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Home My WebLink AboutActive Day of Mansfield - 12/31/2021FOR BOARD OF HEALTH USE ONLY),,,Permit# Issued r FOOD ESTABLISHMENT PERMIT APPLICATION f -- (Application must be submitted at least 30 days before the planned openinVdat , O 3 Establishment Name Active Day of Mansfield Establishment Address 300 Branch Street, Mansfield, MA 02048 Establishment Mailing Address (if different) 6 Neshaminy Interplex, Suite 401, Trevose, PA 19053 Establishment Telephone No 508-339-2119 Applicant Name & Title: Matthew Nehoda, Vice President of Finance Applicant Address 6 Neshaminy Interplex, Suite 401, Trevose, PA 19053 Applicant Telephone No.: 215-642-6600 24 Hour Emergency No.: Applicant Email contracts@activeday.com Owner Name & Title (If different from applicant) Active MA, Inc. Owner Address 6 Neshaminy Interplex, Suite 401, Trevose, PA 19053 Owner telephone number 215-642-6600 Owner email: contracts@activeday.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. [X A Corporation Name Title Address O An Individual Matthew Nehoda Vice President of Finance 1214 Revere Drive Chalfont PA_ Matthew Donnelly VP of Operations 122 Moorhead Ave., Conshohocken, PA 1 0 A Partnership 11 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Karen Amado, Center Director Address: 300 Branch Street, Mansfield, MA 02048 Telephone No: 508-339-2119 24 Hour Emergency No: FAX: 508-339-3820 E-mail: mansfield@activeday.com Alt E-Mail: contracts@activeday.com District Or Regional Supervisor (if applicable) Name & Title: Kristen Close, Regional Director of Operations Address: 6 Neshaminy Interplex, Suite 401, Trevose, PA 19053 Telephone No: 860-719-9795 24 Hour Emergency No: FAX: 860-568-9698 E-mail: kclose@activeday.com GME,I PR Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 1 DAYS/HOURS: Mon -Fri 7:30am to 4:30pm Name of Person(s) In Charge Certified in Food Protection Management: Richard Keefe, Food Service Coordinator Karen Amado, Center Director Name of Person(s) In Charge Certified in Allergen Awareness Training Richard Keefe, Food Service Coordinator Name of pest control company routinely inspecting the premises for evidence of pests Flvnn Pest Control 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. L Yes Does this establishment require a FOG permit? No If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [ Annual Retail Food $125.00 E] Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Q Residential Kitchen $100.00 Rain Date: 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 food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no funherprocessing) Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held EJ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service O Delivery of Packaged PHFs Cold Holding For Single Meal Service 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 E] Customer Self -Service and/or HACCP Plan (including bare hand 0 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 EJ Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities E] Prepares 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 comply with 105 CMR 590.00 nd all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CM�R-�9 O&i0tb faderal-Feed-Code. 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: Signature of Individual or Corporate Name: Active MA Inc Tax ID 04-3392759 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. Active MA, Inc. Signature of Individual or Corporate Name 04-3392759 "Social Security No. (Voluntary) or Federal Identification Number 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:\Users\sleite\Deskfop\Scott's 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 tvwty. mass.gov/dia Workers' (Compensation Insurance Affidavit: General Businesses Applicant information Please Print Legibly Business/Organization Name: Active MA, Inc. Address: 6 Neshaminy Interplex, Suite 401 City/State/Zip: Trevose, PA 19053 Phone #: 215-642-6600 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑✓ I am a employer with 16 employees (full and/ 5. []Retail or part-time).* 6. ❑ Restaurant/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] g ❑Non-profit 3.0 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]* 1 l.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volutnteers, with no employees. [No workers' comp. insurance req.] 12.❑✓ Other Adult Day health center *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 01. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Pennsylvania Manufacturers' Assoc Ins Co Insurer's Address: c/o Connor Strong Buckelew PO Box 99106 City/state/zip: Camden, NJ 08101 Policy # or Self -ins. Lic. # 2020000471367B Expiration Date: 10/15/2021 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonnient, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under theXa m and penalties of perjury that the information provided above is true and correct 10.13.2020 215-642-6600 Official use only. Do not write in this area, to be completed by city or town official City or Town: _ _ Permit/License ff Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #i www.mass.gov/dia Client#: 206417 ADSCHOLDI ACORD. CERTIFICATE OF LIABILITY INSURANCE OATE(MM/OD,YYYY) 10/17/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY. THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the turns and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemenf(s), PRODUCER NAIfEAT Stefanie Bucholski AcotAnalyst -. Conner Strong & Buckelew P He , 856 479-2104 (c Not 856-291-9687 Box 99906 p uAEess: sbucholski�connerstrong.com Ca Camden, NJ O81Q1 INSURER($) AFFORDING COVERAGE NAICf INSURER A; Mb"PhIalnemNry Imumm 18058 _ INSURED - 'Active MA. Inc. INSURER B; uoyav ^i tanEon INSURER C:Pe"^eylvanlPManfneluma•Aea^e NaCo 12262 6 Neshanniny Interplex Suite 401 S INSURER D: INSURER E: Trevose; PA 19053 INSURER F: - CUVEHAUES CERTIFICATE NUMBER: REVISION NNMRER- THIS IS TO.CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED MAMEDA13OVE FORTHE POUCYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, DCCWSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N I HR TYPE OF INSURANCE D I BUD POUCY NUMBER LDI POLIC FF PIN IXP MM/D LIMITS A GENERAL LIABILITY-• X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR PHPK2195482 0/15/2020 10/15/2021 _ EACH OCCURRENCE §1,000,000 _ RAM,p�`ET RENTED PREMISES EaOC EPO _ §i0(tOQQO MED EXP (An onepersan) $20 000 PERSONAL&AOV INJURY $1,000,000 GENERALAGGRECATE '- $3,000 000 GENL AGGREGATE "X. POLICY LIMIT APPLIES PER: ERM LOC PRODUCTS- $3000000. $ A. ADTOMOSILELIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS HIRED AUTOS X NONAWNED AUTOS PHPK2195402 0/15/2020 10/15/2021 94B'NEDSINGLE LIMIT 1,g0(t,000 BODILY INJURY (Per person) $ BODILY INJURY (Per emltlent) $ PROPERTY DAMAGE Per amdentl $ B X UMBRELLA�6'�HCLAIMIMACE IXCE93 LAGGREGATE CCUR SBAHCX0128020 0/15/202010115/2021 EACHOCCURRENCE $5000000 $5,000 QQO_DED ETENTION _ § C AND EMPLOYERS' LIABILITY WORKERS COMPENSATION ANY PROPREETOR,1^ARTDE OFFICEP/MEMB[R EXCLUDED? EXECUTIVE YIN (MandmoryinNH) � Ayyes ESGRIPnIPTION OF OPERATIONS below be antler N/A 20200004793676 MA&MN 2020000471367A All Other States 0/15/2020 0/15/2020 10115/2021 10/15/2021 X WC 'TAT U- OTH- E.L. EACH ACCIDENT. $1000000 E.LOISEASE-EAEMPLOYEE a1 Ooo,ow E.L DISEASE -POLICY LIMIT $1000000 A Professional Liability _ PHPK2195482 0/15/2020 10/15/2021 $1,000,006-Eachlnciden $3,000,000- Aggregate DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Aaach ACORD 101, Adtlltlonal flemarks3chetlule, If mare apace Is required) Excess Liability $5M xs $5M Policy #03125525 Carrier: Allied World Assurance Company (U.S.) Inc. / NAIC# 19489 Policy Period: 10/15/2020-10/15/2021 Limit:.$5,000,000 xs $5,0D0,000 Evidence of Insurance I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION, DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. M 010811-2010 ACORD CORPORATION. ell rinht< ro«.,,ea ACORD 25 (2010/05) 1 of 2 The ACORD name and logo am registered marks of ACORD #S2643465/M2641975 L11 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. X 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. X 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, frozen, semi -frozen, or other forms of beverages to the public for consumption. X 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. I understand violations of this bylaw will result in fines. Applicant Signature Date: 10.13.2020 Applicant Name (please print clearly) Matthew Nehoda, Vice President of Finance Town of Mansfield 6 Park llmv, Mansfield, MassacGnsetts 02048 Health Department Any Donovan-Paliueq MPH, PU Health Agent April 1, 2019 Karen Amado Mansfield Adult Day Health Center 300 Branch Street Mansfield MA 02048 RE: Mansfield Fats, Oil, Grease (FOG) Regulations Dear Ms. Amado, Per our discussion on March 27, 2019, the Mansfield Adult Day Health Center is not required to install a Fats, Oil, Grease pre-treatment system at this time. The Mansfield FOG regulations state "A Food Service Establishment or other facility that generates FOG as a by-product shall install a suitable FOG Pretreatment System..." Upon discussion and inspection, I have found no evidence that the current operation produces any FOG as a by-product. If food operations change, please contact the Health Department for further assessment. This includes but is not limited to: preparing any food at this location, switching to reusable plates, and /or cleaning dishware onsite. Please let me know if I can be of any other assistance. amj)Q��9�rn `LW1 Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 Fax (508)261-7425 Bntailadpaltnei@atansfteldnla.con7 E LL k vSig • m w re s^ t'3'2S J: 14:z. W mu e H✓ H EAR'TSAVER Heartsaverm First Aid CPR AED Keelia Smyth has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver® First Aid CPR AED Program. Optional modules completed: Issue Date MOM Training Center Name ABC Community Training Center, Inc. Training Center ID MA05865 Training Center Address 14 Lilian Road Ext Framingham MA 01701 A623 USA Training Center Phone Number 508-620-0038 To view or verity authenticity, students and Recommended Renewal Date O612021 Instructor Name Carter Coverdale Instructor ID 11091585823 eCard Code 196004527940 OR Code code with their mobile device or go to. wwiuhearLoVcpr/mycdtds dghtsraserved. 15-3002 a/15 W4 0 u W-4 t M! z z W z N W Ww• Y m o � U v Q