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Home My WebLink AboutB. Good - 12/31/2021w o5 l s °j FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION z`y (Application must be submitted at least 30 days before the planned opening date Name O G •F'oFAA Un Sf �e IIA L L G AA- F. Good Establishment Establishment Address a<60hool Sfifee+ y vi Am S �I e id /V l t-f Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: _S(AS 0 t1 Sol ee ne - 0Co t) 'e r Applicant Address fj0 1 I-ey.l0 +C)h S �% t� II I VYG I I ha /•lA G) qS, Applicant Telephone No.: 'W 7 d a5 D_ 24 Hour Emergency No.: Applicant Email 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 ID An Association f L IN A Corporation _ -C partner. -�N^ame LLC Title Address S Sk(1 O An Individual A Partnership JGS 1 AS r. JiWU W<379 E1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: t maht- i 2 Vrnitp dO+'sS �Cid�$ojA ei /Vji� �a 3 Address: �}i i U St fJa 24 Hour Emergency No: Telephone No: FAX: (G h 1 00arts®� E-mail: Yd1,IG� 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: 10 y, y, SEWAGE DISPOSAL: QW,,^ DEP Public Water Supply No: (If applicable) No. of Food Employees: -12 DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: D2I mUr1� Valla�r�res ahA (SAC It'tOSFc YrM Name of Person(s) In Charge Certified in Allergen Awareness Training Del rro.rie Tito GAws ahtA CUr l' �CiS �at�%QS Name of pest control company routinely inspecting the premises for evidence of pests FCO 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. X Yes Does this establishment require at FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual Q 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 Dessertslice Cream Temporary Start Date: 0 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: 0 Supermarkets $400 Residential Kitchen $100.00 Rain Date: ei Milk &Cream $10.00 � Caterer $35.00 Food Operations: Definitions:PHF-Potentially hazardous food(fimMemperature controls required) Non-PHFs -non-potentieily hazardous food(no tlme/temperaf ue controls required) (Check all that pP y): RTE-ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) apply): E] Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order 0 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 Cold Holding For Single Meal Service Eq PHF and RTE Foods Prepared For Highly Q Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended 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 Customer Self -Service contact alternative, time as a public health Q Customer Self -Service of Non PHF and Non- control Pedshable Foods Only Q Ice Manufactured and Packaged for ) Preparation of Non-PHFs Retail Sale IS Offers Raw Or Undercooked Food Of 0 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale a Vacuum. Packaging / Cook Chill EA Offers RTE PHF in Bulk Quantities Ej 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 590.000 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: Pursuant to MGL Ch.62C, sec. 49A, I cVrtif and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: under the penalties of pepury that I, to my best knowledge 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. Signatur f Individual or Corporao Name By: Corporate Officer (Mandatory, if Applicable) 75-3103699 *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:\Users\sleite\Desktop\Scotfs Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: BG Food Mansfield LLC Address: 280 School Street City/State/Zip: Mansfield MA 02048 Phone #: 6178770252 Are you an employer? Check the appropriate box: Business Type (required): 5. Q Retail 1.7 I am a employer with 1 /10 employees (full and/ or part-time).* 6. 0 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. g. Non-profit [No workers' comp. insurance required] 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.Q Manufacturing no employees. [No workers' comp. insurance required]*4 I LQ Health Care 4,n We are a non-profit organization, staffed by volunteers, 12.0 Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **lf 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: Hanover Maurer's Address: 440 Lincoln Street City/State/zip: Worcester, MA 01653-0002 Policy # or Self -ins. Lie. # W2N D05921300 Expiration Date: 10/1 /21 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, under the pains and penalties of perjury that the information provided above is true and correet. C\ A n,._ _ 11/15/20 617-877 Official use only. Do not write in this area, to be completed by city or town offrcial 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 www.mass.gowara Phone A`o O CERTIFICATE OF LIABILITY INSURANCE DATE i21o/z0//2020 Y) ozo 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 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 endorsements). PRODUCER McSweeney & Ricci Insurance Agency, Inc. 420 Washington Street Braintree MA 02184 CONT CT NAMP PXONE FAX c o E ; 781-848-8600 Alc Ne:781-843-8807 ab`D`R'LFss: mrirece Lion mcsweene dceLcom INSURERS AFFORDING COVERAGE NAIL# INSURER A: Hanover Insurance Company 22292 INSURED BOFOODM-01 BIG Food Mansfield LLC 280 School Street #D115 INSURER B: NSURERC: Mansfield MA 02048 INSURER D: INSURER E: INSURER F : rnvCDAGES CPRTIPICATP MI HVRPR- Al 11 QRA3fi 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 LTR TYPE OF INSURANCE A SUER pODCY NUMBER MMtODY EFF Mh11�D7YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MND06460703 iomii2019 10/31/2020 EACH OCCURRENCE $1.000.000 CLAIMS.MAOE a OCCUR PRMSES Ezoccwlencs $1,000,000 MED EXP (Any onePerson) $ 5,000 PERSONAL&ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000.000 GEN'L PRODUCTS - COMP/OP AGG $2,000,000 PRO - POLICY JET F LOG $ OTHER: I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) S ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS PAUTOS PROPERTY DAMAGE Peraccldent $ A X UMBRELLA LIAR X OCCUR UHND08554500 10/31/2019 10I31/2020 EACH OCCURRENCE $ 4,000,000 AGGREGATE $4,000,000 EXCESS LIAR CLAIMS -MADE DED y` RETENTIONS 1 o $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORMARTNEWEXECUTIVE Y� W21,1005921303 101W019 1011/2020 X STATUTE OERH E.L. EACH ACCIDENT $1,ODQ000 E.L. DISEASE - EA EMPLOYE $1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) N/A E.L. DISEASE -POLICY LIMIT $4,000000 If yes describe antler DE SGRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space le required) Re: 280 School Street, Mansfield, MA Route 140 School Street LLC and WS Asset Management are included as additional insured With respect to the General Liability Policy as required by written contract for the leased premises at 280 School Street, Mansfield, MA Route 140 School Street LLC c/o WS Asset Management Inc 33 Boylston Street, Suite 3000 Chestnut Hill MA 02467 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED A— i, Y�') 14V ems. l ACORD ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Mailing Address:_ 6k' r . P Phone/Fax Number: ^10 0' �U J — I S Contact Person/Title for Grease Traps: U JI v 1�� Name of Company scheduled to pump internal grease trap(s) monthly: V V � f-xA p2 j UQ Name of Company scheduled to pump external grease trap quarterly: W t hCA ' j JL( 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 thatthe information submitted in these documents is true, accurate and complete. Signed �OQ?bl Y.0� Date dM Print 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): i Seating Capacity (Actual Count): 'C Normal Hours of Food Preparation/Service: Monday r Thursday�7 p _ Sunday Tuesday �_ q a 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 q/ Handwashing sink Commercial Dishwasher Bar sink Mop Sink �— Garbage Disposal aIce Making Machines a Fryolators `— Grills or Ovens — Exhaust Hoods Floor drains Other: C Cr U& How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? Yes ✓ No If yes, at what station/sink? Iva kFyn P h (I a i P Grease Trans 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 h"(,Ck i 1 P c-( Grease Trap 2 SG�G�fC Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? V Yes No Size _I�CfI� 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 Owners Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? L Where is the grease storage unit located?_ How often is this grease storage unit emptied? Please list the vendor who removes the waste: 3 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. qp Ihave received a copy of the Polystyrene Container Reduction bylaw. I understand my onsibility 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. y1 have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my bility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. 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