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HomeMy WebLinkAboutJersey Mike's Subs - 12/31/2021UPDATED FOOD ESTABLISHMENT PERMIT CONTACT INFORMATION (Health Department should be notified within 10 business days of change in managementation ) Inno,f1 T Nrn JU Establishment Name: Jersey Mike's Subs -01' Establishment Address: 333 School Street, Suite 130 Mansfield, MA 02048 a 7 different): - - Nor----.,,.. Establishment Mailing Address (if j Establishment Telephone No: 508-452-1352 Applicant Name & Title: Alexandra Doucette Applicant Address: 4 Crocker Street Taunton, MA 02780 Applicant Telephone No.: 508-452-1352 24 Hour Emergency No.: 508-567-7613 Applicant Email: alex@coggeshailgroup.com Owner Name & Title (If different from applicant): Randall K. Scott (co-owner) Owner Address: 8 Linden Lane, Rehoboth, MA 02769 Owner telephone number: 401-651-1174 Owner email: randy@coggeshallgroup.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. M A Corporation Name Title Address ® An Individual Randall K. Scott Co-owner 8 Linden Lane, Rehoboth, MA 02769 Sean Sullivan Co-owner 188 Wompatuck Rd, Hingham, MA 02043 M A Partnership ® Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Alexandra Doucette, General Manager Address: 4 Crocker Street Taunton, MA 02780 Telephone No: 508-452-1352 24 Hour Emergency No: 508-567-7613 FAX: E-mail: alex@coggeshallgroup.com Alt E-Mail: isabel@coggeshallgroup.com District Or Regional Supervisor (if applicable) Name & Title: Isabel Dupee, Operations Manager Address: 4 Crocker Street Taunton, MA 02780 Telephone No: 774-419-2512 24 Hour Emergency No: 774-419-2512 FAX: E-mail: isabel@coggeshallgroup.com FOR BOARD OF HEALTH USE ONLY Permit## FOOD ESTABLISHMENT PERMIT APPLICATI, (Application must be submitted at least 30 days before the planned 41bi Establishment Name :ryr {eoe) t-nA"i-6,.u,54_"i LLe- Jl bb 1C y Aa-'--e's �ugJ. Establishment Address �33 (C i4ai,, S ftee v S4,rC /,30 6hrRClctt� CTZaYS Establishment Mailing Address (if different) Establishment Telephone No IYS Z _ 2 Applicant Name & Title: 41-a m i- Applicant Address t? LrNae Z /}wc R-eoe4dr"k , d14 CrZ761 Applicant Telephone No.: 1/61- G y ( - /17e1, 24 Hour Emergency No,: 461 -6,ye - I t le Applicant Email RA-"YO �GGGe5if1}eL(�1�� CCU Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: ❑ An Association If a corporation or partnership, give name, title, and home address of officers or partner. ❑ A Corporation El An Individual nnName Title. Address fsr%9t (�f �,ff_.�/$BAt�tiL �1N1SEnii� r�z(kfiiC7t,1itA6Z7 it j_S A Partnership ❑ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: r()Qy trca mtue 5 Address: 0, Stgcet, �/cacli PRC"Vloewcz !TL (3. % ; Telephone No: q6 t _ 300 - 2 oaz sl 24 Hour Emergency No: yol-3ac z�g� FAX: E-mail: 773aY C a(rGeStFotL[(r2UUalCufin Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: zj C� lRCekv- SfRee r 7_4* vT'eti , Intl P2-7 � 0 Telephone No: '77q -Nt9 _ZS12_ 24 Hour Emergency No. FAX: E-mail: IS1a(�ei �aGGCSi{Az�GRotA,Ca,s. Food Establishment Information WATER SOURCE: %GAl i`I SEWAGE DISPOSAL: Tok tj DEP Public Water Supply No: (If applicable) No. of Food Employees: /15 DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: r AY Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests-&LJ1 �YT212rt i�AI/ U 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? Yes —_ If yes, please attach the FOG permit application. Length of Permit: - - -- - --.. Establishment Type: -- ---- ---- - — - Q-Hnmual ❑ Retail Food $125.00 ❑ Mobile Food Concession Temporary Ij 1.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 El Manufacture ❑ Food service up to 101 -too $250.00 Temporary End Date: ❑ Food Service ❑p to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 ❑ Residential Kitchen .$100,00 Rain Date: ❑Milk &Cream $10A0 ❑ Caterer $35.00 Food Operations: Definttlons: PHF -Potentially hazardous food(Nmettemperature controls required) (Check all that apply): Non-PHF's-non-patentialtyhazardous rood(no timeRemperature conuals required) RTE -ready-to-eatfoods (Ex. sandwiches salads, muffins which need re, lertharpmcessing) Sale of Commercially Pre -Packaged Non-PHFs 'j)4 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And far More Than a Single Meat Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Susceptible Population Facility to be Prepared by Consumer Foods Processed Foods for Service Within 4 Hours for Servllyice [] Use of Process Requiting A Variance ❑ Customer Self -Service of Non PHF and Nan- ❑Customer Self -Service and/or HACCP Plan (including bare hand 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 �Q Offers RTE PHF in Bulk Quantities ??Prepares Food/Single Meals for ❑ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Sendce 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 c ly with 105 CMR 590,000 and all other applicable law. I have been instructed by the board ofhei on how to obt�aiccopies of 105 CM 0.000 and the federal Food Code. Signature of Applicant:, AdAZ4j-X. er-1 I trim Pursuant to MGM 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: Signature of Individual or Corporate Name: U d � � I 1 L "I .4 Q� @ .z ! 12 �( z � } W-0 0 W-4 ® ¥ ƒ; w !� )\ � .W ) t 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. Member, Intrepid Management, LLG Signature of Individual or Corporate Name By. Corporate Officer (Nlaiidato y, Ef Applicable) 83-3480174 "Social Security No. (VOluuumy) or Federal fdent�ieatipn Number *This license will not be issued unless this certification clause is signed by the applicant. "Your social security number will be fuinished 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. CADsers's1ei1e\Deskt0p\SC0u'S DoeumentsWood tsiablisinnents-Temp\7',AX.CF.R'rlt:]CATION FORNl.doc .� !ne c ammonweaun of iviassacttnsens Department of Industrial Accidents Office of'Irpvestigations 600 Washington Street Boston, MA 02111 UT www.naass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Letsibly Business/Organization Name: Intrepid Managament, LLC d/b/a Jersey Mike's Subs Address: 333 School Street Suite 130 City/State/Zip: Mansfield, MA, 02048 - Phone #: 508-452-1352 Are you an employer? Check the appropriate box: Business Type (required): LQ I am a employer with 15 employees (full and/ 5. ❑ Retail or part-time).' 6. Q Restaurant/Bar/Eating Establishment 2.❑ I ama, 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] g• ❑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.❑ ivlanufacturing no employees. [No workers' comp. insurance required]- 1 I.❑ Health Care 4.❑ We are anon -pro Fit organization, staffed by volunteers, with no employees. [No workers' comp. insurance to l.] 12.❑ Other *Any appli=ii thot cbecka box #t must also till out the Section Leto showing their rtvrkers" compensation policy intonation. "If the corporate officers have exempted themselves. but the corporation has othernniployecs, n workers' compensation policy is requiredand such an organization should check box tl1. ]ant all employer that is providing workers' cmntpensation hisurancefor my employees. Below is the policy ueformarion. Insurance Company Name:_ The Hartford Insurer's Address: 3600 Wiseman Blvd. city/state/Zip: San Antonia, TX 78251 Policy # or Self ins. Lie. # 76 WEG AJ1A2K Expiration Date: 11/09/2021 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 MCTL a 152 can lead to the imposition of criminal penalties ora tine 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„iiader tbeplains inert penalties gfperjury that the information provided above is true and correct. Signature: ; F' "[�<`l L'a. f Date: 12/04/2021 401-651-1174 PfBeial use only. Do not write in this area, to be completed by city or tolvaa ajficiat 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 b. Other Contact iwvw,mas,.gov/dia Phone (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Accident and Indemnity Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 10448 Company Code: 5 POLICY NUMBER: 76 WEG AJ1A2K Previous Policy Number: New 1. Named Insured and Mailing Address: INTREPID MANAGEMENT LLC (No., Street, Town, State, Zip Code) 333 SCHOOL 5T STE 130 MANSFIELD MA 02048 FEIN Number: 83-3480174 State Identification Number(s): The Named Insured is: LLC Business of Named Insured: Limited -Service Restaurants Other workplaces not shown above: 333 SCHOOL ST STE 130 MANSFIELD MA 02048 2. Policy Period: From 11/09/20 To 11/09/21 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY 1 ADP BLVD M/S 625 ROSELAND NJ 07068 Producer's Code: 76250871 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877)287-1316 Total Estimated Annual Premium: $2,102 Deposit Premium: Policy Minimum Premium: $286 MA (includes Increased Limit Min. Prem.1 r uaut renou: /NNNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Suffix LARS RENEWAL I I _�I Countersigned by 10/20/20 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (continued on next page) Process Date: 10/20/20 Policy Expiration Date: 11109/21 INFORMATION PAGE (Continued) Policy Number: 76 WEG AJ1A2K 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. 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 C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Estimated Annual Premium (before Surcharges) Total Estimated Surcharges 'See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $2,102 Deposit Premium: Policy Minimum Premium: $2g6 MA (Includes Increased Limit Min. Prem.) Interstatelintrastate Identification Number: Refer to Schedule of Operations NAICS: 722211 Labor Contractors Policy Number: SIC: 5812 $1,639 $338 $60 $2,037 $65 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 10/20/20 Policy Expiration Date; 11/09/21 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment 0 R9 Mailing Address:_ pG QdX 4GSd2i 2ov((A,e,JCe i /t' i o2`l y0 PhoneJFaxNumber: Email: �Fthipy �, f'GG'6'•C' i-i:�LL�f'ult%� CGi'� Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: l+ls NO Air 2 £N�i f2aNrNEr R Cr 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 container $50 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 acknoyvle2 ges that the inmation submitted in these documents is true, accurate and complete. Signed / {A &* Date- 47 L,g2 G Print Name jsn z �C a C I 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 /cA - 912 ThursdayA0_A__-JP m Sunday /U Tuesday &A `�la. Friday 16,4 - qe Wednesday 10A - T'r� Saturday JOA - 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 % Ye 3 compartment sink AU 6 Handwashing sink Commercial Dishwasher © — Bar sink /J d Mop Sink C7 Garbage Disposal / l d Ice Making Machines G Fryolators J t l p Grills or Ovens c� Exhaust Hoods © Floor drains Other., How are hood vents cleaned? (Le_, in three (3) bay sink, off site by private company): U 'Mf Ay PPuyffc CdvnP4-py Is dinnerware pre -rinsed before being washed? ti to Yes No If yes, at what station/sink? 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 J' Al" � Nj<, 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? &SO-c fiP-AA of 1 uc.n+n.b— 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: L(, Property Owner's Address: 120 8u1XL-dY 905 �4,rrA} rrn �J9 M&j' Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? ND j17 r} Where is the grease storage unit located? How often is this grease storage unit emp Please list the vendor who removes the w TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations: Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. _I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. YI have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. _I have received e copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Z66Applicant Signature ' "v l Date: yZ( 7(Z°Z ` Applicant Name (please print clearly) ANOU.- I< • JL' a