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HomeMy WebLinkAboutJersey Mike's (Intrepid Mgmt. LLC) - 12/31/2021� �i3 25 FOR BOARD OF HEALTH USE ONLY <, Permit# Issued ; FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening Establishment Name /%/}(il`16-£016vi G' !plc, 1,cq5£y In, K43 u4y p�C( Establishment Address 333 SC({cul SiR�4T J��Tf %3C mrsr-t>a m(a �2G4 Establishment Mailing Address (if different) Establishment Telephone No j 0 9 - Applicant Name & Title: &tj&t,L x V d }{ mfi2t�4(2 Applicant Address �- 11fun w L6tiC ,!t' yzt3a�l{ , /}�/� 01-M Applicant Telephone No.: y6/ . to sl - 11'7 i 24 Hour Emergency No.: L/Gf 6,5 1 - ((7 y Applicant Email �7 C',�G(ri"lido-LCr`ltG�4 Ca�'D1 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 El An Association partner. �A Corporation Name rr�� �nl Title Address h &jfA,-j7(rjol017(.y �RA/AMc�r AnIndividual rJCAACA k�,IN4 1N d CQtk&j 9kLL-1 V &0 /%1fa> Nk �l^ 41Pr(i11cYc (1C Il /nK I IAA .01A 02 El Partnership ❑ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: % of 6a,�$,�-Lvc S U-ENEe2AL 441-te-iIL- Address: /% ILLoho S A2(LT Nd.2iit tppiwilwec fqI I Telephone No: 4A I , 3C0 24 Hour Emergency No: z/UI - 3 v u • 1 & 8 FAX: E-mail: 7IZ6 y 0 Ct 6fr 14(_(,(_6 qp. Cc++, Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: y(ig41 �4/�4,. (jjoCa2i4T(ini3 ✓Y111N141rL L Address: </ eaw_K�IL S+R i i r"I-Tew MA 027,S6 , Telephone No: '77y _ 4119 _ 2S1 2 24 Hour Emergency No: 77Si Z_ FAX: E-mail: 1?0134 a� ed66 SI4r Lt_ ROuA.dauv� Food Establishment Information WATER SOURCE: u SEWAGE DISPOSAL: No. of Food Employees: d DEP Public Water Supply No: (If applicable) DAYS/HOURS: - 'Gt GA - 9 Name of Person(s) In Charge Certified in Food Protection Management: �j�0�/ CTENj�{LV4.S' Name of Person(s) In Charge Certified in Allergen Awareness Training .lp6v dd__ Name of pest control company routinely inspecting the premises for evidence of pests /rwe je f_X Leo ur M'+T J 0J(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. ❑ Yes Does this establishment require a FOG permit? -.Lt- If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ❑ Retail Food $125.00 ❑ Mobile Food Consession ❑ 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 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 ❑ Residential Kitchen $100.00 Rain Date: ❑ Milk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food (timMemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperatum controls required) (Check all that apply): RTE- ready -to -eat foods (Er. sandwiches, salads, mums which need no further processing) t4 Sale of commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly (� Delivery of Packaged PHFs Susceptible Population Facility ❑ 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 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 ❑ control) Manufactured and Packaged for ) 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 (� 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 I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will cc ply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to in copies q(105 CA 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Chs2C, sec. 49A, 1 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. Social Security Number or Federal ID: �� _ `-(> ,�� .� Signature of Individual or Corporate Name: a x w 0 H U f-4 w 0-4 U 0 z z I z h�1 w W w 0 � pa v � 6 a a x z � o z � U U A Q ,y. A o` o v Aszo c r t c 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. _ANrq<�ota ac Signature of Individual or Corporate Name y: Corporate Officer (Mandatory, if Applicable) *'"Social Security No. (Voluntan/) 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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc ine uommonweattn airmassacnusens 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: Intrepid Management, LLC d/b/a Jersey Mike's Subs 333 School Street Suite 130 City/State/Zip: Mansfield, MA 02048 Phone #: 508-452-1352 Are you an employer? Check the appropriate box: Business Type (required): 5. Q Retail 1.0✓ I am a employer with 20 employees (full and/ or part-time).* 6. ❑✓ RestaurantBar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no ?• ❑ Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. 8• QNun-profit 3.❑ [No workers' comp. insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.n Manufacturing no employees. [No workers' comp. insurance required]* I Ln Health Care 4.� We are a non-profit organization, staffed by volunteers, 12.0 Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #I 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 41. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Name: The Hartford Insurer's Address: 3600 Wiseman Blvd. City/State/Zip: San Antonio, TX 78251 Policy # or Self -ins. Lie. # 76 WEG AJ1A2K Expiration Date: 11 /09/2021 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, yqn ter tire pai , and penalties of perjury that tire information provided above is true and correct. ka /7d �,. _. 12/21 /2020 401-651-1174 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 6.Other Contact 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gov/dia Phone (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Accident and Indemnity Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 10448 Company Code: 5 tr ROW" Suffix LARSLARS RENEWAL� POLICY NUMBER: 76 WEG AJ1_A2K Previous Policy Number: New 1. Named Insured and Mailing Address: INTREPID MANAGEMENT LLC (No., Street, Town, State, Zip Code) 333 SCHOOL ST STE 130 MANSFIELD MA 02048 FEIN Number: 83-3480174 State Identification Number(s): The Named Insured is: LLC Business of Named Insured: Limited -Service Restaurants Other workplaces not shown above: 333 SCHOOL ST STE 130 MANSFIELD MA 02048 2. Policy Period: From 11/09/20 To 11/09/21 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY 1 ADP BLVD M/S 625 ROSELAND NJ 07068 Producer's Code: 76250871 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 287-1316 Total Estimated Annual Premium: $2,102 Deposit Premium: Policy Minimum Premium: $286 MA (Includes Increased Limit Min, Prem.) Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by �u Cam' 10/20/20 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 10/20/20 Policy Expiration Date: 11/09/21 INFORMATION PAGE (Continued) Policy Number: 76 WEG AJ1A2K 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 3.A. 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 NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined Plans. All information required below is subje our Manuals of Rules, Classifications, Rates and Rating to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Estimated Annual Premium (before Surcharges) Total Estimated Surcharges "See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $2,102 Deposit Premium: Policy Minimum Premium: $286 MA (Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 722211 Labor Contractors Policy Number: SIC: 5812 $1,639 $338 $60 $2,037 $65 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 10/20/20 Policy Expiration Date: 11/09/21 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: zz4rj l�I�Y�(wUM11CaN 1 t e- j Alh, `fR-a y All'C � � 6 Address:333 il'e-Wol- 9+(Kc (7C11) lf]&Q&r t4 .oil 016C E Mailing Address: /(/ A6X 4/6SG �h'Gt6lA�NGi �1 ©2 yd Phone/Fax Number: �d I� - 415 �" /3S-2- Email: Xf+A1NCO(sCr<CIf�L(Gkk k1� CG fUI Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: 6J11V 1.l✓£/i �h'VI�eNp1ti�1T! (L 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 acknoMeshe innff mation submitted in these documents is true, accurate and complete. SignedKLI (' Date lz2 h 6 Print Name �i r1AzG kGd /� 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 16A 1 O Thursday 10A q fl Sunday ldfl_ Tuesday Dy{ Friday Id'4 `4Q Wednesday !ajj -24 Saturday 14,4 - Yjo 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 f 3 compartment sink Handwashing sink 6 Commercial Dishwasher ® Bar sink ^I tJ Mop Sink C7 — Garbage Disposal AJO ice Making Machines Fryolators Grills or Ovens /JU Exhaust Hoods Q — Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): ON SiTt Qy egiv TC Complgd y Is dinnerware pre -rinsed before being washed? M114 If yes, at what station/sink? Yes No 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 SIN i 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? a'AT-S'8< RoA 11 r 6UI I g1AJ6— 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: C Property Owner's Address: 12 0 //h lkL�� /�11< r a J Ut 1 t qoi " un 1('A fN96 J Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? N 1 /� Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: 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. X 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. %f 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. _ V 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 'ga&&)Psz l Date: �l 2GZu Applicant Name (please print clearly)