HomeMy WebLinkAboutClassic Pizza - 12/31/2021#Issued FOR BOARD OF HEALTH USE ONLY Permit !
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name
C ri t
a v i
Establishment Address
Establishment Mailing Address (if different)
Establishment Telephone Noc,�
Applicant Name & Title:
Applicant Address
Applicant Telephone No.; 24 Hour Emergency No �r
Applicant Email r ; , .
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Owner Name & Title (If different from applicant)
Owner Address
5
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
—'An Association
partner.
1 A Corporation
N me Title Address
r
' �. `°� � �` � `� �
Ll_sAnIndividual
r i A Partnership
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El Other legal Entity
_
Person Directly Responsible For Doly Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: � L 4 C \ '_ '`.
! a
Telephone No { >`� _ r C 24 Hour Emergency N
E-mail:`l\���
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address: J
Telephone No: r"'� 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: -To W yt
SEWAGE DISPOSAL: l mw.t
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:-- S
Name of�Person(s) In Charge Certified in Food Protection Management:
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Name of Person(s) In Charge Certified in Allergen Awareness Training
N
Name of pest control company routinely inspecting the premises for evidence of pests1
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. 'V Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Type:
�
''E���,,srrrtablishment
nnual
stall Food $125.00
U Mobile Food Consession
_] Temporary
Food Service up to 100 INCLUDING
`
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
[• Food Service up to 101 -200 $250.00
Temporary End Dale:
'] Food Service up to 201 + $300.00
—
'] Pushcart $50.00 # of Pushcarts:
Temporary Time:
I] Supermarkets $400_
1 Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
?.. Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food((mellempereture controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous tood(no lime/temperature controls required)
RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessmil)
t Sale of Commercially Pre -Packaged Non-PHFs I/F HFCooked To Order
I] Hot PHF Cooked and Cooled or Hot Held
;1 Sale of Commercially Pre -Packaged PHFs IV,! Preparation of PHFs For Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service
ry
] PHF and RTE Foods Prepared For Highly
]Sale of Raw Animal Foods Intended
Susceptible Population Facility
I] Reheating of Commercially to be Prepared Consumer
Use of Process Requiring di Variance
Processed Foods for Service Within 4 Hours
er
�J Customer Self -Service
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)
[] Preparation of Non-PHFs Retail Sale
0 Offers Raw Or Undercooked Food Of
E Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
[] Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
-] 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 wit Fy 1"055 CMR 590.Q00 and all other applicable law. I have been instructed by the
board of health on how to obtain co0i q i u5 CMR U.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and elief, have filed all state tax returns
and paid state taxes required under law.„7 ,,..,`,`"~�,. f•`*}"�O
Social Security Number or Federal ID:`r .
Signature of Individual or Corporate Name:
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TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, 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 By: Corporate Officer (Mandatonj, 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\s1eite0esktop\Scotr9 Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
o Boston, ALL 02111
www.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
U
Are you an employer? Check the appropriate box: Business Type (required):
112 I am a employer with employees ( full and/ 5. Retail
or part-time).* 6. WRestaurant/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]
8. 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]**
4. ❑ We are a non-profit organization, staffed by volunteers, I LE] 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 run an employer that is providing workers' ckoinpgnsation insurance for my employees. Below is the policy information.
Insurance Company Name:A_'�,_D_�k
Insurer's Address: A V
City/State/Zip:
Policy # or Self -ins. Lic. #\ ::_,I k- ,
Expiration
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 a 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.
Ido hereby certify, tynfler the pai3O'and penalties of perjury that the information provided above is true and correct.
M
Official use only. Do not write in this area, to be completed Uv 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
ww"unass.gov/dia
Phone
NOV-11-2020(WED) 11:32 Tinos Insurance/Tinos Travel (FRX)508 880 5044 P.001/006
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803.0970
(800) 876-2765 NCCI NO 40959
POLICY NO,
PRIOR NO.
ITEM
1. The Insured: MRK Classic LLC
DBA:
Mailing address: 242 Chauncy Street FEIN:.. ^8B9162
Mansfield, MA 02048-0000
Legal Entity Type: Limited Liability Company
Other workplaces not shown above:
2. The pol ay period Is from 08/26/2020 to 08/25/2021 12:01 a.m. standard time at the Insured's mailing address.
3. A, Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
stases fish d here: MA
B. Employer€' Liability insurance: Part Two of the policy applies to work In each state listed In Item S.A.
The limits of liability under Part Two are: Sodlly Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 8
D. This Policv Includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this pollsy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to veriflaatlan and change by audit.
Classifications Premium Basis Rate's
Code
Estimated
PerV00
Estimated
No.
Total Annual
Of
Annual
Remuneration
Remuneration
Premium
INTEA 001093817
INTER SEE
CLASS CODE SCHEDU
E
Minimum Premium $261 Total Estimated Annual Premium $1,597
Gov GOV Deposit Premium $409
STATE CLASS
MA 1 9079 State Assessments/Surcharges
$1,171,00 x 3.5100% $41
This policy, Including all endorsements, Is hereby countersigned by " --'r "el C-- 07/23/2020
nuthonzed signature Date
Service Office:
54 Third Avenue
Burlington MA 01803
WC 00 00 01 A (7-11)
Includes copy0ghtod matertol of the Notlonei Council on Companeminn Ineorence,
used wtih Its pormteslon,
C J Murphy Ins Agency
22 Fruit Street
Taunton, MA 02780
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name:
Mailing Address: g ( g
Phone/Fax Number. A r)j�" \ j s k `— ?Jt C
Email:
Contact Person/Title for Grease
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.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the' formation submitted in these documents is true, accurate and complete.
Signed Date
Print
1
Facility Ooerational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type. C
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday �rS
Thursday
Sunday 1�.;
Tuesday,`;
Friday — l
Wednesday V�
Saturday 0 -,-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
Bar sink
Mop Sink
Garbage Disposal
Ice Making Machines
Fryolators
Grills or Ovens
Exhaust Hoods
Floor drains
Other:
How are-bppd vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed?
If yes, at what station/sink?
Yes V No
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
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)?
Yes No Size ( M 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 Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fr olators?
Y Y g Y �—;
Where is the grease storage unit located?
How often is this grease storage unit emptied? `�41
Please list the vendor who removes the waste: 1'yJ c
t (Pi9 P (i]; i u L•P b91I _X� 7 S�I�7_\>! 3'l I_11it69
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 tq-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, /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 to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature
Applicant Name (please print clearly)