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HomeMy WebLinkAboutGeno's Restaurant - 12/31/2021FOR BOARD OF HEALTH USE ONLY2 i Permit # Issuedy FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name Establishment Address�� ��t}�7it vl�id4t(r1 Establishment Mailing Address (if different) Establishment Telephone No 5 �� — 3 9 `577 f Applicant Name & Title: rl c5Z-t�A J� ii' V--�z to Applicant Address S` Applicant Telephone No.: 724 Hour Emergency No.: Applicant Email CC' 08 '36 Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: El An Association ,4-?701!�orporation LI An Individual C I A Partnership El Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address As yqat>vc—� Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: -40 0 t°C-7 Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: /_NUMIF1iF11A District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: To tv h SEWAGE DISPOSAL: Trot✓ r) DEP Public Water Supply No: (If applicable) - - -- ---------- - ---_ No. of Food Employees:____ ---------5- - DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: KoomC Name of Person(s) In Charge Certified in Allergen Awareness Training -- -- -- - ---- ---- --------- --- CAI ^4<b H Name of pest control company routinely inspecting the premises for evidence of pests 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. El Yes Does this establishment require a FOG permit? V If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual [ i,RetmI Food $125,00 E] Mobile Food Cansession ❑ Temporary '__. Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 [� Manufacture Frozen Desserts/Ice Cream Temporary Start Date: � Food Service up l0 101 -200 $2�0.00 [_r $25.00/freezer Temporary End Date: L] Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 El Residential Kitchen $100.00 Rain Date: , J<li � rvulk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions. PHF Potentially Iazardous food (thnolhurperalum controls required) (Cheek all that apply): Nan-PHFs- non-pofenfhdly hazardous food(notime/lemperature controls required) RTE ready-lo-eat foods (Ex. sandwiches, salads, muffles which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order I i Hot PHF Cooked and Cooled or Hot Held L] Sale of Commercially Pre -Packaged PHFs U Preparation of PHFs For Hot And for More Than a Single Meal Service of Packaged PHFs Cold Holding For Single Meal Service Delivery Y 9 [_� PHF and RTE Foods Prepared For Highly Susceptible Population Facility L] Reheating of Commercially Sale of Raw Animal Foods Intended to Prepared Consumer LJ Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours st Customer Self -Service l er 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 I,] Ice Manufactured and Packaged for control) E] Preparation or Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill L] Offers RTE PHF in Bulk Quantities n 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 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;Q67MR 590.000 apct)he federgt Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certil and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: under the penalfies of perry that I, to my best knowledge and belief, have filed all state tax returns / -A3 <9It-2-73 <�;4? 7,6� Business/ Food Establishment NameYl// mot/0 W © S T►C �8l �V��Ul � Address: b ` 4-rk lS - Mailing Address: -�5A444 Phone/Fax Number: ;5' 33z"— �77. C^ voP Email: G G44-35 Contact Person/Title for Grease Traps: -A C Pt l `c -at 7 L Name of Company scheduled to pump internal grease trap(s) monthly: 1 tsci— C 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 $SO 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 Date -1 G Print Name -� y`f �l 1C ii'(> Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an ernplgyee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written. - An eutlVoyer 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 it 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 nnaintcaance, construction or repair work oil 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, w'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 m• 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, yv'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 ontown 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 Thal the affidavit is complete and printed legibly. The Department has provided a space at the bottom of (lie 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 fit the permit/license number which will be used as it reference number. In addition, an applicant (fiat must submit multiple permiNicense applications it 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 oil each year. Where a home owner or citizen is obtaining it license or permit not related to any business or commercial venire (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 its a call. 'file 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-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Donn Revised 5-26-05 Facility Ooerational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. �t Seating Capacity (per Fire Department Regulation): I l /" Seating Capacity (Actual Count): sawile—_ Normal Hours of Food Preparation/Service: Monday 1 '4 - - Thursday ) 2,— f U Sunday '1 "Z— q Tuesday I Z- q Friday 1 'Z Wednesday 12 - C1 Saturday (2 6 C> 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 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 i��N0 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 C Ctt (<- Ave 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 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? Ii1Ci Where is the grease storage unit located? How often is this grease storage unit emptied? 4(✓CC Please list the vendor who removes the waste:64 wo2 la)(Iytx "EC,� The Contmonivealth of Massachusetts Department oflndustrialAecirlents Office OfInvestigations Lrefiiyette City Center 2 Avenite de Lafayette, Roston, MA 02111-1750 ��= t wwnanass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Lct?ihly Business/Organization Natne: Address: City/State/Zip: N fill "'- Q it � Phone #: Are von an employer? Cheek the appropriate box: Business Type (required): 1. am a employer with _r,employees (full and/ 5. El Retail or part-time).* 6.. estatnant/Bar/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] 9. ❑ 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]* 1 LE] 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 It I must also fill all the section below showing their workers' compensation policy information. **If the corporate oaieers have exempted themselves, but the comporation Iles other employees, a workers' compensation policy is required and such all organiwtion should check box 111. / am nu enrpinyer tJrnt is prnniding war/rerc' cnmpensntinn insurnuce far my coup/nyees. 11elow is t/te policy igfi�rnrntinn. Insurance Company Name: Insurer's Address: C-,4S-fbt.4 YnA City/State/Zip: ,Yl Policy H or Self -ins. Lie. 9 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 $ 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. / do hereby certify er 7lre pains r peualtiesafperjoy that the information provided above is nwe and correct Signature: t/ �!!j� Date' S'o1 � �;? X.(,— �2Z Official use only. Do not write in this area, to be completed by city or town offic/al. City or Town: Issuing Authority (check one): 1011loarelof health 2TI Building Department 50Selectnum'sOffice 6.❑Other Contact Permit/License 30City/Town Clerk 4.❑Licensing Board Phone www.mass.gowdia WWAIwMej- IIIKW_VIMilkIi[Q � 11 I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all Stale Tax Returns and paid all State Taxes required under law. Sign/me of Indio r . o1 rporate Name VS i tf ism' t=cw--A, v � 2 -13 66 Social Security Number (Voluntary) or Federal Identification Number" By: Corporate Officer (Mandatory, IF Applicable) 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. ,AE l CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DDN" 11/03/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 certiflcato holder Is an ADDITIONAL INSURED, 4he policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the forms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certiTtcato holder in lieu of such ondorsement(s). PRODUCER CONTACT Boynton insurance NAME: Boynton Insurance Agency PHONE (781)449-6788 43-4289 o : 4 lac, wo): ( 7B1 4) 72 River Park Streetm _ E-MAIL ADDRESS: cenl(ICeles(o}[wyntonins.COm v INSURERIS) AFFORDING COVERAGE HAD Needham MA 02494 INSURERA: Merchants Mutual insurance Company INSURED INSURERS: Splezlo Enterprises Inc INSURER C : DBA Geno's Italian Restaurant INSURER D: 407-411 North Mein Slreel INSURERS: Mansfield MA 02048 INSURER F: GVv=nJu atb CERTIFICATE NUMBER: Gu7TU20T2697 REVISION NUMBER' THIS IS TO CERTIFY THATTHE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 AULnUUUH POLICY NUMBER MMJO YD/YEYY MpCY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S 2,000,00D PREMISES Eao rranee S 100,000 CLAIMS -MADE ® OCCUR MEDEXP(Anyonaperson) 3 5,000 PERSONAL aADV INJURY S 2,000,00D A CMP9155986 041101202D 04/10/2021 GEMLAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE - $ 4,000,000 POLICY ®J ❑ COT LOC PRODUCTS-COMPA)PAGG S 4,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANYAUTD EA accident BODILY INJURY(Porperson) S OWNED SCHEDULED BODILY INJURY (Par Accident) S AUTOS ONLY AUTOS HIRED NON 01ANEO AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE EM2wgMl S 3 �®. UMBRELLA LIAe OCCUR EACH OCCURRENCE S AGGREGATE S EXCESS LIAR CLAIMS -MADE DEO RETENTION 3 S WORKERS COMPENSA71ON AND EMPLOYERS' LIABILITY YIN ! STATUTE ERH E.L.EACHACCIDENT S 100,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE oFFlCERIMEMBER EXCLUC �N NIA WCA9100757 08124/2020 06/24/2021 E.L. DISEASE -EA EMPLOYEE S 100,000 (MZ oosdaarilhounder ry In NH) II ym, E.L. DISEASE -POLICY LIMIT S SOD,000 DESCRIPTION OF OPERATIONS halo, Liquor Liability Common Cause Limit $1,000,000 A CMP9165986 04/1012020 04/10/2021 Aggregate Limit $1.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101, AddWonal Romerke Schedule, may be aRachad It mom apace la required) Town of Mansfield 6 Park Row Mansfield MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTRORe:ED REPRESENTATIVE WOINUIRTI i[+Tq�nesmia ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ui N 0 N N N W O 0 W Z U/ X w X, C LL 0v W 6 H w Q c 0 WE I ll \ \ 4 ± . V2 \ m y:< .� \ � [ \ / \ } a : ® r _ LOWE 2i§04 ra ) / 4p,% « &,%\ Q`®2 \ t )\2\ x§\\ \ / }+/) 5 \ƒA / 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. 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 T ti nd 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. 4�0, e 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 Date: P4 `';7� Applicant Name (please print clearly) ., e&� '&J '�50l�t § 180-16 ARTICLE III Plastic Waste Reduction [Added 4-10-2018 ATM by Art. 451 i1 � § 180-17 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. 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