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HomeMy WebLinkAboutEpicurean Feast (Medtronic) - 12/31/202170. FOR BOARD OF HEALTH tUSEONLPermit#Issued FOOD ESTABLISHMENT PERMIT APPLICATION � "' '?o (Application must be submitted at least 30 days before the planned opening da`4_ — -- - Establishment Name JCJ�i(t PGvrnw pgea Establishment Address 66 �6vnp' ihs ^ Establishment Mailing Address (if different) yC Establishment Telephone No ° -d a)- (a Applicant Name & Title: t � Knorr Applicant Address- &a )7 Applicant Telephone No.: 1 24 Hour Emergency No.: N-9 - MI Applicant Email (, y Owner Name & Title (If different from applicant) KKQ rwovp Owner Address -0 WbAn Owner telephone number Lfi(al V6- Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or EJ An Association partner. LEA Corporation An Individual Name Title Address} y t - !& 1 1 A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: n4,Qvi . - gqr- `- Address:'Te „, c , 14VA, ON)7 Telephone No: B @ u, _ M 24 Hour Emergency No: W _rdU) ` ' I FAX: E-mail: � ' ` � G�. C'r ® Y Alt E-MaiCec 16'u1 C �. --- District Or Regional Supervisor (if applicable) Name & Title: (( Address: Telephone No:� �&.0 0 24 Hour Emergency No: ri T- % Wo FAX: } E-mail: eta t 1 J, , , (D1, Food Establishment Information WATER SOURCE: an SEWAGE DISPOSAL: bV DEP Public Water Supply No: (If applicable) No. of Food Employees ,�g.y -S- _ DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Ban rt Vv.' Name of pest control company routinely inspecting the premises for evidence of pests L'D la #r 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. Klees Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: `t f Annual ❑ Retail Food $125,00 L] Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Dale: FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream 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: Ll Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: j Milk & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions:PHF- Polenh'ally hazardous food(limeftemperature controls required) (Check all that apply): Non-PHFs- non-potentlariy hazardous food(no rtmeJlemperatum controls required) PP y)' RTE -ready-to-eat foods (Ex sandwiches, salads, muffins which need no fudher processing) Sale of Commercially Pre -Packaged Non-PHFs [,pHFCooked To Order [] Hot PHF Cooked and Cooled or Hot Held 1 1 Sale of Commercially Pre -Packaged PHFs ja.Prapnralinn of PHFs For Hot And for More Than a Single Meal Service 1] Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Reheating of Commercially ❑ Sale of Raw Animal Foods Intended Processed Foods for Service Within 4 Hours to be Prepared by Consumer ❑ Use of Process Requiring A Variance 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 n Ice Manufactured and Packaged for control) - of Non-PHFs Preparation Retail Sale p [] 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 n Prepares Food/Single Meals for �] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 1, the undersigned, attest to the accuracy of the Information provided in this application and affirm that the food establishment operation will comp with 105 CMR 590,000 and all other applicable law. I have been instructed by the ealth board of hon haw to obtajO.f 0pas of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: 0_4;z .I'`' II � 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 lax returns and paid state taxes required under law. Social Security Number or Federal ID: !r ' Signature of Individual or Corporate Name RECOGNITION OF COMPLETION Kristen Farrar has successfully completed ASHI Online Training for: CPR and AED All Ages (G2015)-DC (Blended) Completion Date: 12/17/2019 Blended learning consists of computer -based, online lessons combined with hands-on skill practice and performance evaluation. This document confirms that the above -named individual has completed the required online lessons and is now eligible for hands- on skill practice and performance evaluation by a current and properly authorized ASHI Instructor. is � � � � r; \z�< - � 7 ._� w ¢� < ©_ £ :. �������� e � . : . ���� � � � � � } � � � � � ° ;- �.�� � � « � � � � � � � � � � \ > � \ % ,} � � � � � � � � m«���/�� ' � &\ �� v� f �o tf .e a .o j z 1 o c P .L Ew Q m o c -E m � a uv � � u v NL U O .0 �. 3 7 ® A� O CERTIFICATE OF LIABILITY INSURANCE DAM(MMIDDIYYYY) 10/21/2020 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 ORALTER 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(les) 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 Roger Keith & Sons Insurance Agency Inc. CONTA NAME:CT Elise Fiano PHONE 506 583-1108 FA (5 AIO No. E„1; ( ) A/C. No): E-MAIL eflano@mgerkeith.com ADDRESS: 1575 Main Street INSURERS) AFFORDING COVERAGE NAICN INSURERA: The Charter Oak Fire Insumace Company 25615 Brockton MA 02301 INSURED LPM Holding Co. Inc. INSURER B: The Travelers Indemnity Company 25658 INSURER c, Travelers Property Casually Company ofAmerica 25674 INSURER D: The Phoenix Insurance Company 25623 INSURER E: MA Retail Merchants WC Group Inc. 580 Main Street; Suite 1 INSURER F: Association Members WCT Bolton MA 01740 GUVt:lI ucrcI - THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED, NOTWITHSTANDING 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. ILTR TYPE OF INSURANCE INS WVD POLICYNUMBER POLICY EFF MMIDDIYYVY POUCYEXP MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 IMUTISSTURENTED PREMISES Ea oocurance $ 10 CLAIMS -MADE FX OCCUR MED UP (Anyone person) $ 1,00,000000 A 630-6C830447 011011202E 01/01/2021 PERSONAL &Am/ INJURY $ 1,000,000 GENERALAGGREGATE $ 31000,000 GEMLAGGREGATE LIMIT APPLIES PER: ❑ PRO- PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY JECT LOG LIQUOR LIABILITY $ 1,000,000 OTHER: COMBINED SINGLE LIMIT Ea accident $ 1,000,000 AUTOMOBILE LIABILITY BODILY INJURY(Per Person) $ X ANYAUTO BODILY INJURY(Peraccident) $ B OWNED SCHEDULED 810-9N416097 01/01/2020 01/01/2021 AUTOSONLY AUTOS HIRED NON-OVMED PROPERTY DAMAGE Per accitlenl $ AUTOS ONLY AUTOS ONLY X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 25,000,000 AGGREGATE $ 25,000,000 C EXCESS LIAB CLAIMS -MADE ZUP-91M48908 01/01/2020 01/01/2021 G: EXCESS LIABILITY $ 35,000,000 DIED RETENTION $ PER OTH- WORKERS COMPENSATION STATUTE ER E.L. EACH ACCIDENT 1,000,ODO $ AND EMPLOYERS' LIABILITY YIN D ANY PROPRIETOMPARTNEWEXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? N/A 118-9H942545 01/01/2020 01/01/2021 1,000,000 (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE S E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below Bl by Accident Accident $1,000,000 E WORKERS COMP & EMP LIAB 014000502016120 01/01/2020 01/01/2021 BI by Disease Policy Limi $1,000,000 MASSACHUSETTS ONLY - BI by Disease /Employee $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) F: WORKERS COMP NH ONLY, 030009100240120, 1MI2020-1/1/2021,$1,000,0001$1,000.000/$1,000,000 G: EXCESS LIABILITY, Federal Insurance Company NAIC 20281 POLICY LIMITS IN EFFECTAT POLICY INCEPTION. Town of Mansfield 6 Park Row SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Mansfield MA 02048 I ( "f n 10 R-Prods Ar.nRn OnRPORATION. All riahts reserved ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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. &1 ,1143 dCv / By: Corporate Officer (Mond Cory, ' plicable) 1k - 2Q q 32L? "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:10sers\sleite\Desktop\Seott's Documents\Food ❑sutblishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.moss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: t P MY L }GIJM,0, City/State/Zip: Are you an employer? Check the appropriate box: i.❑ i am a employer with C,XD employees (fill and/ or part -tine).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 31 We are a corporation and its officers have exercised their right of exemption per a 152, § 1(4), and we have no employees. [No workers' comp. insurance requied]' 4.❑ We are a non-profl organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #: 4(1 4 - (-(` Business Type (required): 5. ❑ Retail 6. ❑ Resti urant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. ❑Entertainment 10.❑ Manufacturing 1 Ln Health Care 121 Other *Any applicant that checks box # 1 must also Ell out the section below showing their workers' wmpensalion policy information. **If the corporate officers have exempted themselves, bat the corporation has other employees, it workers' compensation policy is required and such an organization should check box #1. I am art empkiter that is providing workers' compensation insurance, for my employees. Below is tine policy information. r InsurauoeCompanyName: ((-`(2\ h Insurer's Address: � • (� - �-- -F ��i City/State/Zip: �i: .0y-v Policy 9 or Self -ins. Lic. # <_,} , C 1 3 `'ri..> :. } > { d i%3 Expiration Date: C) I j % J I It Attach a copy of the workers' compensation policy declaration page (showing the policy number expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a Fine up to $1,500.00 and/or one-year knprisonnient, 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cent y, under llte pains and penalties of perltery liar the information provided above is true and correct. 0jf1ci d use only. Do not write in this area, to be completed by city or town gfficial. City or Town: Issuing Authority, (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Phone www.mass.gowdm Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Mailing Address: w i)1 'a e <3 Phone/Fax Number: ( 9 Email: gwt (rift { Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: A�)i t 1y ar 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 information submitted in these documents is true, accurate and complete. Date Print Name 41k 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): I Seating Capacity (Actual Count): T Normal Hours of Food Preparation/Service: Monday Thursday 7 u Sunday t _ Tuesday ''7 - f ; Friday 9 f,0" -s Wednesday --sJ 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 I a Handwashing sink VAO Commercial Dishwasher Bar sink Mop Sink ''�q Garbage Disposal q Ice Making Machines _ Fryolators VIC-) Grills or Ovens y V'l() Exhaust Hoods L i 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? V, Yes If yes, at what station/sink? t h b 4fiVtk9 rk-r No Grease Traos 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 S. 3 @ e, 't Grease Trap 2 s 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 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? 0 3 How often is this grease storage unit Please list the vendor who removes the waste: % Vbmymd, i d! 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. 'r°' 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 4tj.r Date: Applicant Applicant Name (please print clearly) K` 1� is tJe r L