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HomeMy WebLinkAboutBertucci's - 12/31/2021�UL 2 ZUCI fit FOR BOARD OF HEALTH USE ONLY Permit#Issued 1j (I D ESTABLISHMENT PERMIT CONTACT UPDATE Establishment Name: K 1C+G��CiCc� s Establishment Address; 08V SC40c,( �r%),YXP .4, AU.4 620VJ' Establishment Mailing Address (if different):, , L} G&A /S.S"s S.&l,aouJy AAf 0153 Establishment Telephone Noo 6b e" 2(el -. Z 37/ Applicant Name&Title: ((-r- ApplicantAddress: 16,50W5 56 nj ,r> , � o �ffjl ,L�y 0163 Z Applicant Telephone No.: W ?51- d 24 Hour Emergency No.: Applicant Email: C ccrt1506e4e-�jc ;a. 4.0M Owner`Name &Title (If different from applicant): 13&_R eu c'c.� 1�5 Owner Address: °Y*70,0 !t. C('e/LI ISIVeC iit.t G t{O®. t�Q6raLc#o, FG J�'3�/ Owner telephone; number: 410.7 - 7 o 3 -5fo 57 Owner email: r!;C ¢1t 5sn� (jg) beoeL 0 +=G 5. c,O.AA Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 0 An Association partner. 0 A Corporation. Name Title Address: IN An Individual ® A Partnership Pi Other legal Entity LG G Person Directly Responsible For Daily Operations (owner, person in charge; supervisor, manager etc.) Name & Title: y66 Cvj G i 6 6y Address; Deb 0 C4 C>Q ( St Telephone No: $- L4p j . Z b %( 24 Hour Emergency No: 077gr��` 21937 FAX: �2 «e� E-mail: J +JCS. C40M be !z 9 AltE-Mail• (i � l ,5 (P fJ S- Go-". District Or Regional Supervisor (if applicable) ° Name & Title: q y((,L e? tcG Address: 165z� 630�3 5 Telephone No: 7?V - ?,` e -121 iu7 24 Hour Emergency No: FAX; E-mail: .SIB /tG�.2z/ Id e Jc-4 .5. cxo�U R a ro ,5. W rt 0 n o ro- m m a tu' to r P C1l z C! A z 0 BPJAN LI BBY Who rr `s met ail the food starvice ,,at f; and sanitali ii. Exam 3811; Recognized By Gonerence For Food Protection accmm�ev rnoonaa la e�na von���sa io i oaea�m�ia� Q �r M��� Certificate No: 191 Exam Dates 08L271167116 Ryon ivicio lion, diem servimaNaneger Test'Code: 6203,043811 Promeop 17941 CorpolpleDrive, Ndnngnem Mo2r236 ,1 80(t624 U36 Expires on: 08127/21 BRIAN LIBBY ON THE BORDER 2201 W ROYAL LN. S IRVING, TX'T6063 9n The Border - Cpfm �! 6 Cut Here: Prometric Score Report Congratulations! You passed the Certified Professional Food Manager examination. Your Score is as follows: Score Status Exam Date 88 PASS 08/2712016 — — — -— iAi9k i ' • G. I I I BWAN LIBIBBY i I �I 111eM 1 Exam 3811 Reeognized By Conference FaWood ction i. ouQ056884s2 en.nmo08/27/16 cad g 1917643 Expires 0A Q8/27121 I Cut Bete 6 Exhibit A Bertucci's Restaurants, LLC - Officers and Directors Liquor License holder for Bertucci's State of Incorporation - FL Current President Thomas Avallone Thomas Avallone 9211 Point Cypress Drive Orlando, FL 32836 Secretary Jeffrey C. Sirolly Jeffrey C. Sirolly 1886 Meeting Place Orlando, FL 32814 CFO Brian Connell Brian P. Connell 3 Patriot Lane Whitman, MA 02382-2379 Assistant Secretary Christine A. Moscaritolo Christine A. Moscaritolo 70 LaGrange Street West Roxbury, MA 02132 -146�oo _ 360'IP FOR BOARD OF HEALTH USE ONLY5 Permit # Issued r FOOD ESTABLISHMENT PERMIT APPLICATION ' . 4w,, ire.. (Application must be submitted at least 30 days before the planned opening da Y, r Establishment Name cc. 5 �" Address ��'J2�✓ �s Establishment Establishment Mailing Address (if different) / g 5,� OJ7,5 5'6 It, O C' �J Establishment Telephone N``oo� cc j - Applicant Name & Title: h s rGGC fS / aS�' %L 1Sr L Applicant Address �'%C7C3 L cCt��ttG�j 2/G!Zv�b'3 Applicant Telephone No.: i'- 351- t? 5-00 24 Hour Emergency No.: C G/ Applicant Email ` 5�1 � CC 5 , , 4A 7 / - 7c�,3 ?r 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. F91 A Corporation Name Title Address 1091 An Individual WA A Partnership X Other legal Entity t C° Person Directly ResponsibleForDaily Operations (owner, person in charge, supervisor, manager etc.) Name & Title:/J< `� rT %� �n 12-c-/- f Address: Telephone No: L1p f - !Ci "7" - C)5,3(? 24 Hour Emergency No: FAX: ? E-mail: Cl��L� / Cf �l �ciSe r2t c5C 2c d �ccS< Alt E-Mail: District Or Regional Supervisor (if applicable) Name&Title: t" f/�6 2cG f r3 y Address: 151 i 0:6 ,5 Telephone No: 24 Hour Emergency No: YY FAX: E-mail v� F C c S, C f✓ M Exhibit A Bertucci's Restaurants, LLC - Officers and Directors Liquor License holder for Bertucci's State of Incorporation - FL Current President Secretary CFO Assistant Secretary Thomas Avallone Thomas Avallone 9211 Point Cypress Drive Orlando, FL 32836 Jeffrey C. Sirolly Jeffrey C. Sirolly 1886 Meeting Place Orlando, FL 32814 Brian Connell Brian P. Connell 3 Patriot Lane Whitman, MA 02382-2379 Christine A. Moscaritolo Christine A. Moscaritolo 70 LaGrange Street West Roxbury, MA 02132 Food Establishment Information WATER SOURCE: '� � SEWAGE DISPOSAL: 7 0 DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: {�Lc� fin% j%( —/�P ✓�lt7FLS5 — lit i/�ci Name of Person(s) In Charge Certified in Food Protection Management: 8; L-C— l4e-IL444 6eIL'i- � a'6 c'n _ Name of Person(s) In Charge Certified in Allergen Awareness Training 1�rCLL ref Name of pest control company routinely inspecting the premises for evidence of pests C��v 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. P4 Yes Does this establishment require a FOG permit? T f,5 If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual 0 Retail Food $126.00 RR Mobile Food Consession ® Temporary Ltl 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 701 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 !N Pushcart $50.00 # of Pushcarts: Temporary Time; ❑rH- Supermarkets $400 [9 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 ;`,3] Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(fimeRemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous(ood(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing) 0 Sale of Commercially Pre -Packaged Non-PHFs WHFCooked To Order no Hot PHF Cooked and Cooled or Hot Held ® Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly Delivery 9 of Packaged PHFs Sale of Raw Animal Foods Intended Susceptible Population Facility Fingi 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 Customer Self -Service of Non PHF and Non - contact alternative, time as a public health Perishable Foods Only FMJ Ice Manufactured and Packaged for control) Preparation of Non-PHFRetail Sales ,Offers Raw Or Undercooked Food Ot Juice Manufactured and Packaged for Animal Origin /'5edA L D I ) Other Food Operations Retail Sale C ® Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities E3 Prepares Food/Single Meals for Eq 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 establishment operation Wll comply with 105 CMR 590.000 all other ap board of health on how to obtain copies of 105 CMR 590.Q 0 nd the fader, Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: lio"nd'affirm that the food ,law. I have been instructed by the Code. perjury 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. t Signature of Individual or Corporate Name By1f Co o ate Officer (Mandaton/, if Applicable) ?,3_0?c5�5,71 **Social Security No. (Voluntanj) 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. CSUsers\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents e 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly i Business/Organization Name: 3 eR--tyC4s Address: (O� , p City/State/Zip: '� � r CC�O F Phone #: 8�- '23 f Are you an employer? Check the appropriate box: Business Type (required): 1.0 I am a employer with rI 0 employees (full and/ 5. ❑ Retail or part-time).* 6. ®Restaurant/Bar/Eating Establishment 2.0 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. 8. ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have I 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box # I 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 # I . I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ,Z U/Z.i Ch 14m e2% CCdI % n CUiEC✓t C CO Insurer's Address: /' 013 O K GCa.5ge/ City/State/Zip: �h%G0.go4 /C !o0(VG Cc—OC/�/ Policy # or Self -ins. Lie. # WG 7 (a / 03 - as Expiration Date: :V110041 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. under #m4pains and penalties ofperjury that the information provided above is true and correct. Offlcial etie only. Do not write in this area, to be completed by city or town official. City or 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 Page 1 of 1 - --1e A� O CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YWY) 07/02/2020 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 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 Willie Towers Watson Northeast, Inc. C/o 26 Century Blvd P.O. Box 305191 CONTACT Willis Tower. Watson Certificate Center NAME: PHONE FAX 1-877-945-7378 AIC No: 1-88B-467-2378 E-MAIL certi£icatesilwillis. core ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Nashville, TN 372305191 USA INSURERA: Zurich American Insurance Company 16535 INSURED INSURERS: American Guarantee and Liability Insurance 26247 INSURER C: Bertuccila Restaurants, LLC 4700 Millenia Boulevard, Suite 400 Orlando, E7. 32639 INSDRERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: W17167759 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 men SUER POLICY NUMBER MM/DDY FF MMIODY/Y YY LIMITS X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,850,000 CLAIMS -MADE I OCCUR DAMAGE TO RENTED PREMISES (Ed oaurrence $ 100,000 MED EXP (Any one person) $ A GTA 8376989-18 07/01/2020 07/01/2021 PERSONAL B ADV INJURY $ 1,850,000 GEN'L AGGREGATE LIMIT APPLI ES PER: GENERALAGGREGATE $ 10,000,000 PRODUCTS -COMPIOP AGO $ 3,700,000 %� POLICY❑PRECTO- ❑LOC OTHER: Per Lou Aggregate g 3,700,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Par accident) $ A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY BAP 8376990-18 07/01/2020 07/01/2021 PROPERTYDAMAGE Par accident $ B X UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE AGO 6548039-11 07/01/2020 07/01/2021 EACH OCCURRENCE $ 20,000,000 [I AGGREGATE $ 20,000,000 DID I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANVPROPRIETORIPARTNER/EXECUTIVE YIN OFFICFMMEMBEREXCLUDED7 No (Mandatory In NH) N/A WC 7969103-02 07/01/2020 07/01/2021 X STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ L,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below A Liquor Liability GLO 8376989-18 07/01/2G20 07/01/2021 Aggregate: $3,750,000 Each Co.. Cause: $1,850,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Re: Evidence of Insurance 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. AUTHORIZED REPRESENTATIVE Bertucci's Restaurants, LLC 155 Otis Street Northborough, NIA 01532 © 1938-2016 ACORD CORPOKAI ILIN. All rlgnts reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SR xn: 19817066 mcIca: 1735131 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Address: Mailing Address: /55- aJ) ,5 3(--- A(o /&A L24,0J (2 !f 2L)- ail Phone/Fax Number: 15e� — 0C2 / " Contact Person/Title for Grease Traps: st'�% Name of Company scheduled to pump internal grease trap(s) monthly: �/�� Name of Company scheduled to pump external grease trap quarterly: 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. A,. In consideration of the grantin ,eqh`e permit, the undersigned agrees to the conditions of the permit and acknowledges that t formation submitted in these documents is true, accurate and complete. Date 2.-eD Print Facility Onerational 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): 7 Seating Capacity (Actual Count): C"? i9-0 Normal Hours of Food Preparation/Service: Monday Thursday �Gf Sunday 7R - Tuesday ?R /! j2 Friday 11,2 Wednesday Saturday t 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 Handwashing sink Commercial Dishwasher f Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens p� Exhaust Hoods IS Floor drains Other: 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 If yes, at what station/sink? D 6 C ld e"_ No 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 x e 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)? e Yes No Size gallons Where is the existing outdoor GRU located?r2` 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? &Z Where is the grease storage unit located? /VIA How often is this grease storage unit emptied? /VZ14 Please list the vendor who removes the waste: /`b% I 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. 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. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered jo-atthe permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature Applicant Name clearly) 3-elC,, C0/,/ t" C t / r� 1-0 n� I ■2 L � z .� z Im / ) 0 (N N. \ \ ^ ) ( ) k \ � � ) ƒ \ � \ / j \ / , \ � m ) \((\ % \ \/§ \ &®§$ §b n \- /ƒ) ) )ƒ\) 2 � / / 0 / k m . 4 t A o cq f : � � \. / ( / � k ƒ �.ƒ / \ 0 / / ] \ ƒ&)& J � §G° ƒ})\ \ / ) \ 140 �� / 2