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HomeMy WebLinkAboutD'Angelo Grilled Sandwiches - 12/31/2021! FOR BOARD OF HEALTH USE ONLY-7�ermit # Issued" � FOOD ESTABLISHMENT PERMIT APPLICA (Application must be submitted at least 30 days before the planned ol� Establishment Name I} Q1 C v r' 4 1� eve \(A V v Establishment Address v O)V_a ('AuA Establishment Mailing Address (if different) ;'C lzu-)( ;;)—I C� Establishment Telephone No A Applicant Name & Title: vcC ^-1-'n ,Applicant Address � O 07b X 2r1 C1 «' S r tom@ Applicant Telephone No.: (Y V5�su" 24 Hour Emergency No.: Cv) Applicant Email 0�(lY\e�a l Ir1C j�� t Owner Name & Title (If different from applicant) Gt 51 �� L a LY 1� I ✓� OwnerAddress'�C k7//'�x "53`1 W , R, Owner telephone numbec5��y-�-kt' "7 �0 Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ❑l An Association partner. me Address RYA Corporation j O An Individual r� pTitle i�� rr� Iv `� �tiF��i I f L�r k 3�-7 o 3 7' A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CV, G 1 �—'�Ct_ Address: - - Telephone Nod 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: ` Address: J Telephone No: 1-�� \ - (� ® ?7 - '�'3q t'k 24 Hour Emergency No: FAX: E-mail: Fo stablish ent Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees. DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training (; Name of pest control company routinely inspecting the premises for evidence of pests \ If there is seating for 25 por eo more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. of Permit: Establishment Type: 7ngth Annual ❑ Retail Food $125.00 Mobile Food Consession ❑ Temporary Z�Kood Service up to too INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Ei Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: EJ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 ❑ Caterer $35,00 Food Operations: Definitions: PHF - Potentially hazardous food (time/temperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs - PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held 0 Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs 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 Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours 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 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 ❑ 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 th racy of the inf atio rovided in this application and affirm that the food establishment operation will omply ith 105 CMR 0.00 d( nd all other applicable law. I have been instructed by the board of health on how too tain copi s of 105 CMR 90.0 and the federal Food Code. Signature of Applicant: \ � - c) 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: 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. Signature of Individual or Corporate Name By: Corporate Of '(r M andatory, if Applicable) **Social Security No. (Voluntaq) 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\Scou's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: 4u .1'�nd�U'1" U`IY1 ��J1� Phone #: ���'(g/j�l%✓ Are yo n employer? Check the appropriate box: I.EYI am a employer with Lt'employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised thew right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertairnnent 10.❑ Manufacturing 1 L❑ Health Care 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 #l. I not an employer that is providing workers' Insurance Company Name: Insurer's City/State/Zip air employees. Below is the policy Information. Policy # or Self -ins. Lie. # Expiration Date: 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 imprisomnent, 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 r y, under /h aiq and penalties ofperjury that the information provided above is true ^-d correct. Signature: Date: 11� Phone #: J 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 nAMrinlc-n1 MMICU A� CERTIFICATE OF LIABILITY INSURANCE DATIYYYY) 11271DD27/2020 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 License ff 17130862 HUB International New England 300 Ballardvale Street Wilmington, MA 01887 CO CT jac°O,"r o, E.p: (978) 657.5100 1 (NC,No:(978) 988-0038 E-MAIL DDREss INSURERISI AFFORDING COVERAGE NAIC it INSURER A: Hanover Insurance Com anv 22292 INSURED D'Angelo, Inc. 323 Manley Street West Bridgewater, MA 02379 INSURER B: MAPFRE Insurance Company 23876 INSURER C: INSURER D: INSURER E: INSURER F : RF\/11CInN MHMRFR- 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. ILSR A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY ADDL INSO SUBR D POLICY NUMBER POLICY EFF MMIDDIYY POLICY E%P MMIDD/Y1' LIMITS ENCE S 1,000,000 DAMAGE TO ce § 100,000 CLAIMS -MADE ❑X OCCUR LBN-D484878-01 1I1I2020 11112021 one emon S 10,000 DV INJURY ffSO S1,000,000GEN'L AGGREGATE LIMIT APPLIES PER: POLICY❑ of � LOG REGATE S2,000,000 OMP/OP AGG 2,000,000 COMBINED SINGLE LIMIT Ea accident$ $ 1,000,000 B OTHER: AUTOMOBILE LIABILITY BODILY INJURY Perperson) $ X ANY AUTO BJBDMV 11112020 11112021 BODILY INJURY (Per accident) S AUTOS OWNED ONLY SCHEDDUULLEEDp X AIRTES ONLY X AUTOS ONLY AUTOS Pe�aecident AMAGE S S A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE UHN046117401 11112020 111/2021 EACH OCCURRENCE § 20,000,000 AGGREGATE 5 20,000,000 DED X RETENTIONS O S A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERN%ER EXCLUDED? (Mantlstory in H) NIA HND442216 12131/2019 12/3112020 PSTA ER TE OTH- E.L. EACH ACCIDENT 600,000 5 E.L. DISEASE - EA EMPLOYE 500,000 $ DISEASE -POLICY LIMIT 500,000 S If yes, describe under DESCRIPTION OF OPERATIONS belowIF- DESCRIPTIONE.L. OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is reached) Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) V 7aGa-zU'ID Hvvnv vvr%rvK/1I Ivry. /aD nynm rabclvcu. The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS, OILS, and GREASE DISCHARGEPERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Ve11('Itl e-S Address: \ kLfcu^ Wnn, �>1 Mailing Address: % (Nr, Phone/Fax Number: (-.iti9) 2J"-�©1"Ru-0--:� Email: Gt-64lyyi Contact Person/Title for Grease Traps:_ ' k G I Name of Company scheduled to pump internal grease trap(s) monthly: 1 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 acknowl s that th nfor anon submitted in these documents is true, accurate and complete. Signed I . Date. h �� ��"� Print Name 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): o� Seating Capacity (Actual Count): r_ Normal Hours of Food Preparation/Service: yL�s W � fry-) Monday Tuesday Thursday Sunday Wednesday Friday 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 Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal 1 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? Yes No If yes, at what station/sink? 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 X 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: Property Owner's Name: Property Owner's Address: 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: c a CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: MELA011E M4THEws Certificate Number: 6762761 Date of Completion: ' 12019 Date of Expiration: WIM14 Din above-nan¢d person is be, issaed this cert firate Ar tompletiog as allergen awareness naiaingprogranr rerog,,ized 1ps the Mass ach to s at, Department ofPalo fir Health in accordance with 105 CMR 590.009(C)(3)(a). Diis certificate will be valid for five (-iI ),nrs J'rom date ofronrpletion. ❑'4elti` [vmed By: ' Mai NATIONAL 'TM-ml ASSOCIATION,,, Ma.nrhuutro Roetaurant Aswdation 800.765.2122 878 Turnpike Road, Sa1m 102 www.resnmmntorg Southbomugh,MA 01772 508-302-9905 wx+emarcetaurmuaswcurg p m X 3� N n w g' O o T N O Im x 3 �• v 3 Z 'A. e_. T � M. PATRIOUSERVICES, INC* Your Grease Trap Pro & Drain Specialist P.O. Box 294 LIKE Bridgewater, MA 02324 Us ON (508) 697-9565 1 (800) 449-4480 (508) 759-0979 www.PatriotServicesMa.com Date of Service Customer Name Address City Job Address (if different than customer) Invoice # Phone # 'Lip_ Apt. # I hereby authorize you to perform the above described services and 1 agree to pay the the right. I certify that 1 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. Customer Name PARTS LABOR OTHER TAX TOTAL DISCOUNT TOTAL DUE ro Customer E-Mail Address 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 #i Customer Name Phone # City 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. PARTS LABOR OTHER TAX TOTAL DISCOUNT TOTAL DUE Customer Name Customer E.Mail Address PATRIOT/SERVICES, INC. Your Grease Trap Pro & Drain Specialist P.O. Box 294 Bridgewater, MA 02324 LIKEIn (508) 697-9565 1(800) 449-4480 (508) 759-0979 US ON www.PatriotServicesMa.com Date of Service Customer Name Invoice # M Address City 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 l PARTS LABOR Terms: Cash OTHER PO # Bill Out TAX TOTAL This is to acknowledge completion of the above described work DISCOUNT which has been done to my complete satisfaction. TOTAL DUE Customer Name j Patriot Services Inc. PO Box 294 BRIDGEWATER, MA 02324 Bill To D'ANGELO'S 260 CHAUNCY STREET MANSFIELD, MA 02048 P.O. No. Description Quantity I ICLEAN GREASE TRAP FOR 3-BAY SINK TEST TRAP WITH LOTS OF WATER AND EVERYTHING WORKING WELL invoice Date Invoice # 10/22/2020 G3B1022202 Terms Project Not 30 Rate Amount 75.001 75.00 Total $75.0 `® �vlip - t \� � » 2 \ ft k� / / n C /moo I .A 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 c tomers. 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 Testjng and Materials) Standards for compostability. (l/Aty�j Y�—/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, slu ozen, semi -frozen, or other forms of beverages to the public for consumption. rI 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 Anes. Applicant Signature Applicant Name (please print