HomeMy WebLinkAboutEpicurean Feast (Cardinal Health) - 12/31/202100
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FOR BOARD OF HEALTH USE ONLY Permit # Issued, .
n
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening`
Establishment Namecar&ncd
Establishment Address � % t
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title: 3 e 1 d.t"ojt
Applicant Address � emd l� F I KA
Applicant Telephone No.: '7`4-d - UD31 24 Hour Emergency No.: g74--d-00—
Applicant Email Wormr . OVA6, com
Owner Name & Title (If different from applicant) P U
Owner Address W30 % t L fr lirryl V$0 W&Wj
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.
IR A Corporation
❑ An Individual
Name Title Address
IA A Partnership
El Other legal Entity
_ t
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: R t �Q_V-t OA-nw cremml pairarer
Address: I , , Q)r t A
Telephone No: '7t - — 24 Hour Emergency No:
FAX:
E-mail:
Alt E-Mail• oxikVvno
District Or Regional Supervisor (if applicable)
Name & Title: t t%4C {
Address:
Telephone No: 24 Hour Emergency No: `i " FiC it u
FAX:
y
E-mail: ,qt d—�� ( ¢ °i ce...Cowl
im
Food Establishment Information
WATER SOURCE: T e VA
SEWAGE DISPOSAL: T. vh
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS
NameofPe sons In"ChargeCF
Food Protection__()Management:
Name of Person(s) In Charge Certified in
Allergen Awareness Training
i
Name of pest control company routinely inspecting the premises for evidence of pests Ua
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. MYes
Does this establishment require a FOG
permit? JIM If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
❑ Retail Food $125.00 ( Mobile Food Consession
U Temporary
`wFood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
tl 'FOOD TRUCKS $175.00 Manufacture Frozen Desserts/ice Cream
Food Service up l0 101 -200 $250.00 $25.00/freezer
Temporary End Dale:
Food Service up l0 201 + $300.00 L Pushcart $50.00 # of Pushcarts;
Temporary Time:
Supermarkets $400
P LI Residential Kitchen $100.00
Rain Date:
Milk 8 Cream $10.00 ❑Caterer $35.00
i Food Operations: Definitions. PHF -Potentially
hazardous food fDmeltemperature controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous theatre timenemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processfrrq)
-,
.{, Sale of Commercially Pre -Packaged Non-PHFs
MPHFCooked To Order [ Hot PHF Cooked and Cooled or Hot Held
I Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery Packaged PHPs
Cold Holding For Single Meal Service I _ J PHF and RTE Foods Prepared For Highly
of
rAReheating of Commercially
❑Sale of Raw Animal Foods Intended Susceptible Population Facility
Processed Foods for Service Within 4 Hours
to be Prepared by Consumer ❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Self
Customer Self -Service of Non PHF and Non-
,Customer -Service contact alternative, time as a public health
Perishable Foods Only
[ l Ice Manufactured and Packaged for control)
[J Preparation of Non-PHFs
Retail Sale [I Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for Animal Origin
Other Food Operations
Retail Sale
[] Vacuum Packaging /Cook Chill
I] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
n 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 topics+i'n copies of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, see. 49A, i certify under the penalties of perjury that
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
knowledge and belief, have fled all stale tax returns
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.
C
By: Corporate Officer (Maiidatori, if Al licable)
�.U- r�'2,2172D
-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:\Usm\.sleite\Desktop\ScotVg Docaments\Food Establishments -'I emIATAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwmi nass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Pleasc.Print Legibly
Business/Organization Natne:
City/State/Zip:ff`iP, % , `} Phone
Are you an employer'? Check the appropriate box:
1.�I am a employer with 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]
In We are a corporation and its officers have exercised
their right of exemption per c. 152, §I (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/Fating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9, ❑Entertainment
10.❑ Manufacturing
I L❑ Health Care
12.E] Other __- ;
*Any applicant that checks box III must also tits out the section below showing their workers' compensation policy intonation.
O*Ir the corporate orficeis have exempted themselves, but tln corporation has otter employees, it workers' compensation policy is required and such an
organization should check box 111.
I am an employer that is providing workers' compensation insurance for my employees. Below is lire policy information.
Insurance Company
Insurer's Address:. 1. fEx`}r. _
City/State/Zip:-+
Policy # or Self -ins. Lie. 0 �} `: 4-1 C'}- .,J, ``Y� :,7 { { ? iy"7 Expiration Date:
T
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 q/'peijuiy 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
Phone
www.muss.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Na�
Name: C t��' y`�f � T a4{ . 4 st_l e'd
Address: db.
Mailing Address:
pp
Phone/Fax Number: 1 ( ca ml
Contact Person/Title for Grease Traps: ILL L:2- 11
Name of Company scheduled to pump internal grease trap(s) monthly: g
Name of Company scheduled to pump external grease trap quarterly: 6 f Ly er
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)
(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 /0
c
PrintName
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.
dd
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday -r raj
Thursday '9(); gJ�
Sunday
Tuesday. ;
Friday yn— q, e ,'
Wednesday e
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
0
Mop Sink
Garbage Disposal
i
AD
Ice Making Machines
0.
NO
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
If yes, at what station/sink? fj $ n
Id
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
(�vshxbshqr
Grease Trap 2
f t
Grease Trap 3
Grease Trap 4
Grease Trap S
External Grease Traps
Does this establishment have an outdoor Grease 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:
Property Owner's Name: _
Property Owners Address:
Property Owners 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:
Mr.
rvSafe
rIFICATION
WARREN SNOW
for successfolly completing the standards set forth hsr the SerrSafee Pend Protection Manager Oartificoflan Exa ninefion„
which is accredited by the American National Standards lasiliute,(ANSINCdnfemnae for Food Protection (CFP(.
5423
ER EXAM PORM NUMOER
3/19/2019 3/19/2024
DATE OF EX DATE. Of EXPIRATION
local laws apply. Ch cy (or receMhcation "onemeals
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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.
KV_ 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 - _ / �f Date: _ S ..-1"T - d oo-0
Applicant Name (please print clearly)