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Home My WebLink AboutGreat Woods Pizza - 12/31/2021�( —#f 0--23StVU FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name C'rtot} V N boas 0-L10jl Establishment Address `4'2b �1Y`(l E5+i�QQi� Establishment Mailing Address (f different) Establishment Telephone No 7-:1 LA D I'V-9 Applicant Name & Title: Applicant Address 2-Tbr\\j C�rw e_ N' a0.StOn , W2,f 00,a5�p Applicant Telephone No.: 500 (0 24 Hour Emergency No.: J05 '114LA • LA I Applicant Email Owner Name & Title (If different from applicant) (D-Wt6AU5 1,51 CLnCkJL� Owner Address `Z-TY-)_j 6,rvg,- IN. GCl6VOY)) MR 0-a35(o Owner telephone number ✓v6.gLVA -qu,3j Owner email: C-) rP_Glk W 00A6 1Z71z mzO i t • (-\Dm Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. A Corporation Title Address u V)I } An Individual _Name olkontr M C{odW 61, OF L� al fi d S Q A Partnershipl El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �cx 1 � CLVka 1, _as Address: 2 'Tool &v \ J-E N, 1✓OLShD n / I trl iq D ��o Telephone No: 5D6 • WA1A l_+(P 24 Hour Emergency No: 5_0'8• 9LILI Li I�(P FAX: E-mail: C r�r� v� l�C>[x��7\ 21AYV GLIB • �YYI Alt E-Mail: District Or Regional Supervisor (f applicable) Name & Title: Address: Telephone N 24 Hour E rgency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: 1 ,� 1v1� _ q q ._ q Name of Person(s) In Charge Certified in Food Protection Management: j�{-h e►� n e; Ts i � rru�-kc�S �i Name of,Pperson(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests 2C> 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. Yes Does this establishment require a FOG permit?_ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual Retail Food $125.00 Mobile Food Consession 0 Temporary L��3"/Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Ei Manufacture Frozen Desserts/lee 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 Ej Pushcart $50.00 # of Pushcarts: Temporary Time: Q Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions :PHF - Potentrallyhazatdous food (firma rtperature controls requimc9 Non-PHFs-non-potentiaWhazardous footl(no fimaRenpera(ure controls requited) (Check all that apply): RTE- ready-toeat foods (Ex. sandwiches, winds, muffins which need no further processing) X Sale of Commercially Pre -Packaged Non-PHFs XPHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held 0 Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service Lj PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility U 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 anchor HACCP Plan (including bare hand Customer Self -Service contact alternative, time as a public health Customer Self -Service of Non PHF and Non - Perishable Foods Only lee Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of 0 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Ej Vacuum Packaging / Cook Chili Offers RTE PHF in Bulk Quantities 0 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 tp obt�in copies opal-q R 590. nd-th federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties 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: I ,r�� -'UV ^� / 69!, Signature of Individual or Corporate Name: " 1 ' I O - 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. __\Z' 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. VI 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. _L/_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 kz Date: I I'� Applicant Name (please print clearly) Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment M Mailing Address: 3k YtY�-0— Phone/Fax Number: l 9 0' 1 Contact Person/Title for Grease i Name of Company scheduled to pump internal grease trap(s) monthly: o i zr a b19 Name of Company scheduled to pump external grease trap quarterly:1_ I u✓wCi �� [� 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 acknowl dges that the i mation submitted in these documents is true, accurate )l and complete. Signed Date Print Name \Yv � & ou\a i a -S 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): Normal Hours of Food Preparation/Service: Monday r 1 Tuesday p �� Wednesday 1-9 Thursday �� 1 Friday �� Saturday Sunday�D 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 1 \les 3 compartment sink -- Handwashing sink r Commercial Dishwasher y l� Bar sink Mop Sink Garbage Disposal Ice Making Machines 2 Fryolators r Grills or Ovens 2 Exhaust Hoods 2 Floor drains 1 Other: X i e_. 6) 0 K How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? „ qaM� V Yes �y /� No If yes, at what station/sink? �1�� 3 COW D 0) f`� 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 I �, ►� � � � lS � Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap S External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? i/ Yes No Size gallons Where is the existing outdoor GRU located? l X' h,inoA VAAAAi to If the owner is responsible for external trap pumping, provide the Name, Addres nd 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 locatec How often is this grease storage unit err Please list the vendor who removes the TAX CERTIFICATION FORM I certify under the penalties of perjury that L to my best knowledge and belief, have filed all State Tax Returns and paid all State Taxes required under law. C-ly-ei k:, wads VizZ a Signature of Individual or Corporate Name 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. The Commonwealth of Massachusetts Department of lndustrialAccidents € OKice of Investigations Lafayette City Center 2Avenue de Lafayette, Boston, MA 02111-1750 9�. wwramass.gav/ilia Workers' Compensation Insurance Affidavit: General Ilusinesses Applicant Information (� p -. Please Print Legibly Business/Organization Name: a, � N t) oo S p —a Address: 140t,!Yn S� . City/State/Zip: Are you an employer? Check the appropriate box: Business Type (required): L n I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6.] Restaurant/Bar/Eating Establishment 2. ElI am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp. insurance required] 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]* 111] 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 fill outthe 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. I am an employer that is psevitling workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -irks. Lic. # V 1 `1 1 U Expiration Date: I oC, I J /C7`.1 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 I do hereb,Lcofy,,, a lheomA and penaMes ofperjury that the Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (check one): L❑Board of Health 2.0 Building Department 5.❑Selectmen's Office 6.00ther true and correct 3n City/Town Clerk 4. ❑Licensing Board Contact Person: Phone #: wwwmass.gov/dia ---i CERTIFICATE OF LIABILITY INSURANCE Dy01/20 0Dm�) , 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(ies) 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 endorsements . 'RODUCER CONTACT Paychex Insurance Agency Inc NAME- PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE PHONE . 877-266-6850 FAX - 585-389-7426 E-MAIL Ceris@paychex.com ROCHESTER, NY 14620 INSURER(S) AFFORDING COVERAGE NAIC# VSURED INSURER At NorGUARD Insurance Company 31470 INSURER B: GREAT WOODS PIZZA CORP 428 ELM STREET INSURER C: WRENTHAM, MA 02070 INSURER D: INSURER E: INSURER F: ;OVERAGES CERTIFICATE NUMBER: 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. s .R TYPE OF INSURANCE DDL NSR UBR VD POLICY NUMBER POLICY EFF MMNDNYYV) POLICY EXP (MWDDNYVY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY �LAIMS-MADEODCCUR DAMAGE TO RENTED PRFMI.RFq IF, "CoDneperson) $ MED EXP(Airy $ PERSONAL BADV INJURY $ GENERAL AGGREGATE $ ENL AGGREGATE LIMIT APPLIES PER: POLICY 1=1 PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY ANYAurD ALLOWNED SCHEDULED AUTOS AUTOS HIREDAUTOS �pIRO5WNE0 COMBINED SINGLE LIMIT (Eaacddent) $ ODILY INJURY (Per person) Br,rpemon) $ BODILY INJURY (Per amWent) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLALUB =OCCUR EACH OCCURRENCE $ AGGREGATE $ IXCESI =CLAMS -MADE DED RETENTION$ $ WORKERSCOMPENSAMNANO RRPLUYERSIIAmUTY GRWC188399 12/05/2020 12/05/2021 X WCSTATU- OTH- E.L. EACH ACCIDENT $ 100,000.00 ANY PROPRIETORMARTNER,EXECUTIVE OITICERIMEMBERE OWDED4 E.L. DISEASE - EA EMPLOYEE $ 100,000.00 F.L. DISEASE -POLICY LIMIT $ 500,DDO.00 �yM� (Mmtlanry u, xx) I N WA n yes, aexareunner DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (AIIaeh ACORD IM, Additional Remarks Schedule, "more space is required) CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 Park Row THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN Mansfield, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE WORD 25 (2016103) 01988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �7 x w r ❑ O / e � \ �