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HomeMy WebLinkAboutThe Fresh Catch - 12/31/2021490 � IP FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned openingfate OCT Establishment Name // j"re g(l, dkA Inc. Establishment Address 30 6rI 134-, i Establishment Mailing Address (if differ t) p0 flV- 3'l Establishment Telephone No S0S' g^-6)97 Applicant Name &Title: W ifl;,IA4 F JANw Applicant Address Jt53 7-1!/ r; L, 8f- (jam"ZAA ffK F2 1311f Applicant Telephone No.: So 5 --yee f- &(0 Fb 24 Hour Emergency No.: �f of (4 PEa tr ff� Applicant Email tilt 0 fps e4 0ne. eo Owner Name & Title (If different from applicant) Owner Address JAAOL Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. VA Corporation An Individual Name Title Address &fjjV&4 Sojm d 42 dajK 0�k A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: kf-ffirm F.'f / Address: AW A11-1tfe 2 48tg-s Telephone No: 24 Hour Emergency No: 5,og_4j0q_Ul��d3 FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: r-'ei s Address: 19 F 0&4A 14M.*"Vart M4 0613AII Telephone No:S'e9 ,, /SIX 24 Hour Emergency No: FAX: v06'.391 ° Jly/ E-mail: l-t ja.Gee dam[°. c®Pi Food Establishment Information WATER SOURCE: f PSEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: S ,'t DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: re,, d-A its Name of Person(s) In Charge Certified in Allergen Awareness Training Se%e 4 �� J�6Z ilo act; os a Name of pest control company routinely inspecting the premises for evidence of pests 4,/tff e �roq If there is seating for 25 peolale or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. L!fl Yes Does this establishment require a FOG permit? Yo If yes, please attach the FOG permit application. Length of Permit: Es ablishment Type: VAnnual etail Food $125.00 Mobile Food Consession EJ Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Q 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 E] Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 '.. Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food (time4amperature controls required) Non-PHFs- non -potentially hazardousfood(no dme/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs L' PHFCooked To Order T Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Ri Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Susceptible Population FoodsPr par d For Highly Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer E] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand contact alternative, time as a public health Customer Self -Service of Non PHF and Non- Perishable Foods Only I Ice Manufactured and Packaged for control) Retail Sale Preparation of Non-PHFs 0 Offers Raw Or Undercooked Food Of E] 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 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 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 ofM 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 fled all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: 044-.� 701 / to Signature of Individual or Corporate Name: AauLt, l.nlla ana Imam Lrm/ACU CERTIFICATE NUMBER 156398649773388 Brenna Audette INSTRUCTOR DATE ISSUED RENEW BY 24JUI2019 24 JUL 2021 ROY W.SHAW R1DD i THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTMININGS scan code Or enter certificate number at pmnainings.com/validate i CURRICULUM ANDTHE 2015 AMERICAN HEART ASSOCIATION®GUIDELINES µwW,pmlrainings.com support@pmlrainings.com i L------------------------------------� Dear Brenna, Your Community CPR certificate is printed above. You can access this page anytime by logging into www.protrainings.com and clicking Print Certificate. Expect your durable card in the mail 5-7 business days from now. If there are any errors with your card or your mailing address below, please contact us at support@protrainings.com BRENNA AUDETTE PO BOX 23 MONPONSETT, MA 02350-0023 US Sincerely, The ProTrainings Team P.S. If you had a good experience with us, please tell others about ProTrainings! N-..'°'' M y 00656 6751 Forum Drive, Suite 220, Orlando, FL 32821 P (800) 446-0257 F,(407) 352-3603 www.NRFSP.com National Registry of Food Safety Professionals` Notification of Test Results ID#: XXX-XX- Scaled Test Score: 92 Candidate Status: Pass Test Date: August 24, 2020 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES. BRENNA J AUDETTE HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS Congratulations! Attached is your certificate and wallet card. Please notify the National Registry of name or address changes at the address below. Ensuring Personal Hygiene (Competent) Managing Food Holding Time and Temperatures (Mastered) Preventing Contamination, Cross -Contamination, and Cross -Contact (Mastered) Managing Cooking Times and Temperature (Mastered) Monitoring the Flow of Foods (Competent) \�� Actively Managing Controls in a Food Establishment (Mastered) Managing the Physical Food Establishment/Equipment Design and Maintenance (Mastered) Managing Cleaning and Sanitizing Activities (Mastered) PRESIDENT: LAYVRENCE J. LYNCH, CAE ISSUE DATE: AUGUST 24, 2020 EXPIRATION DATE: AUGUST 24, 2025 CERTIFICATE NO: 21698079 TEST FORM: EXE88 This ceNficam Is oat vaaC far mom thm 6n years 5om 4ete din., in., National Registry of rood Safety Professio CERTIFIED FOOD SAFETY MANAG) BRENNA J AUDETTE BRENNA J AUDETTE 39 OCEAN AVE HANSON, MA 02341 Certificate Noe 21698079 Issue Date: August 24, 2020 Expisa0on Date: August 24, 2025 National Registry of Food Safety Professionals® 1 6751 Fomm Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407.352.3830 1 Fax: 407,352,3603 40 C m 8 n 0 � a H a � O U � � o � w O 1--1 --a), H W � U 0 0 0 H A C 0 L7 me *v � ` / � $ k eq ƒ � CN q � � $ � L B t \ w t % % z 0 \ !,\ / \\<2 \)k) \ )§)\ » w}\) \ 7[)5 A � 41, / � / I o \ ~ 2 � 7 C4 o eq § E 2 E 1 � CL � CL 2 � § @ k . . CL / \ w % z k� 2 «■) \ \ »\\\ \ -'Zt 2 a \R P / � � I � § � / 7 W-4 u 6w B k ' ' - 0 0 Q w e % ° 22 e � W *4 �-4 I � V) 6w z / § § k C f L C%4 e LL / L k tB w © z % 2 0 o k 0 \ ) «r) / §®•° of\\ ) §`#§ )(\\ \ /�$ \ � / TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. PiN1 41 o Signature of 1 ' al or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **Social Security No. (Voluntanj) 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. CAUsers\sleite\Desktop\Scott'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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEibly Business/Organization Name: & eta&, 4,4kA Aa. Address: do C&VA c*f St City/State/Zip: AfAlhe4 IM 07-04 Phone#: S64'331'SiS7 Are you an employer? Check the appropriate box: Business Type (required): L MI am a employer with employees (full and/ 5. Retail or part-time).* 6. estaurant/Bar/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 [No workers' comp. insurance required] In 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, I1.❑Health Care 12.0 Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #] 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: MIT &41 ogl /t LrJ i e`d Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 01416® 311 "12° Expiration Date: 1111A* 2.i 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 of perjury that the information provided above is true and correct. 0 Phone #: 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 FRESCAT-01 AKAHANOWITZ T ACORD" CERTIFICATE OF LIABILITY INSURANCE 14 / DATE(MM/DD/YYYY) 10114/2020 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(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 endorsement(s). PRODUCER CAME:ONTACT N R. S. Gilmore Insurance 27 Elm St North Attleboro, MA 02760 PHONE (ac, No, Exq: (508) 699-7511 (wc, rvo : 508) 695-3597 ADDRESS: INSURERS AFFORDING COVERAGE NAIC If INSURER A: Arbella Protection Insurance Co. 41360 INSURED INSURER B: MA Retail Merchant's Workers Comp INSURER C: The Fresh Catch, Inc. INSURER D PO Box 34 Mansfield, MA 02048 INSURER E INSURER F : CnVFRARPS CFRTIFICATE NIIMRFR- REVISION NUMBER: 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. INSR LTR rypE OF INSURANCE ADDLSUBR N D D POLICY NUMBER POLICY EFF DD POLICY EXP MM DD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 8500069643 2/2812020 21281202, i EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREM SES Eao 100,000 MED EXP (Anyone arson 51000 PERSONAL &ADV INJURY 110001000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jEC`j 0 LOG OTHER: GENERAL AGGREGATE 2,000,000 PRODUCTS - COMP/OPAGG 2,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X ALTOSyy Ep X AUTOS ONLY X AUTOS ONNLY 1020080964 2/28/2020 2128/2021 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Per person)$ BODILY INJURY Per accident $ Perr scaRld AMAGE U MBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE DED I RETENTION$ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICERIMIMTRI�EXCLUENEEIECUTIVE Y� (Mandatoryin NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 014005031479120 1/1/2020 1/112021 BTATUT DERH E.L. EACH ACCIDENT 500,000 E.L. DISEASE - EA EMPLOYE 500,000 E.L. DISEASE - POLICY LIMIT 500,000 A Liquor Liability 8500069643 2/28/2020 2/28/2021 2,000,000/1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) CFRTIPIr:ATP 441711 DPR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) 01988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: f rreS 0n6 Address: d owet &4 3f - 'and hri l °C 0 Mailing Address: APO &C jf A4orkef Y Phone/Fax Number: " : - Srs 7 Email C,,4-e& r t7C. em Contact Person/Title for Grease Traps: *6 Name of Company scheduled to pump internal grease trap(s) monthly: A h&Vk I S fed Name of Company scheduled to pump external grease trap quarterly: 1W 4e�Axd� 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 container $50 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 �� // — Date /d/Ll/ 102 CJ Print Name Wilk4A U 1tr _ Facility Onerational 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): Normal Hours of Food Preparation/Service: Monday /I - Thursday /,r - Sunday %" 7 Tuesday Friday Wednesday A® 7 Saturday M-F 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 OIL 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal ® Ice Making Machines Fryolators CPI Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., inthree (3) bay sink, off site by private company): �6r�®9dtdd!��do byb I A ®d r)..'fr. "e, Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? '14 & 2 Yes 11 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 �'kk J 4 X k, Grease Trap 2 h4ela s> A 0(eii 11thk 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 Owners Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? ) tc How often is this grease storage unit emptied? Please list the vendor who removes the waste: & L14PA4m ®cue hD 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. 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 /`/ ' ((1T Date: / 111 2i12 oO Z Applicant Name (please print clearly) IM444 c3AWf