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HomeMy WebLinkAboutDomino's Pizza - 12/31/2021HEALTH FR BOARD OF HEALTH USE ON Permit# is O FOOD ESTABLISHMENT PERMIT APPLICATIO op - e> kfe (Application must be submitted at least 30 days before the planned opehina date) Establishment Name '/(aAtllrlt7(5 lei Establishment Address AW Establishment Mailing Address (if different) Ypnl1 SI��k,(�It�(„1f�� O�E1 Establishment Telephone No C547'3M --i coo Applicant Name & Title: Tat P Applicant Address `, rA 111 s% � FlaN Uhl mA ogo3g Applicant Telephone No.: (57016) -6 —j p©(a 24 Hour Emergency No.: Applicant Email 0(ki dAt'a tit+ Owner Name & Title (If different from applicant) 11,10 t, t.itCtl��1' 1 1 `CSi j�G Owner Address�� (35 u Owner telephone number (5-44) j V —10 0 Owner email: DTI (�' 0 AA kA -Piet Establishment Owned By: L1 An Association A Corporation r[1 An Individual El A Partnership Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner, Name Title Address Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: �6(7(lL ��t(7U(a" y� ( (� / n oat 1` `� Address: �j'$ l-6'1C1'�'' ✓�J6'�L�Ylta4flSTlt�dC. A "2 Telephon) I— OOL) 24 Hour Emergency No: FAX: 65-Q $) 5t -to'00 E-mail: A ale_ daft l ,'id Alt E-Mail: 1 District Or Regional Supervisor (if applicable) Name &Title: (/q�� �dUrkmandf, VP bf Address: ml�'l leC � ketIt I�njwhA oaDSS G^ Telephone No: (St�6) v-0 l (}to 24 Hour Emergency No: � Sd�� FI �J � "' 1 6ck2 �`-/1h vise FAX: C�Gt�C>tg E-mail: (}FBI (� C� Ltt"I tG �. ✓'vf WATER SOURCE: 6WY1 SEWAGE DISPOSAL: *6� DEP Public Water Supply No: (if applicable) No. of Food Employees: DAYS/HOURS: - SiJ �V id'�3t��vj i��iiv1 _ M5 - (d'•3oA�M-' IAnt � ��_'St _�`.3�11�h-'_3AM_ t Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training M Name of pest control company routinely inspecting the premises for evidence of pests %1vlh°yi uw Ckkm(rm If there is seating for 25 people or more, a person trained in manual choice saving procedures will be onsite at all times food is being prepared. O Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application L ngth of Permit: Establishment Type: Annual M�Retall Food $125.00 0 Mobile Food Consession 0 Temporary [?Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Dessertslice Cream Temporary Start Date: 0 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: Definilions:PHF- Polenliallyhozardous food(time/temperature controls required) (Cheek all that apply): Non-PHFs- non-potentiallyhazarclousfood(no limademperatuie controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [Sale of Commercially Pre -Packaged Non-PHFs u PHFCooked To Order [] Hot PHF Cooked and Cooled or Hot Held []z§ale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And for More Than a Single Meal Service �yDelivery of Packaged PHFs Cold Holding For Single Meal Service [P E] PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility [J Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours ,-,/ Ur Customer Self -Service Customer Self -Service of Non PHF and Non - and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only Q Ice Manufactured and Packaged for control) F-134Retail Sale Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Q Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Q Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Q Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or riconditioned Food I, the undersigned, attest to the accuracy of. inf establishment operation will comply v 5 CMR board of health on how to obtain copies f 105 CM Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify and paid stale taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: . d in this application and affirm that the food other applicable law. I have been instructed by the is federal Food Code. penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 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. 041 li.9 6W(Vff W j IVIC.. Signature of fiidividual or Corporate Nurse ©q-366Je�I **Social Security No. (Vohrnfa y) or Federal Identification Nnmber By: Corporate Offi(rq A 'ndato 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. C:AUsers\sleileADcsklopAScott's DocumenlsTood Esiablislunenis-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrittl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wivminass.gov/rdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: ly t city/state/Zip: (V\asa. i InA 0)-Vgq Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1.I am a employer with employees (full and/ 5. []Retail or part-time).* 6. ZRestaurant/Bar/Eati ng 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] 8. 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] 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant thatcheeks 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 #I. I am as employer that isprovidin n,orlrers' conLrpeusation insrn'mlrce,for• ury employees. Below is thepolicy in rotation. Insurance Company Name: VA+4� �VIC�4AVI l t"' C Q Insurer's Address: I" . c _ �b , 3? o City/State/Zip: l/'Miih A CY6 1)14 Policy # or Self -ins. Lie. # a-)6!r;30q?01 O i Expiration Date: 1 t'2-1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 insurancA coverage verification. I rto hereby certify, and re p ns r 1 penalties ofperjury that the hiforination provided above is true and correct. mate [tlli-u� Official use only. Do not orite in this area, to he completed by city or torvre offlcial. 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 #: www.mass.gov/dia ,ac Elr CERTIFICATE OF LIABILITY INSURANCE DA E(MMIDD YYV `"� 10l08/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, 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 rights to the certificate holder in lieu of such endomement(s). PRODUCER Insurance Marketing Agencies 308 Main Street, 5th Floor - - - NAONTAC Brandon Reamers ME: PHONE (508)753-7233 FAX (508)754-0487 AIC No E-MAILc Aooaass: _bhr@imaagency.com INSURER(SI AFFORDING COVERAGE NAICX Worcester MA 01608 INSURERA: Continental Indemnity Company 28258 INSURED INSURER B: _ DuRcy Enterprises Inc DBA Dominos PO Box 707 INSURERC: INSURER D : INSURER E: Franklin MA 02038 INSURER F: COVERAGES CERTIFICATE NUMBER- CL20i06uOi7/ ---- ,�cv,Jl Vl\IY VIYIOGR: 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 CONTRACTOR 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. LTR TYPEOFINSURANCE INSD WVD POLICYNUMBER DUCT EFF MM/DD POUCYEXP MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ PREMISES Eaecmnence $ CLAIMS -MADE DOCCUR MED EXP (Any one crew) $ PERSONALdADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ ❑ JECOT LOC PRODUCTS -COMPIOPAGG $ E LIABILITY COMBINED SINGLE LIMIT Ea aaidenl $ TO BODILY INJURY (Par person) $ SCHEDULED ONLY AUTOS MDEDi BODILY INJURY (Par accidart) $ NON -OWNED ONLY AUTOS ONLY PROPERTY DAMAGE Per accitlenl $ $ LLALIAS OCCUR EACH OCCURRENCE $ AGGREGATE $ - UAB CLAIMSMADE RETENTION $ WORKERS COMPENSATION PER OTH- $ ANDEMPLOYERS'LIABILITY YIN STATUTE ER E.L. EACHACCIDENT $ 500,000 A ANY PROPRIETORMARTNER)EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? NIA 376530970101 09/01/2020 09/01/2021 E.L. DISEASE -EA EMPLOYEE 500,000 $ ((yes.atory I d embe under NH) If yes, EL. DISEASE -POLICY LIMIT $ 600,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD tot, Additional Remarks Schedule, maybe allached if mote space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield MA ©1988.2018 ACORD CORPORATIAN All Ylninte .ne.—A ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name Address: a35' , Mailing Address: Mill � ! fv(w i1 .j MA 0438 Phone/Fax Number: Emai I �39 "labs Contact Person/Title for Grease (—I at) (PA�4) 11 Name of Company scheduled to pump internal grease trap(s) monthly: P&, (iot syyi PJ-s Name of Company scheduled to pump external grease trap quarterly: N 16 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 acknowledges that the infer io itted in these documents is true, accurate and complete. Date 11,11%I-W Print Nam 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): NI li Normal Hours of Food Preparation/Service: N /A Monday Tuesday jo'-36AM-• I3,�kfA Thursday )O`,60Ay11" i INM Friday 10,joAM 3AM Sunday 10'.30AvA, mAM Wednesday 10.30AVA� I AM Saturday /d 38AM- 3r\PA 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 0 Bar sink 1 { Mop Sink ® Garbage Disposal Q Ice Making Machines O Fryolators �t _ Grills o Ovens t Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): 1400eQ- &6M_00_1\u Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? N I N 2 Yes '< No Grease Traps 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 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)? Yes No Size gallons Where is the existing outdoor GRU located? Nik 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? N© Where is the grease storage unit located? w JJJ A How often is this grease storage unit emptied? N IA Please list the vendor who removes the waste: NIA 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. J 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 (pie r" z 0 LLM R � a o H � Z D Zm s FC pj �T E � s� Q r a _ � U 3 u, N a x a mo W-.4 0 � � u � W-4 � � � � Q� z �-o z Q#n Un W-4 z g m� � 2 2 CV � § § N N k E § k � § B B � k \ CL 2 \ / 0) R 6 a) k ) < »7ƒ\ } ■!%! 2 ` $ O poi M 0 0 n C 0 0 O N •� O M O V pp Oy ° E 00 O ° N M s O O O c N a a 0 N — 0-2 a� c� MO o Otri O� o O m V p 6 s Z vVm� w H W4 u V z H z •�I 3 z W W tN GLO O J cc co L 41 d oc� L d d � ° o Q o L �. 4- w O Gs Z 0 � O ❑ 8 14 0 LLM V 00 0 0 c E u 0 c o •E _u O t o_ V o W 0 0 c -Q V c c m o O aY Q d ry® 0 2 V1 � 5 �o i5 Q _0o p�z No r-) o� �o "as '^ vJ E W a E v 0 U 2v V . U v�i a z " QLO° w v LL Q O v LO a �v rn X LO � w �— C) o C V µ0 c O N a 13 i o E 0 � O L � Q J 6 � \ O N o S O N M 6 -• � LL. Nt U w � m W H � � C cY) CD M N W ^ ` W O M N Nt M t • E o Zo s 00 QU w OO O N •- a Q M V N V O O M o E M Q � u _ M U C Mt O _ ? > U . PiO.E- M P 0 N NEON V V aV O� o6 a 6 uQ o ZNUro� TOURK CHOUTAKH - 70UF1K Cf4c UAKH I - >2/ S \f0 /y \ \ E . \G »{ \ ^^ \`)) � q^L 61m A f) LL )\ _ \ � D }\ } \ƒ \ « ! ^ �2 \ } LO ^ / 2\ § }) z z 0 u w