HomeMy WebLinkAboutJuice on Main Ltd. - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening
Establishment Name �G c c e /i �41{ 1� b� J
Establishment Address '2 yu �✓ i ("4r'> S/
Establishment Mailing Address (if different)
Establishment Telephone No 7 9 t(, 7 J(
Applicant Name & Title: d "N) I V w//PtlL
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Applicant Address ) l$o5 Sj, f�/)✓✓f/�%C'iO� �ti�
Applicant Telephone No.: 24 Hour Emergency No.:
Applicant Email / G/(I ? J')iW 6, V11 iA
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
O An Association
partner.
A Corporation
Name Title Address
An Individual
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r� A Partnership
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Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: Z U'r l /� (,l,4 N)
Address:
Telephone No: ( � �h24 Hour Emergency No:
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FAX:
E-mail:
Alt E-Mail: Jc �N_. � J ✓,er �N y✓i,�a. 6ieM
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:
DEP Public Water Supply No: (If applicable)
No, of Food Employees:
DAYS/HOURS: P ,_ S
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Name of Person(s) In Charge Certified in Food Protection Management:
(I I�F� L/✓ l�n ✓�//ire
Name of Person() In Charge Certified in Allergen Awareness Training
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Name of pest control company routinely inspecting the premises for evidence of pests ar
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. 9 Yes
Does this establishment require a FOG permit? )1 n If yes, please attach
the FOG permit application.
Length of Permit:
Establishment Type:
AnnualF}etail
Food $125.00
Ea Mobile Food Consession
Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100,00
FOOD TRUCKS $175.00
e3; Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
yr,J,,i Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
r❑''- Pushcart $50.00 # of Pushcarts:
Temporary Time:
® Supermarkets $400
k? Residential Kitchen $100.00
Rain Date:
Milk & Cream $10.00—'
Caterer $35.00
Food Operations: Definitions: PHF-Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
JRTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
W/Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order
[H Hot PHF Cooked and Cooled or Hot Held
[>i] Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And
for More Than a Single Meal Service
F� Delivery 9 of Packaged PHFs Cold Holding For Single Meal Service
F PHF and RTE Foods Prepared For Highly
Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer
(] Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
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 F1 Ice Manufactured and Packaged for
control)
u� Preparation of Non-PHFs Retail Sale _ /
'❑� Offers Raw Or Undercooked Food Of
�i Juice Manufactured and Packaged for
Animal Origin
Other Food Operations (',, {., Q );�' Retail Sale
� Vacuum Packaging /Cook Chill
fYIQw la fhl�I VVrJQ O� IV1 Offers RTE PHF in Bulk Quantities
i] Prepares Food/Single Meals for
MQdQ IU Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
6a 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 cooies-of 105 CMFA 59OX00 and the federal Food Code,
Signature of Applicant: up'tf Lf X-' L' c
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of
and paid state taxes required under law.
that I, to my best knowledge and belief, have filed all state tax returns
Social Security Number or Federal ID: (/ ?
Signature of Individual or Corporate Name: T b j-
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.
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Signature of ndividual or ate Name By: Corporate Officer (Mandatory, if Applicable)
1V7 %YV,0;)-
**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:\Users\sleite\Desktop\SCuU'S Docnments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
rvww.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address
City/State/Zip:
Phone #: '? ) %- 2 f t/' t14)� �
Are ou an employer? Check the appropriate box: Business Type (required):
1 � I am a employer with 5 5. Retail employees (full and/ ❑
or part-time).* 6. Restaurant/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.
[No workers' comp. insurance required] g• ❑ Non-profit
3.0 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, 1 I.❑ Health Care
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.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: IN e _S c D
Insurer's Address: 14 D ) U
City/State/Zip:
Policy # or Self -ins. Lic. # W it7 C 3 y l � 2 � Expiration Date: z / 2 '7 t/ t /
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 WORD 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, %nder the pains and penalties of perjury that the information provided above is true and correct.
1A�..' / 2/ 2/2 0
signature:✓ Date:
Phone#• -79Y- Zj I/-tVV4)
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 #:
itiMTOto] WFiMa67g14R17SoZr1ilR iWTAY1.1
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
Applicant Name (please print clearly)
7 JUICt•b
14�i CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYY)
1213112019
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 ri hts to the certificate holder in lieu of such endorsements .
PRODUCER 888.467-3330
Kapatoes Insurance Services LL
725 Primera Blvd Suite 115
Lake Mary, r 32746
Meister
NTACT Dane Meisler
PHONE g88-0673330 FqqXX 888-053-5755
PIC No Ext: NC. No:
AIL 19&6,,dane@kisllc.com
INSURER(St AFFORDING COVERAGE
NAICp
INSURERA,WESCOINSURANCECO
25011
JN9URED
uiceon Main LTD
INSURER B•
Jon Copppolino
240 N Il9aln St.
Su
IHSURER D:
Mansfield, MA 02048
INSURER E :
INSURER F :
UUVEKAGES r.PPTIFl1'ATG MIIMnGo•
"'�"�"'��•`• R4:Y W,VIY IYVIYIVGR:
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,,.
TYPE OF INSURANCE
ADD,
SUB
pOLICYNUMBER
POLICY EFF
POLICYEXP
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE L_I OCCUR
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES Me
S
ocou,n,,)
MED EXP An ane eraon
$
PERSONAL a ADV INJURY
GENT
AGGREGATE LIMIT APPLIES PER:
POLICY ❑ PE� LOC
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
8
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
AEa
ANYAUTO
OWNED
D SCHEDULED
AUTOS ONLY AUTOS
OWNEE D
AUTOS ONLY AUTNOS ONLY
BODILY INJURY Par arson
$
BODILY INJURY Peracddem
$
Pe�accltlent AMAGE
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
AGGREGATE
S
EXCESS LIAR
CLAIMS -MADE
DED RETENTION S
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
MYPRCRIETORXCLE]ECUTIVE YIN
FMWMMBEEEUDD
(Mandatory In NH) er
I DESCRIPTION
a OF O
DESCRIPTION OF OPERATIONS below
NIA
WWC3451626
02/27/202
02127/2021
PER
X OTH-
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYE
$ 500,000
E.L. DISEASE -POLICY LIMB IS
500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD101,Additional Remarks Schedule,maybeattachedll rtlordapacelarequired)
Town ofFoxborough
40 South St.
Foxborough, MA 02035
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
W 1U66-ZU10 AL;VKU CUKPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
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