HomeMy WebLinkAboutCatman Cafe - 12/31/2021)5
FOR BOARD OF HEALTH USE ONLY Permit# Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name
Establishment Address W v � 0 000061
Establishment Mailing Address (if different)
Establishment Telephone No y^,, 33 r, tap 3
Applicant Name & Title: S4tPWe- T Ce^ I lv
Applicant Address j W W wwrVe rr. R O -k)Uv"tv "J m a j 5 V a i to U
Applicant Telephone No.: yW i3Y OW 24 Hour Emergency No.: bDa )3`+•OG3V
°LI13 wli{
'0y, 3Yt,- .-
ApplicantEmail h cewtlo a eol'CAS'I-, "JET -
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
11 An Association
partner.
CAA Corporation
Name Title Address
ClAnIndividual
CJ'TePlntr�_TLecd(10 prtstdUrcT 14wa,rv,pun, RO _
17 A Partnership
No t,{ay MA 04 1 u G
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: s4 e9(r,e , `d Cevw i(�D
Address: i, G\ 1rJ q:kw.V�J vvr t20 7 v-FO N
Telephone No: �� g i3 4 ou 3 `I 24 Hour Emergency No: 50q "f3 y O U 3 11
FAX:
E-mail:
AltE-Mail: k Lest 00 0'_ \1L �
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
i• 0 6MMI t ITUMA" rii e u. e
WATER SOURCE: avr11
SEWAGE DISPOSAL Tt7�
DEP Public Water Supply No (If applicable)
No. of Food Employees. 3
DAYS/HOURS:
Name of Person(s) In Charge Certified in
Food Protection Management:
`���v'hcv\ "'S' CervttJ
Name of Person(s) In Charge Certified in Allergen Awareness Training
Si r.pht� Cev-v Ito
Name of pest control company routinely
inspecting the premises for evidence of pests `EV' mini)(
If there is seating for 25 peoggle or more,
a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. LY Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
Food $125.00
[] Mobile Food Consession
E] Temporary
—0/Retail
Lid Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
0 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Q 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:
EJ Supermarkets $400
E] Residential Kitchen $100.00
Rain Date:
['Milk &Cream $10.00
i] Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(time/tempeafure controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous food(no lime/temperature controls required)
RTE - ready -to -eat /Dods (Ex. sandwiches, salads, muffins which need no /urtherprocessing)
0 Sale of Commercially Pre -Packaged Non-PHFs [VPHFCooked To Order
EJ Hot PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs
[]'Preparation of PH Fs For Hot And
for More Than a Single Meal Service
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
[Y'Reheating of Commercially
toPrepared Consumer
Use of Process Requiring di Variance
Processed Foods for Service Within 4 Hours
Customer Self -Serer vice
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only
Ice Manufactured and Packaged for
control)
0 Preparation of Non-PHFs
Retail Sale
(-] Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations
Retail Sale
0 Vacuum Packaging /Cook Chill
0 Offers RTE PHF in Bulk Quantities
0 Prepares Food/Single Meals for
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 55n90,00000 and the federal Food Code.
Signature of Applicant: ,l%L� IV- a lX:
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: 'NChX"` b4 3 3' 1 L 3 LIU
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: o" ! '—'g
Address: t6 Ot-0 Q-0 (Q04
Mailing Address:
Phone/Fax Number: J�O �� Ck C)O 3
Email: Y-` Cecv((o Cl Wvv"t. t, v_r= T-
Contact Person/Title for Grease Traps: J 1 f p6e n I CeN h
Name of Company scheduled to pump internal grease trap(s) monthly: t Fv(J t 4Jt�t
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
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 acknowledges that the information submitted in these documents is true, accurate and complete.
Date /off— )5 -A72C)
Print Name 3ito vey, Y CerJ j(-0
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): (IV Vrgh c y
Seating Capacity (Actual Count): Ip 0
Normal Hours of Food Preparation/Service:
33 30 3J 3n 3o d 0
Monday f I I z Tuesday Ill12 Wednesday (f 6Z
Thursday34 30 �d 3J 30
(I t2 Friday (1 I'L Saturday (� lL
Sunday Alovis — 1Z b0
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
d
3 compartment sink
Handwashing sink
'3
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
®
R
Ice Making Machines
Z
Ob
Fryolators
y
Grills or Ovens
Z,
TP
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
yes - ('�ePr3 L401 a'ys "7U
PjFPA -a_10 -i ce nst * wo c'o -al
Is dinnerware pre -rinsed before being washed? Yes No
Ifyes,atwhat station/sink? 3 $qy skr k-< ih k<06\c-
2
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
A q e InIL i> 1t 1, w 4- A s
Grease Trap 2
u } i In LO 01yk Rv w } r
Grease Trap 3
/tN (OLV Rdojn }hf biAo-- 0A S &V-t5ed cm(wk
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes t/ No Size gallons
Where is the existing outdoor GRU located?
4—
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? '\I'e5
Where is the grease storage unit located? iD &Adt R¢s)
How often is this grease storage unit emptied? L- r en 31H Tv V cnit . f} is 6eA0e d
Please list the vendor who removes the waste: Qi -AM't- �OVhmo to }t 5
IJQ4F' 6,avtt�. , 4'78 4sy 6a➢I
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.
fl LiQa
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
*"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\Sco(Vs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
I1119Irit L • u : 1 _0TU, 13'IWATAP,
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.
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.
Did C' I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
d 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�i ,p6 — G� le..Sf rra Date: 1.2 fir- - 0Z-0
Applicant Name (please print clearly) 9 Vr_(Jlneyl T %ry \,D
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: XA-t QV D 6A Cafpv,ciy, (Cc Ft
Address: UtyL-o Cj(owy
a)ovP
City/State/Zip: AA tw S 5 Phone #: ti U ? 33 `► "C') S
Are you an employer? Check the appropriate box: Business Type (required):
1. R I am a e to er with 5� employees (full and/
5. Retail
or art -time) 6. Restaurant/Bar/Eating Establishment
2.❑ I am a so a 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• ❑Nou-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]* 110 Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #t 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: RA j chc.x 'an s Abeocy
Insurer's Address: 150 5 Aw & rAss Der 4
City/State/Zip: 140 2ti
Policy # or Self -ins. Lie. # -7 (O l.V L- Co AO 1 Vl 1- 4 Expiration Date: y" 2 ` 20 2-(
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 ofperjuty that the information provided above is true and correct.
Signature:. ,e.ra(``��- • 1 �-r �) Date:
Phone #: 1 5-0 1 -13 4 U Q 3 t(
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 #:
www.mass.gov/dia
•'`�—� (e
stG[]tr® CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYY)
102120
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
Barrows Insurance Agency, Inc.
215 North Main Street
Mansfield, MA 02048
ON
NAMEAu'; Brent Barrows
PHONE 508-339-7260 a No: 508-339.9524
No Ext
FWAIL
ADDRESS: brent@barrowsins.com
INSURER(S) AFFORDING COVERAGE �
NAIC #
_
INSURER A: Hospitality Mutual Ins Co
INSURED
INSURERS:
INSURER C:
Chamberlain Avenue Enterprises Inc
INSURER D:
dba Catman Cafe
19 Wampum Road
Norton, MA 02766--
_
INSURER E
'— ---
INSURER F :
reormrAYC Kuniummo- REVISION NUMBER:
y 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.
I�TR
TYPE OF INSURANCE
OUL
INSD
Wilt
MID
POLICY NUMBER
MWDD EFF
MMIDD EXP
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
-
D R
100,000
CLAIMS -MADE � OCCUR
PREMISES Eacccurrence
$
MED EXP An one eraon
S 5,000
-A
00101170GL
04/16120
04/16121
PERSONAL A ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
-
PRODUCTS-COMPIOPAGG
$ 2,000,000
X POLICY LOC
$
OTHER:
Ca acccideNSINGLE LIMIT
$
AUTOMOBILE LIABILITY
BODILY INJURY (Per person)
$
ANY AUTO
BOOILYINJURY(Pmaccident)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
-
PROPERTY DAMAGE
Per accident
$
AUTOS ONLY AUTOS ONLY
$
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED I RETENTION$
$
WORKERS COMPENSATION
-
STATUTE ER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORPARTNERIEXECUTIVE❑
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
NIA
E.L. DISEASE -POLICY LIMIT
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
'
Per Occurrence
$500.000
A
Liquor Liability
00101171LL
04/16120
04116121
Aggregate
$500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Town of Mansfield
6 Park Row
Mansfield, MA 02048
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
'6. )
reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
11/02/20 13:38:30 1-855-893-4357
-> 500 339 9524 The Hartford Page 004
'°�. .•->�(" CERTIFICATE OF LIABILITY INSURANCE
oA71 (mm,ODrvrYY)
11/02/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AN CONFER NO RIGHTS UPON THE C RTIFICATE
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 8 , AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANTi If the certificate holder Is an ADDITIONAL INSURED[ the policytioc) must be ondorcod. If SUBROGATTONIS WAIVED,
subject to the terms and condition* of the policy; certain policies may require an endorsement. A statement on this certificate does
not confer rights to the certihcaXo noltler In lieu Of sucn endorsements .
PRODUCER
c6NTACY NAME:
PAYCH V9 INSURANCE AGENCY INC
70210700
150 SAWGRASS DRIVE
ROCHEOTER NY 14020
PHONO 877) 2 -6850
(AID, N., e,A)I
FAX (585) 389-7894
(A/C. NO):
EMAIL ADDRESS:
WOVM1Lm(0) ArrpRDINO 00YCM1AOC NATO*
moVncn A, Hertford Aaoidont and lnticPlnity Company
•2Ga
INSUAEO
INSURER a 1
CMAMSERLINE AVENUE ENTERPRISES OBA
INSURER 0:
CATMAN CAPE
10 00 COLONY RO
INSVRER D:
INSURER E:
MANSFIELD MA 02048.2113
IN5VRPA P:
'
COVERAGES CERTIFICATE NUMBER• 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
INOICATED.NOT ATHSTANOING ANY REOUARMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCLNMENY WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFPOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TORM5, EXCLUSIONS AND CONDITIONS ON SUCH POLICIES. LIMITS SHOWN MAY MAVB W9N REDUCED DY PAID CLAIMS.
INSR
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TYPEOPINSVRANaE
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'
A NJU
GEN'L AGGREGATE LIMIT AP'Ppyra PER:
OBNERAL AGGREGATE
PRODUCTStRJMPIOP AGO
POLICY❑PRji�C 1 ILOG
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OTHER:
,
AUTOMOBIL5 LUAWTV
.ni
BODILY INJURY (Pm r WMN
ANY AUTO
BODILY INJURY (Per O"ent)
AI.I OVM+ED yOHEOUl.EO
AU'r09 AUTO*
NIREO NON-OwNMO
AUTOS AUTOS
PROPERTY DAMAGE
(Per Pn, I5m)
--
UMBRELLA UAB
EXOESS LIAR
OccuR
CLAIMS.
MADE
EACH VC UR @ C
AO0AJ%$ATff
E
RB'fENI'ION.�
WORHERSCOMP N5ATION
�(
ER
OTM•
AND EMPLOYERS' UABILI7Y
ANY YIN
EL EADH ACCIDENT
$1,000,000
A
PROPRICfORIPARTNGkIG%GCUTIVR
Ot•PICGPJMAMQGa EXOLUDBD'1
NIA
78 WE4 A01 NS8
04/0212020
04/02i2021
E.L pISCPSEEA EMAIDYEE
S1,DDD,DOO
—_
E L DISEASE- PDLIOV LIMIT
$1,000,000
1 rd.tg14f NH)
If pep, OpaC,W?•I^ass
_
DE6OR0TION OF O E AT OH3 belay
CESCRIPT10NOf OPERA I NS/LOCATIONS/ VEHICLES (ACORD lot, Ada10on81 Remarks eenedOle, may 00 atrecnoe 0 more Saace Is reeblrea)
Th0S4 V4041 t0 the I06Ur4d'B OP?W!011e,
Getman Cdfe
16 Old Colony Rd
Manfield MA 62048
BEPORE THE EXPIRATION DATA THEREOF, NOTICE WILL BB DELIVERED
IN ACCORDANCE VWTH THE POLICY PROVISIONS,
ACORD 20 (2010103) - The ACORD name and logo are registered marks of ACORD
Congratulations! Attached is your certificate and wallet card. Please notify STEPHEN J CERULLO
the National Registry of name or address changes at the address below. 14 WAMPUM RD
NORTON, MA 02766
Preventing Contamination and Cross Contamination (Competent)
F risuring Personal Hygiene and Employee Health (Competent)
Actively Managing Controls in a Food Establishment (Competent)
Monitoring the Flow of Foods (Competent)
Ensuring Product Time and Temperature (Needs review)
Conducting Cleaning and Sanitizing (Mastered)
Managing:Physlc it Facility Design & Maintenance:Preventing & Controlling Pests (Needs review)
National Registry of Food Safely ProfessionalsO 1 6751 Forum Drive Ste 220 1 Orlando. FL 32821 1 Phone: 407.352.3830 1 Fax 407.352.3603
I
�
United Hauling, Inc.
200 FRIBERG PARKWAY #4001
WESTBORO, MA 01581
Phone: (508) 543-1389
Fax:(978) 206-2622
UNITED MATERIAL MANAGEMENT
CUSTOMER NO
027581
INVOICE DATE
10/1/2020
INVOICE NO
0000437941
CUSTOMER PO
DUE UPON RECEIPT
BALANCE FWD
$274.00
PAYMENTS
$0.00
CREDITS
$0.00
CHARGES
$274.00
BALANCE DUE
$548.00
CURRENT
1-30 DAYS
31-60 DAYS
61-90 DAYS
OVER 90 DAYS
BALANCE DUE
$ 274.00
$ 274.00
$ 0.00
$ 0.00
$ 0.00
$ 548.00
To process credit cards & setup payments, please visit WWW.UMM.NET and choose customer login.
To receive email invoices choose Manage Paperless.
DATE FREQUENCY DESCRIPTION QUANTITY RATE AMOUNT
New Charges
Site 027581-0001- CATMAN CAFE - 16 OLD COLONY RD, MANSFIELD
10/01/2020 - 10/31/2020 Weekly 6 YD FRONT LOAD TRASH 1.00 $271.00 $271.00
10/01/2020 - 10/31/2020 COMMERCIAL DISPOSAL CHARGE 1.00 $3.00 $3.00
Total New Charges: $274.00
PATRIOT/SERVICES, INC.
Your Grease Trap Pro & Drain Specialist
P.O. Box 294
Bridgewater, MA 02324 LIKE
(508) 697-9565 1 (800) 449-4480 (508) 759-0979 US ON
www.PatriotServicesMa.com
Date of Service
Invoice #
Customer Name Phone #
Address Cityi
job Address (if different than customer)
DESCRIPTION OF WORK
Zip_
Apt. #
I hereby authorize you to perform the above described services and I agree to pay the amounts indicated to
the right. I certify that I am duly authorized to order and approve the work requested.
Signature
Terms: Cash
PO # Bill Out
This is to acknowledge completion of the above described work
which has been done to my complete satisfaction.
Ciannfure -
PARTS
LABOR .>
OTHER
TAX
DISCOUNT
TOTAL DUE
Date
Customer Name
Customer E-Mail Address
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01
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7
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4
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