�zs ttG�,iei s r r1i `\ XoyrN
Contact Person/Title for Grease Traps: lxy' (��r (Xa�
Name of Company scheduled to pump internal grease trap(s) monthly:
Name of Company scheduled to pump external grease trap quarterly: N
Please attach the following documents to this application:
• Most recent waste hauler receipt orwaste 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 acknoyjledge�s that the information submitted in these documents is true, accurate and complete.
Print Name �� Sl��b
Date ' Y 2oz-
`P %
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 CAo�q
Thursday (» —
P
Sunday jp t .•��i
Tuesday , sftaj_ d cif
Friday "a• (( P(Y)
(11
Wednesday' g v\
Saturdayi1 t r s
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
1
3 compartment sink
Handwashing sink
9
f ty
Commercial Dishwasher
Bar sink
3
Mop Sink
d�
Garbage Disposal
v ?
Ice Making Machines
Fryolators
Grills or Ovens
Exhaust Hoods
1
Floor drains
Other: (' '( 1r "
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
011Cade (L)
Is dinnerware pre -rinsed before
If yes, at what station/sink?
washed? Yes
tyke
2
M
Grease Traps 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
;mi
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? Y% 5 k Where is the grease storage unit located? Q041h "'
How often is this grease storage unit emptied? L
Please list the vendor who removes the waste: UIVA5� 'wa' d
Documents to Assist with Illness Reporting Policy
According to the 2013 FDA Food Code:
2-201.11 Responsibility of Permit Holder, Person in Charge, and Conditional
Employees. [590.002(E)]
(A) The PERMIT HOLDER shall require FOOD EMPLOYEES and CONDITIONAL
EMPLOYEES to report to the PERSON IN CHARGE information about their
health and activities as they relate to diseases that are transmissible through
FOOD. A FOOD EMPLOYEE or CONDITIONAL EMPLOYEE shall report the
information in a manner that allows the PERSON IN CHARGE to reduce the
RISK of foodborne disease transmission, including providing necessary
additional information, such as the date of onset of symptoms and an illness, or
of a diagnosis without symptoms...
The code goes on to outline symptoms and illnesses that must be reported to the
Person in Charge. It also describes when an employee should be excluded or restricted
in their duties.
Forms 1-A through 1-C are designed to assist those responsible for managing
employees in order to prevent foodborne disease. The Food Code specifies that the
permit holder is responsible for requiring conditional employees or food employees to
report certain symptoms, diagnoses, and past illnesses, as they relate to diseases
transmitted through food by infected workers. The conditional employee or food
employee is personally responsible for reporting this information to the person in
charge. These documents can be found in the 2013 FDA Food Code Annex 7.
FORM Conditional Employee and Food Employee Interview
1-A
Preventing Transmission of Diseases through Food by Infected Food Employees or Conditional Employees with
Emphasis on Illness due to Norovirus, Salmonella Typhi (S. Typhi), Shigella spp., ShigaToxin-producing Escherichia coli
(STEC), nontyphoidal Salmonella or Hepatitis A Virus
The purpose of this interview is to inform conditional employees and food employees to advise the
person in charge of past and current conditions described so that the person in charge can take
appropriate steps to preclude the transmission of foodborne illness.
Conditional Employee Name (print)
Food Employee Name (print)
Address
Telephone Daytime: Evening:
Date
Are you suffering from any of the following symptoms? (Circle one)
If YES, Date of Onset
Diarrhea?
YES / NO
Vomiting?
YES / NO
Jaundice?
YES / NO
Sore throat with fever?
YES / NO
Or
Infected cut or wound that is open and draining, or lesions
containing pus on the hand, wrist, an exposed body part, or
other body part and the cut, wound, or lesion not properly
covered? YES / NO
(Examples: boils and infected wounds, however small)
In the Past:
Have you ever been diagnosed as being ill with typhoid fever (S.Typhi) YES / NO
If you have, what was the date of the diagnosis?
If within the past 3 months, did you take antibiotics for S. Typhi? YES / NO
If so, how many days did you take the antibiotics?
If you took antibiotics, did you finish the prescription? YES / NO
History of Exposure:
1. Have you been suspected of causing, or have you been exposed to, a confirmed food borne disease
outbreak recently? YES / NO
If YES, date of outbreak:
a. If YES, what was the cause of the illness and did it meet the following criteria?
Cause:
I. Norovirus (last exposure within the past 48 hours) Date of illness outbreak
ii. E. coil O157:1-17 infection (last exposure within the
past 3 days) Date of illness outbreak
ill. Hepatitis A virus (last exposure within the past 30 days) Date of illness outbreak
iv. Typhoid fever (last exposure within the past 14 days) Date of illness outbreak
v. Shigellosis (last exposure within the past 3 days) Date of illness outbreak
I
If YES, did you:
I. Consume food implicated in the outbreak?
ii. Work in a food establishment that was the source of the outbreak?
ill. Consume food at an event that was prepared by person who is ill?
2. Did you attend an event or work in a setting, recently where there
was a confirmed disease outbreak? YES I NO
If so, what was the cause of the confirmed disease outbreak?
If the cause was one of the following five pathogens, did exposure to the pathogen meet the
following criteria?
a. Norovirus (last exposure within the past 48 hours)
YES I NO
b. E. coli O157:1-17 (or other STEC (last exposure
within the past 3 days)
YES / NO
c. Shigella spp. (last exposure within the past 3 days)
YES I NO
d. S. Typhi (last exposure within the past 14 days)
YES I NO
e. Hepatitis A virus (last exposure within the past 30 days)
YES I NO
Do you live in the same household as a person diagnosed with Norovirus, shigellosis, typhoid fever,
hepatitis A, or illness due to E. co11O157:H7 or other STEC?
YES / NO Date of onset of illness
3. Do you have a household member attending or working in a setting where there is a confirmed
disease outbreak of Norovirus, typhoid fever, shigellosis, STEC infection, or hepatitis A?
YES / NO Date of onset of illness
Name, Address, and Telephone Number of your Health Practitioner or doctor:
Name
Address
Telephone -Daytime: Evening:
Signature of Conditional Employee
Signature of Food Employee
Date
Date
Signature of Permit Holder or Representative Date