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Home My WebLink AboutHoliday Inn - 12/31/2021413o5 — ?6O,Cool 1 �' FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opehl a Establishment Name �J�jt_l Establishment Address Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: Applicant Address ��i� Applicant Telephone No.: �y��ai� 3� '! r� 24 Hour Emergency No.: Applicant Email Owner Name & Title (If different from applicant) Owner Address 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. O A Corporation Name Title Address C1 An Individual O A Partnership VOther legal Entity Person Directly Responsible For Daily Operations (owner, person in charge supervisor, manager etc.) Name &Title / J 6, � y ( Fz /- �j � FYI, /)a ��'% Address �T l % �/Y j 7 i/GI - i /h�z 24 Hour Emergency No: J� Telephone No: ,r2 �;� ;� =,� �i FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: �� --:SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Persons) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training 0 I r � Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 peop� or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. LYes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: �nnual H Retail Food $125.00 E� Mobile Food Consession j Temporary rya 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 to 101 -200 $250.00 $25.00/freezer Temporary End Date: V't Dori Service up to 201 + $300.00 Ed Pushcart $50.00 # of Pushcarts: Temporary Time: e1 Supermarkets $400 "❑i Residential Kitchen $100.00 Rain Date: N4611< & Cream $10.00 L7i Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(timeAemperature controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no time/tempereture controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing) H Sale of Commercially Pre -Packaged Non-PHFs s - PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held E Sale of Commercially Pre -Packaged PHFs 6 reparation of PHFs For Hot And for More Than a Single Meal Service FJ 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 to be Prepared by Consumer !i Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- Customer Self -Service contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) (] Preparation of 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 FP16ffers RTE PHF in Bulk Quantities 0 Prepares Food/Single Meals for d 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 of 105 CNIR 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 filed all state tax returns and paid state taxes required under law. 3 } Social Security Number or Federal ID: . ,� p /l9 Signature of Individual or Corporate Name. (" — �'�/� Gc^ - 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. r_� Gtt-lam -5harl)14 1151 ded - Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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:\Osers\sleite\Desktop\Scott's Docoments\Food Establishments- Temp\TAX CERTIFICATION FORM,doc ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MMmon vvY) 11/6/2020 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(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 endorsement(s). PRODUCER Diversified Insurance Industries, Inc. 307 International Circle Suite 610 NAME: ACT Brianna FOertschbeck PHONE Z. Ex , q10-433-3000 ac NP): 410-433-3440 EMIC -MAIL ADDRESS: brianna.foertschbeck dii-ins.com Hunt Valley MD 21030 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Endurance Amer Spec Ins* 41718 INSURED GLOBVIS-01 Vision Hampshire, LLC—--- t/a Holiday Inn Mansfield, MA INSURERS: SOm o America Insurance Co* 11126 INSURER C: Allied World Assurance Co` 19489 INSURER D: Continental Insurance ` 35289 c/o Hospitality Cover Plus, LLC INSURER E: P.O. Box 1572 Cockeysville MD 21030 — INSURER F COVERAGES CERTIFICATE NUMBER: 535879990 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 OF INSURANCE ADDLSUBRTYPE INSD W/D POLICY NUMBER MMIDDVEFF MM/DDfYyy LIMITS A X I COMMERCIAL GENERAL LIABILITY GLOBVIS-GL 11/1/2020 11/1/2021 EACH OCCURRENCE $1,000,000 CIAIMS-MADE 111 OCCUR DAMAGETOR TED P EM SES Ea occu ante $1,000,000 __X_ MED EXP (An one person $ EXCLUDED Empl Benefits Liquor Liability PERSONAL B ADV INJURY $1,000,000 X AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 GEN'L POLICY JEa [XI LOG PRODUCTS - COMP/OP ADD _ $2,000,000 Engel Benf(Li uor $1,000,000 OTHER: B AUTOMOBILE LIABILITY GLOBVIS-AU 11/1/2020 11/1/2021 COMBINED SINGLE LIMIT Es accldent $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLYNXAUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ X HIRED NON -OWNED AUTOS ONLYAUTOS ONLY $ X $2,000 cam $2,000 toll D X UMBRELLALIAB X OCCUR CUE 5094764769 11/1/2020 11/1/2021 EACH OCCURRENCE $10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE DED X I RETENTIONS in nna $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OERT STATUTE ER ANYPROPRIETOR/PARTNEWEXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED9 ❑ N/A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ C Excess Llebility GLOBVIS-XS 11/1/2020 11/1/2021 UrnIVAggregale 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more epece is required) Re: Holiday Inn Mansfield - 31 Hampshire Street, Mansfield, MA 02048 General Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE J i� Mansfield MA 02048 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 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 Legibly Business/Organization Name: City/State/Zip: M &/(_1 1,\5-, ,L.0 , ? Phone #: 6Z)YO — V« Are yo an employer? Check the appropriate box: Business Type (required): S. Retail 1. am a employer with employees (full and/ or part-time).* 6. 0,destaurantBar/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. 8. Non-profit [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised 9. F1 Entertainment their right of exemption per c. 152, 1(4), and we have §10. 'anufachuing no employees. [No workers' comp. insurance required]* 4. We by 11.Q Health Care are a non-profit organization, staffed volunteers, with no employees, [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #1 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 #1. lam an employcr that isproviding workers! rcompenssattion insurance for my entploj�ees. Belot, is the policy information. Insurance Company Name: 1J � VerSl i1 �� 1 l) �l t UZ hCc � f'1 �L{S i't�� / 3� C' Insurer's Address: 607 Sz4k' (p/U City/State/Zip: %jal)7L ✓� %�J h� / mJ ::�2 163D LL Policy #or Self -ins. Lie.# c �J~�� J Da Expiration Data: f CN �oL1 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 andpenalties ofperjury that the information provided above is true and correct Signature 3-,33as" Official use only. Do not write in this area, to he eo»ipleted 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 #: EMPLINEW Workers' Compensation and Employers Liability Insurance Policy EMPLOYERS ASSURANCE CO. Policy Number From olicy PeriodTo A Stock Company EIG 2656163 02 06/24//20tl20 06/24/2021 1 Insw.l .M.,Et tetl n`eremme at the address olihe Transaction RENEWAL DECLARATIONS NCCI Carrier # 36870 WCIRB CARRIER# PRIOR POLICY NUMBER EIG265616301 1. Named Insured and Address Agent ' VISION HAMPSHIRE LLC DIVERSIFIED INS INDUSTRIES INC 6465200 DBA HOLIDAY INN MANSFIELD 307 INTERNATIONAL CIR #610 31 HAMPSHIRE ST HUNT VALLEY, MD 21030 MANSFIELD MA 02048-1113 Telephone: 4104333000 Customer # Carrier# FEIN # Risk ID # Entity of Insured 1 36870 473112140 001033835 LIM LIABILITY CO Additional Locations: 2. The Policy Period is from 06/24/2020 to 06/24/2021 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except NO, OH, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. Minimum Premium $ Assessments and Taxes $ SEE EXTENSION OF INFORMATION PAGE 231 Expense Constant $ 338 Premium Discount $ Total Estimated AnnualPremium $ 8,966 ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly Countersigned this Day of issued Date: 06/19/2020 Authorized Representative Issuing Office EMPLOYERS ASSURANCE CO. 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 Issued Date 06/19/2020 WC990630 (5/98 Ed) AGENT COPY Page 1 of 4 EMPLOYERS EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: EIG 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 EXTENSION OF INFORMATION PAGE CLASSIFICATION OF OPERATIONS Premium Basis Rate Per Estimated Code Total Est. Annual $100 of Annual No. Classification Description Remuneration Remuneration Premium Massachusetts Rating Period: 06/24/2020 through 06/24/2021 Site 00001 8810 CLERICAL OFFICE EMPLOYEES NOC 0 0.070000 0.00 9052 HOTEL: ALL OTHER EMPLOYEES & SALESPERSONS, 350,000 1.490000 5,215.00 DRIVERS 9058 HOTEL: RESTAURANT EMPLOYEES 150,000 1.380000 2,070.00 Site 00001 Total $ 7,285.00 Total of Sites for Rating Period $ 7,285.00 Rating Period Total $ 7,285.00 Rating Period: 06/24/2020 through 06/24/2021 9037 RATE DEVIATION ADJUSTMENT 7,285 0.080000 -583.00 9812 INCREASED COVERAGE II 6,702 0.020000 134.00 9898 EXPERIENCE MODIFICATION 6,836 1.100000 684.00 0277 ALL RISK ADJUSTMENT PROGRAM 7,520 0.090000 677.00 0900 EXPENSE CONSTANT 338.00 9740 TERRORISM PREMIUM 500,000 0.030000 150.00 0986 DEPARTMENT OF INDUSTRIAL ACCIDENTS ASSESSMENT 8,014 0.035100 281.00 Rating Period Total $ 1,681.00 State Total $ 8, 966.00 Policy Total $ 8,966.00 Issued Date 06/19/2020 WC990630 (5/98 Ed) AGENT COPY Page 2 of 4 EMPLOYERS EMPLOYERS ASSURANCE CO. A Stock Company 14120 BALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 State MA VISION HAMPSHIRE LLC 31 HAMPSHIRE ST MANSFIELD MA 02048-1113 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Policy Number: El G 2656163 02 Named Insured: VISION HAMPSHIRE LLC Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 SITE LOCATION SCHEDULE Issued Date: 06/19/2020 AGENT COPY WC990410 (7/06 Ed.) Page 3 of 4 EMPLOYERS WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY EMPLOYERS ASSURANCE CO. Policy Number: EIG 2656163 02 A Stock Company INamed Insured: VISION HAMPSHIRE LLC 14120 SALLANTYNE CORPORATE PLACE, SUITE 100 CHARLOTTE, NC 28277-2685 Agent: DIVERSIFIED INS INDUSTRIES INC 6465200 State Form Nbr. Ed. Date Description MA WC000000C (1/15) WC/EL INS. POLICY FORM BOOKLET MA WC000115 (1/20) ENDT OF PEND LAW CHG TO TRIPRA MA WC000403 (4/84) EXPERIENCE RATING MOD FCTR MA WC000406A (7/95) PREMIUM DISCOUNT ENDORSEMENT MA WC000414 (7/90) NOTIFICATION OF CHG OWNERSHIP MA WC000422B (1/15) TERRORISM RISK INSURANCE PROG MA WC000424 (1/17) AUDIT NONCOMPLIANCE CHARGE END MA WC000425 (1/17) EXP RATING MOD FACTOR REV ENDT MA WC200301 (4/84) MA LIMITS OF LIABILITY ENDT MA WC200302A (9/08) MA ASSESSMENT CHARGE MA WC200303D (8/10) MA NOTICE TO POLICYHOLDER ENDT MA WC200405 (6/01) MA PREMIUM DUE DATE ENDT MA WC200601A (7/08) MA CANCELLATION ENDORSEMENT MA WC200604 (11/02) MA POLICY DEFINITION ENDT MA WC990405A (3/07) INSTALLMENT PAYMENT ENDT Issued Data: 06119/2020 AGENT COPY WC990633 (5198 Ed.) Page 4 of 4 u.1.1,A,.cf I, t a EV Nmnml l:e.a..rura A.,o:ni,. 2<mhle wa & , G.wva m.a233 S. ::Sck« Gi+.$wb J<OJ,flncrge.& (IXb nY,;..:.r•4�It3re.breua,,,� r .. . III . Name of Recipient: MRTiN08nen Certificate Number: 90e6884 Date of Completion: 1v1a 01e Date of Expiration: 1v1v2 za Die above -named person is hereby issued this cert7 rcate forcompletingau allergen awarenesstiai iingprogram recognized by the MassacbusettsDeparhrtentofPublicHealth in accordance with 105 CMR 590.009(C)(3)(a). Dis certlfrcate will be valid forfive (5) year'spion: date ofcompletion. p.m'-wl iseucdBy: —/� REST URRAN ASSOCIATION, Massachusetts ResmmantAssodntion 800,765.2122 333 T.pike Road, S.R. 102 mv:ercstaumne.mg Soathh.mgh, Nffi 01772 568-303-9905 mvmmacestnucantaswc.org g .62 : m... . E`B f \ \..�. \. � \ j � \ . } � :. Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment r I Addracr /h l>" Mailing Address:G��-�"n� Phone/Fax Number: '_�7�i' :� "� `I . a� c��G'C Emai i)u �, f '14')M �I ?�Zb Contact Person/Title for Grease Traps:�'�' Name of Company scheduled to pump internal grease trap(s) monthly�� s Name of Company scheduled to pump external grease trap quarterly/ LS LJP. C i 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. Signed l��( �C�', 7 )ip", ,i Date f ` i ? i✓ f r Print Name �r (' `,L%� �7fI qy)_��) 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 1 Thursday ail m Sunday `%Gi, Tuesday Friday Wednesday 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 r- r Handwashing sink Commercial Dishwasher r �U Bar sink Mop Sink Garbage Disposal Ice Making Machines �k Fryolators � } po Grills or Ovens C� Exhaust Hoods �f> 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 No If yes, at what station/sink? iLy�, j �d — 5 ki, 6 (,In 2 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 l �(j/ C 9/1/ >✓2a ". ✓i vz') 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? 11-07) /- 0��- 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: V IJ I UY t { L 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 locate How often is this grease storage unit en Please list the vendor who removes the waste: 61 r 3 lip ic'., - ?,V V 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. _�q 11' 1 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. II 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 —Date: Applicant Name (please print clearly) a/ J