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HomeMy WebLinkAboutBarpizza & Salad Co. - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit# Issued f �, FOOD ESTABLISHMENT PERMIT APPLICATION AN 19 � 2I1,?l (Application must be submitted at least 30 days before the planned opening date f Establishment Name: (jA'p-022A r $14LA6 h Establishment Address: L?D StA& D L 5 f J- I S 5 Establishment Mailing Address (if different): Iz NW"rVGK.FT_ rLU, w "L(zR1, ►m�, Dc�N�'I Establishment Telephone No: b ('"I- qt, l- kj%A q b Applicant Name & Title: J NS50N C_0tA0'-� Applicant Address: IZ tJjW /CVV e �y�, IP/L S/' %I ✓��/ ��� �� Applicant Telephone No.: Vp (T 4q1' 94 yio 24 Hour Emergency No.: Applicant Email: p C +l �Iiwv\e e com 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 71 An Association partner. El A Corporation ❑ An Individual QName Title Address A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: j P(SS0 J (,t Rop 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: M.l� io� 90 _ __ Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑,(, Location: -, Permanent Location Establishment Type: ❑ Caterer $35.00 Mobile Mobile Start Dale: El Retail -NO FOOD PREP ( Sq. Ft) $125 WMilk & Cream $10.00 Mobile End Date: ❑ Mobile Food Consession Moblie Comments: Food Service to 100 seats INCLUDING FOOD TRUCKS $175.00 Food Service for 101 -200 seats $250.00 NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit Annual ❑Food Service for 201+seats $300.00 El Pushcart $50.00 # of Pushcarts: ❑ Residential Kitchen 0 00 ----- Seasonal Seasonal Dates: ❑ Supermarkets $400 n Tobacco Products $150. 00 ❑ Retail Snack Food $50.00 _ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF - Potentially hazardous food (bmeRemperafure controls required) Non-PHFs- non -potentially hazardous food(no twx0emperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs HFCooked To Ober ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service Delivery 9 of Packaged PHFs - Susceptible Population Facility ❑Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- Customer Self -Service Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service _ Retail Sale of Salvage, Out -Of -Date — or Reconditioned Food To be completed by the Board of Health Total Permit Fee: " ^ A Payment is due with application waived I, the undersigned, attest to the accuracy of the inf establishment operation will comply with 105 CMR board of health on how to obtain copies of 105 Cq Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify u er and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 8 J_ provide this application and affirm that the food and 1 her applicable law. I have been instructed by the 0 aA the federal Food Code. the penalties of Ix,-Agy3 and belief, have filed all state tax returns 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 %5--,z,aIL\3 **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. CAUsers\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: bAIVLPIJ2 b1,(. Address: 12 IV A-PV UCA AK i (� t Wl�LL_0;tZq t ✓ 41 0,191 City/State/Zip: Phone #: h�'►- y`{�' �{vI Ub Are yt:u an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. E3'Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. 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, 11.❑ 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: R%—V-6&b Insurer's Address: too eAVe0— PAt)K Af, 1P]0(o City/State/Zip: ►✓019/K+lrb /YI i 07,00- Policy # or Self ins. Lic. # 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 againe violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA or n urance c age verification. I do hereby certify, un r ee p in d penalties of perjury that the information providedt above is true and correct. Signature- Dntw i 11617,1 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 #: .� .." o.Wdia I ® A� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02/08/2021 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 PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 Charles River Insurance Brokerage, Inc. 5 Whittier Street, 4th Floor CONTACT NAME: Beth Berardi PHONE FAX (508) 656-1455 A/c No:(508) 656-1499 ADDRIESS, beth®bethberardi.com Framingham MA 01701 INSURERS AFFORDING COVERAGE NAICN INSURERA: The Hartford 20605 INSURED INSURER B : Bar Pie LLC INSURER C : INSURER D: 280 School Street STE J135 Mansfield MA 02048 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: Cert ID 7568 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 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. INSR R TYPE OF INSURANCE ADnL 5UBR POLICYNUMBER MMIDDY/YYry MMID�Y%YYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES P. occurrence $ MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑,EO CT LOG OTHER: GENERAL AGGREGATE 5 PRODUCTS - COMP/OPAGG It $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) It PROPERTY DAMAGE Per acc mnt $ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE I EACH OCCURRENCE $ AGGREGATE S DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 08WECAEIBHB 01/05/2021 01/05/2022 STATUTE ERH E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYEE $ 11000,000 E.L. DISEASE -POLICY LIMIT $ 11000,000 $ $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health Mansfield Health Department AUTHORIZED REPRESENTATIVE 6 Park ROW Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1 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. �_ I 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, fr zen, semi -frozen, or other forms of beverages to the public for consumption. I have received a 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. 1 understand violations of this bylaw will result in fin94. Applicant Signature Applicant Name (please print df6arly) 1CQ Z] § 180-16 § 180-17 ARTICLE III Plastic Waste Reduction [Added 4-10-2018 ATM by Art. 451 § 180-16. Purpose. The purpose of this bylaw is to protect the Town's natural beauty and irreplaceable natural resources by reducing the number of single -use plastic check-out bags that are distributed and used in the Town of Mansfield and to promote the use of reusable bags. § 180-17. Definitions. The following words shall, unless the context clearly requires otherwise, have the following meanings: CHECK-OUT BAG — A bag provided by a store to a customer at the point of sale. Check-out bags shall not include bags, whether plastic or not, in which loose produce or products are placed by the consumer to deliver such items to the point of sale or check-out area of the store. DEPARTMENT — The Mansfield Health Department. HEALTH AGENT — The Health Agent for the Mansfield Board of Health or their designee. RECYCLABLE PAPER BAG — A paper bag that is 100% recyclable and contains at least 40% post -consumer recycled content, and displays in a visible manner on the outside of the bag the word "recyclable" or a symbol identifying the bag as recyclable and a label identifying the bag as being made from post -consumer recycled content and the percentage of post -consumer recycled content in the bag. RETAIL ESTABLISHMENT — Any business facility that sells goods directly to the consumer, whether for or not for profit,' including, but not limited to, retail stores, restaurants, pharmacies, convenience and grocery stores, liquor stores, seasonal and temporary businesses. REUSABLE CHECK-OUT BAG — A sewn bag with stitched handles that is specifically designed for multiple reuse and that: A. Can carry 25 pounds over a distance of 300 feet; B. Is machine washable; and C. Is either: (1) Made of natural fibers (such as cotton or linen); or :1 a \ » ®4 f ^(§\ \ � f\[� 7°°(/SIR\ : } § \ox � � � I