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HomeMy WebLinkAboutCousin's Pizza & Subs - 12/31/2021do V,5164 - 1 T: °%/ FOR BOARD OF HEALTH USE ONLYI') Permit# FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Y l Establishment Name Establish mentAddress ,�� Establishment Mailing Addre4ss (if different) Establishment Telephone No Applicant Name & Title: �i1 1�L�( PP Address „� ( Applicant �� -al �I[(V�10 Applicant Telephone No.: _ (p y, , r( 24 Hour Emergency No.: lA� U v Applicant Email rou, Cr `101� Owner Name & Title (If d erent 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 Association Corporation partner. Nfiffie Till dress( h� hlt � ff�� o w° © An Individual El A Partnership 6 �� f� I� P�" Gi} d�it� 11 Other legal Entity ( �� R���eeessspWonsibjllee For Daily Operations r(�owlnerj, persons in charge, supervisor, manager etc.) Person Directly�11 Name &Title{:h�1\k� �G/J�I�¢��J� I I`!��u4� i I �JIJ�G,) Address: (� � . �J � ru i L� � Telephone No: �`'� / /� (� O ( 24 Hour Emergency No: Cf6 _ Z10 u FAX: E-mail: CO ���U�6, Alt E-Mail: Not . (0 y j gi District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 0 ap15 Food Establishment Information WATER SOURCE: a SA h SEWAGE DISPOSAL: er4( G DEP Public Water Supply No: (If applicable) No. of Food Employees: O DAYS/HOURS: uno - -- . Name of Person(s) In Charge Certified in Food Protection Management: 6-1w w- f6lo f Name of Person ) In Charge Certified in Allergen Awareness Training I � 4�((I�BV�J/pg��(y (loll �( Name of pest control company routinely inspecting the premises for evidenced pests G�NI t � � WOOL' 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. O Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. LLejngth of Permit: Establishment Type: Lvj Annual/Retail Food $125.00 0 Mobile Food Consession Temporary I� 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: 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 Residential Kitchen $100.00 Rain Date: 0 Milk &Cream $10.00 E] Caterer $35.00 Food Operations. Oefinidons: PHF-Polenfiallyhazardous food (lime fempemture wakols mqulred) Non-PHPs-non-potenh"alyhazardousmod(no timeRemperamre conWlsrequhed) (Check all thata apply): RTE -ready-toEat foods (Ex. s ndwlches, salads, murfins whichh need no lherpmcessing) Ej Sale of Commercially Pm -Packaged Non-PHFs .-: PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held E] Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service E] Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended E] Reheating of Commercially to be Prepared by Consumer E] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours 0 Customer Self-service and/or HACCP Plan (including bare hand Ej 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 E] Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities [j 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obtalp copies of 105 CMR 590.000 and the federal Food 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. C Social Security Number or Federal ID: Signature of Individual or Corporate Name: 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. S' ature of Indivi utor Corporate Name ""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\Desktop\ScoWs Documeuts\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses DDlicant Information_ _ Please' U� ac75 A 6 Z�, " 6� Phone #: �U U- 3 S I i Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Re I LF1 I am a employer with employees (full and/ or part-time).* 6. ' estaurantBar/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. 8• ❑Non-profit o 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 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.] *Ally 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 am an employer that is providing workgrf cpmpensallonsurance for my rpla ees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. U1 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 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, (funder the pains and penaa ties of perjury that the information provided abo{j}(e � � !s true and correct. E€ o:.........._,.. :.f• ..i✓i.eA// i�sr/ii '� �� n.ft - S 1 S 26, Official use only. Do not write in this area, to be completed by city or town oJJuial 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 A� o® CERTIFICATE OF LIABILITY INSURANCE UA E 126/20A'YYY) 10/28/2020 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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 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 endomement(s). PRODUCER C& S lnswerimAgency, Inc. 190 Chauncy St Mansfield MA 02048 CONTACT Debra Genaughty NAME: PNHCONE (508)339-2951 jac xol: (508)339.4811 AOD Lss: DebbieQcandAins.com INSURER(S)AFFORDIN)COVERAGE NAICS _ INSURERA: Twin City FireInsurance Co 29459 INSUREO Cousins Pima and Subs Inc. 44 Cannon Forge Dr Foxboro MA 02035 INSURERS: Commemelnsurance Co 34754 IN AIRER C: NorGUARD Insurance Company 31476 INSURER D: NURERE _ IN!.Z.RF: COVERAGES CERTIFICATE NUMBER: 2020 Cert of Liab REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE INSO Verde MUCYNUMBER MMATCYEFF MMUNYEXP UNITS A X COMMERCULLGENERAL ABIL TY CLAIMS -MADE ® OCCUR GOSBAAC8155 04/26/2020 04/26/2021 EACH OCCURRENCE 4 2.000,000 PREMISES Eeocc ce 4 1,000,000 MMEXPWryoneperess) 4 5,000 PERSONAL&AM/JWlmY $ 2,000,000 GENLAGGREGATE LIMITAPPUES PER: PONCY 0 JET LOC OTHER: GENERALAGGREGATE 4 4,000,000 PRODUCTS-COMPIOPAGG $ 4,000,000 4 B AMOMOBILELIABIDTY ANYAUTO OMM scHEDULED AUTOSONLY AUTOS HIRED HNON-OWNED AWOSONLY AUTOS ONLY BBDBBB 10/21/2020 10/21/2021 COMSINEDSINGIELIMIT aaident 4 1000ODO _ SODILYINJURY(Perpercon) $ eODILY]MI-W(PeraceldeM) S PROPERTY DAMAGE eraWdent 4 E UMBREITA BAB EXCESS UAB OCCUR CVJMSMADE EACH OCCURRENCE s AGGREGATE $ DED I I RETENTION $ 4 Q WORKERS COMPENSATION AND EMPLOYERS' LIABILITY AM PROPRIEfORNARINER@XECMNE YN OFFICER MEMBER EXCLUDED? (Mantlrtoryin NH) Ryes. describe under DESCRIPTION OF OPERATIONS below NIA COWC151041 08/01/2020 08/01/2021 X1 PSinn IE OMR ELEACHACCIDENT S 500,000 ELDISEASE-EAEMPLOYM T 500,000 EL DISEASE -POLICY UNIT 500,000 4 DEWRIPUON OF OPEMMONSI LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be aeached Amore apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 2 Park Row AUTHORED MWITESEMATIVE Mansfield MA 02048 LA, ' � H 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 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. V 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. (/J 1 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: G ll Applicant Name (please print clearly)' i �� Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishmenr1t� N AddrPss- 6 V Mailing Phone/Fax Num/jber:�(_ Finail• C0usI�s Contact Person/Title for Grease N raii n� Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest a • 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) V/S. 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' true, accurate nd complete. Signed H.,-P'i�"'"y Date 11 12 Print e-' -1. u. 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 Departmen Regulation): f Seating Capacity (Actual Count): i Normal Hours of Food Preparation/Service: Monday I tJ 3o Tuesday Wednesday Thursday Friday Saturday Sunday 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 IHandwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods 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? 4 Yes No If yes, at what station/sink? Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 6 (V" P��l(ease list fixtures attached to each grease trap Grease Trap i Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Gre se Removal Unit (GRU/Interceptor)? Yes No Size 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: AI'll Property Owner's Name: Property Owners Addre: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators?, Where is the grease storage unit located? How often is this grease storage unit emptied?_ Please list the vendor who removes the waste: m \ \\ƒ2 9&»� \ i`~ |sue / !qn } \ ° (/ t $ ® ? J 0 ¥ ( \ k e x ) # \ k ( k M too, t—1 ml � � � z � � � z 0-4 z 0 � � � I Name of Recipient: FRANK MYLONAS Certificate Number: 2359244 Date of Completion: 602016 Date of Expiration: -1202, Die above -named phson is hereby issual this re, i/iraa, for completing as allergen awareness I,aining proguna reeognivd by the Massaebaseus Department of Pubfic Health in accordance with 105 CMR 590.009(C)(3)(a). Dhis eertifimte will be valid for five (5) yearefiom date ofcomplelion. rem r Issued By: NAL RESTAURANT ") ASSOCIATION„ Massuhusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 Southharough,MA 01772 ...Wlant.otg 508-303-9905 www.marestaumntasmcorg w O W U w H W U V z 00* z Un Un W z W P4 All a F N U M v N N o v U 4-i O O y z Q Q �114 o 0Fu d a �a M0 � ,a M 0 w tl tl � o ZS O El d Q N �v IN b Cam' RY � twa N C v O 4