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Cafe on the Common - 12/31/2021
1' ` FOR BOARD OF HEALTH USE ONLY' Permit # Issued ESTABLISHMENT PERMIT APPLICATION must be submitted at least 30 days before the planned opening date) E bli ent Name Ca P r /Y1 A+ eo m �gs(ablishment Address 12 t j� / Y1G{ 1 Y! s of {ri 1 u�17�✓i�'eQ� mA oaGy� Establishment Mailing Address (if different) I(A flud"M Pr Wasp WA oavc-/ Establishment Telephone No 5a& 3 317 9/30 - - -- Applicant Name & Title: , Jane L3(fa 4t1, T>re jJe`n+ W v�_& ✓r'A Applicant Address I &P l jad�JOK Dr Applicant Telephone No.: #03 $)% 603 9 3 24 Hour Emergency No.: (90.3 &3 93 Applicant Email J 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 El An Association partner. X A Corporation O An Individual Name Title Address ne . Hprej (i2n4r A(P A Partnership nA/wbtxEl El Other legal Entity %~ Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: Dla"-/e' 3(�a+4 �,o der'+ "��'Wa4A—VPA 771� -�� Address: /tp ✓Trc�� DY 1 03vg/ Telephone No:.&03 8-n 0393 24Hour Emergency No: Cf/0;3 en o3T3 FAX: E-mail: �Iah c �ea4_�Ly 51 ct (9 IL C�r� Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: /I'O w�� SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) No. of Food Employees: DAYS/HOURS: WA--TAa iPYYI (gym-,�p_�► Name of Person(s) In Charge Certified in Food Protection Management: I, l y L at'k'n f lC Name of Persons In Charge Certified in Allergen Awareness Training l� vy J71 a� L ea.�kj l e t o-m �A�-- Gcr� 'Gt� 111 s � l �I -5 t L�-�� ± bu ( f 6. Name of pest control company routinely inspecting the premises for evidence of pests 7 If there is seating for 25 pe�o0or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. 1.!Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. of Permit: Establishment Type: ,LLength ,P Nnnual , Retail Food $125.00 Mobile Food Consession El Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 El Manufacture Frozen Desserts/Ice Cream Temporary Start Date: [ewt'Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: El Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: ,Milk &Cream $10.00 Q Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(timeRemperature controls required) Non-PHFs- non -potentially hazardous food(no timeRemperaturs controls required) Check all that I t PP Y) RTE- ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ,2 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held El 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 i] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended 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 of Non PHF and Non- Customer Self -Service 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 El Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill E] Offers RTE PHF in Bulk Quantities i] 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 CM�R 590.000 ar}d the federal Food Code. Signature of Applicant: 1 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: t� WE tue uommonweattu of/vlassacuusetts 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: Address: #`:' Are you an employer? Check the a propriate box: Business Type (required): 1�I am a employer with M employees (full and/ 5. ❑ Retail or part-time).* 6.7estaurantBar/Eating Establishment 2. ❑ 1 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.❑ 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, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 must also FII 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. lain an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: San A 7MS-/ City/State/Zip: /ry %� !'1 I � � � �tr Policy # or Self -ins. Lic. # it E IAZ !/ C 9k,6Oc;- I o� 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 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. / 1 do hereby certify, under the pains and penalties ofpeVwy that the information provided above is true and correct. 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 www.mass.gov/dia Phone 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. -ic�-r1 cJ -Pay 1�P� Signature of Individual or Co rate Name By: Corporate Officer (Mani atory, if Applicable) ,355 ay 3) "*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\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc C..- f (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Twin City Fire Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 14974 Company Code: 7 1W TTIEA fl"TFORD Suffix _ LARS RENEWAL POLICY NUMBER: 08 WEC NK6212 15 Previous Policy Number: 08 WEC NK6212 1. Named Insured and Mailing Address: CAFE ON THE COMMON INC (No., Street, Town, State, Zip Code) 16 AUDOBON RD WALPOLE MA 02081 FEIN Number: 04-3552431 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 12-14 MAIN ST MANSFIELD MA 02048 2. Policy Period: From 04/01/20 To 04/01121 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: UNDERWRITERS INS BKGE INC/PHS PO BOX 796 NORFOLK MA 0205607 Producer's Code: 08088324 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 Total Estimated Annual Premium: $9,137 Deposit Premium: Policy Minimum Premium: $265 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by IfF—'1`41 Cav 1 02120/20 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 02/20/20 Policy Expiration Date: 04/01/21 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. 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, sl1urryy,, frozen, semi -frozen, or other forms of beverages to the public for consumption. V 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 ��[�� /y✓ G�//// Date: /00 & Applicant Name (please print clearly) j J1 r✓ § 180-17 ARTICLE III Plastic Waste Reduction [Added 4-10-2018 ATM by Art. 451 § 180-16. Purpose. The purpose of this bylaw is to protect the Town's natural beauty and irreplaceable natural resources by reducing the number of single -use plastic check-out bags that are distributed and used in the Town of Mansfield and to promote the use of reusable bags. § 180-17. Definitions. The following words shall, unless the context clearly requires otherwise, have the following meanings: CHECK-OUT BAG — A bag provided by a store to a customer at the point of sale. Check-out bags shall not include bags, whether plastic or not, in which loose produce or products are placed by the consumer to deliver such items to the point of sale or check-out area of the store. DEPARTMENT — The Mansfield Health Department. HEALTH AGENT — The Health Agent for the Mansfield Board of Health or their designee. RECYCLABLE PAPER BAG — A paper bag that is 100% recyclable and contains at least 40% post -consumer recycled content, and displays in a visible manner on the outside of the bag the word "recyclable" or a symbol identifying the bag as recyclable and a label identifying the bag as being made from post -consumer recycled content and the percentage of post -consumer recycled content in the bag. RETAIL ESTABLISHMENT — Any business facility that sells goods directly to the consumer, whether for or not for profit, including, but not limited to, retail stores, restaurants, pharmacies, convenience and grocery stores, liquor stores, seasonal and temporary businesses. REUSABLE CHECK-OUT BAG — A sewn bag with stitched handles that is specifically designed for multiple reuse and that: A. Can carry 25 pounds over a distance of 300 feet; B. Is machine washable; and C. Is either: (1) Made of natural fibers (such as cotton or linen); or :1 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: L PY) cY--Pt Ue( i'Y? MA"Y(._—�L-/i�') Address: Mailing Phone/Fax Number: 4P/,3 a % 103 93 Emai Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: U m t'l i T }'LG%/ Name of Company scheduled to pump external grease trap quarterly: Y�(%i, b / srl Please attach the following documents to this application: rvt a - Yw I 1 • Most recent waste hauler receipt or waste hauler manifest 6t r-O IU,la • 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 information submitted in these documents is true, accurate and complete. Signed ��.CJ �l�I/ v� Date 1420—/a22 Print Name C P 7� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSA-FE Fax # 617-727-7749 www.mass.gov/dia -orm Revised 5-26-05 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): Seating Capacity (Actual Count): I � � / /.ems /UM-) Ozyid Yyl;f"A J Normal Hours of Food Preparation/Service: Monday /off vY�-3torn Tuesday O/q yy')-3,Oto Wednesday O/w 3�rn Thursday Friday �)� Saturday UZ 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 Handwashing sink Commercial Dishwasher j� Bar sink Mop Sink loo 0 Garbage Disposal Ice Making Machines PO 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): 1 nri va �-e ('ry . —` & c%a-n Is dinnerware pre -rinsed before being washed? Y�es, No If yes, at what station/sink? tu soap 2 Grease Traps 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 �Sn vv 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 NNo� '//n,, Size gallons Where is the existing outdoor GRU located? /� f3)( i7 'ox If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: —� k Property Owner's Name: ja m-e— �/� f Property Owner's Address: // M /�bl— U/' Cf lJ/—� n1)' Property Owner's Telephone Number: &03 g1% bQ q 3 Qde'vdl Yellow Grease Waste Do you store yellow grease waste from fryolators?? Where is the grease storage unit located?u'rci'Yt/J How often is this grease storage unit emptied?_ rISW/ rf/`fLKJ �— Please list the vendor who removes the waste: Scanned by TapScanner the A ways company 4h _idl�[P%�Ld �^ Merrie Levy j� O The Always Food Safe Company Allergen Awareness Employee Food Safety Online Course & Exam Date: 01/25/2019 (valid+ until 1/25/2022) course reference: ALGN Learner reference: ALGN100162141 This training is approved for 1 continuing education hour toward the initial or recertification application for ACF certification Nick Eastwood The Always Food Safe Company President 899 Montreal Circle, St. Paul, MN 55102. The Always Food Safe Company www.alwaysfoodsafe.com ANS/ ACGPEDITED Congratulations! Go ahead and frame the big copy-- you've earned it! Keep in your wallet for anytime, anywhere proof you passed! For your managerto keep and admire s rr,� w ' Always Safe company -, Mania Merrie Levy The Always Food Safe company Allergen Awareness Employe. Food $.W, Online CAasse & Exam Dare, 0112512019(yalidt until 125/2022) cea,ae mrerena: ALGN IPerne.....eocm ALGN100162141 This training is approved for t continuiag edon hour coward the initial or reced6kation application for / ACF certification HI<t Ea[IwooJ 1ne Nways Feoa Sara Company pl]a) P,Psiaenl B99 Monheel Cl,tle.Sl Paul. MN S51n]. mealway[rooasnaePmwnv w.aw.vway.mne:,r:.<Pm Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! Ithe ,4fways safe pcompany ' 2�F t <]!�:/ j r/� ,.a„ern!•,., moo�J.dla: ' Marra Levy The Alwoys Food We Company Allergen Awareness Employee Food Solety Online Course & Exam Dare: 0125/2019 (validt until I25/2022) coa,aerela,ana: ALGN soa.ne, mrarence, ALGN100162141 This training is approved for 1 mminuirg education hour toward The initial or recertification application for ACFcer00catton Nltla EaitwooE .11 NWaya Pootl Sare Company P,esltlenl 899 Monneal L'vflp. Sl PauI.MN551o]. ThaawavPoou serecamwm smrw.mwyaloodaa(P<om ALUMNI REFERRAL CODE vc-alumref-30272-1129734 Managers: Get the best training for your staff at alwaysfoodsafe.com/manager and get 10% off $25 or more with this referral code! 'the r F .. Safe company ✓�'MM r " �Ja� dTl" eXr�ayPrnzP�2t `td a�vmsrderL �• William Fisher Off -line.Jucc*A1e crvrrz��'alfec` The Always Food Safe Company Allergen Awareness Employee Food Safety Online Course & Exam Date: 01/24/2019 (validt until 1/24/2022) course reference: ALGN Learner reference: ALGN1001601172 This training is approved for 1 continuing education hour toward the initial or recertification application for ACF certification a Nick Eastwood The Always Food Safe Company #1203 President 899 Montreal Circle, St. Paul, MN 55102. The Always Food Safe Company www.alwaysfoodsafe.com Congratulations! Go ahead and frame the big copy-- you've earned it! Keep in your wallet for anytime, anywhere proof you passed! w x x Safe company ?�. - 41)1 / William Fisher - Me/Jways Ewa Sale company Allergen Awareness Employee Food Solety online Comse L Exam oases 01124/2019(vallit until 1124/20n) eamaerere,ea[e: ALGN mnncrmmmn[p ALGN1001601172 This training is approved for l continuing education hour loward the initial or recertification application for f ACF ceddleatbn Nlek EaMwppa Thp Nways Faatl sab[ampany O Glr<Ie. 54..1.M N551at. 9In. r,Vd-1 11:e Nways Roa Sale x Mont[eal wmpanY wwvr.always(optlsafe.[on: Students: Did you buy this course yourself? Give this code to your manager! If they use it, we'll refund your purchase (up to 1 course)! For your managerto keep and admire the Alway =Safe r r �� company William Fisher lee Always Fa of Safe Company Allergen Awareness Employee read Safety Cnllne Coarse 5 Exam m9e: 0112412019 (validt until 1124/2022) eoarserenrep[.: ALGN Laame, roremp[e. ALGN1001601172 This training is approved for l continuing education hour toward the initial or recer110cagon application for / ACF cenJicaUon NFalwooa me NwaYs raoE santpmpany nxos —ltl es enl MN 2 B99 SL pa Montreal CLtle. u1.551n nne Nwayf lopaSte Campary warva.alwayilppmare.[um ALUMNI REFERRAL CODE vc-alumref-30202-1127370 Managers: Get the best training for your staff at alwaysfoodsafe.com/manager and get 10% off $25 or more with this referral code! w O W U w_ l W U V uzu I� z � J W z W E4 m O � N � N N 0 0 U 0 CLI ry 0 Z U . Q Q Z '^ O �M Pi X 0 NMI M fi 4 Q � y C Ga N y Y a I. G ti q h f` Y V O y y V V 1 h C K C � ^O O C V A L O �yY � AN fi O C �wrv� y V � M ■� � E \ \ ) \ / ! § ® : a � .G,70Z z gG! of-0 z \�[ %®\ y % / 3 ) (\\) © R H \ � / Q� z *-..0 z V) con �w z � z W-4 (M� � � � � W o } § \ ) ) \ \ ƒ � § % \U \ \\\\ ) � / w O W U w w U V z z Cn W z �w 14 I z w W ` o 9 IA I c o_ E LL u� U c c o o 'o ;c Q v w w o� 'Z o w O o m f ¢ o m o Z a E d 1 x 2 Q N LL Q 0 O 0 o 00 V R = (0¢ N Z c N r Ln X ¢ w s O 'D W t _ _0 C O � Z "U O � � m Z) m� a 3 M ws M 2 o ti N O o LTWMXw ANSI o., o fuawt.w qxd-,. 175 WM ".&. A. f 4 aSrr5de9rabua+_ap 0 BRANDON JENNER for successfully completing the standards sel forth for the ServSufe®:Food Protection Manager Certification Examination, Which is accredited by the American National Standards Institute (ANSIFConference for Food Protection (CFP). 5340 ba ER EXAM FORM _NUMBER 3/12/2018 ' 3/1212023 DATE OF I Loral laws apply. DATE OF EXPIRATION Solutions C-W ulM 1� .)33 S. Wady a.:.e, S6l 3WU. chka , L �83 a SwWea�e�wmn.o-p. 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