Loading...
HomeMy WebLinkAboutMansfield Council on Aging - 12/31/2021vlt�'iA FOR BOARD OF H JAN It, ?oe3f) E ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name mal/1S Establishment Address 2-s5 kj f - S vrl S Fl.Q jl� GZa �✓I Establishment Mailing Address (if different,) Establishment Telephone No -50? Applicant Name & Title: JO h r iti..e ma'4ra" 0 1 ✓� ~` Applicant Address 'L" 55 s I GtiYl �Ft L1 �(i� G�DC� Applicant Telephone No.: .���^ �(Q'- �(a 24 Hour No.: pEmergency Applicant Email jmad rn--p P_ Owner Name & Title (If different from applicant) Owner Address (e P0­VV- Owner telephone number, jO V-_ I Owner email: 1 rac-o Establishment Owned 13 If a corporation or partnership, give name, title, and home address of officers or • An Association partner. • A Corporation Name Title Address ® An Individual © A Partnership _ N Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title:'Jus-e- at 2 lMC4- 01 r-(,L-Z-pb Address: °�� � o � �` M "sr (t� �J�6 ��- Telephone No: �(��- rZ (� (- _73 (e� 24 Hour Emergency No: S6Fs^ q 5-3 `1 (g-j FAX: 506_ %J�Qj _L(19�Lp / E-mail: J MAO(Ya7 4�' �) YVI S��.R' p1 jf l GL • C�%vl 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; --T ie ) No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS; 1 Name of Person(s) In Charge Certified in Food Protection Management: VVtowlil Name of Person(s) in Charge Certified in Allergen Awareness Training Widwr Name of pest control company routinely Inspecting the premises for evidence of pests If there Is sealing for 25 peo le or more, a person trained In manual choke saving procedures will be onsite at all times food Is being prepared. ('es Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: /Annual [DRetail Food $126.00 (MJ Mobile Food Consession n Temporary ood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100,00 FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: I" Food Service up l0 101 -200 $260.00 $25.00/freezer Temporary End Date: @ Food Servlce up to 201 + $300.00 IM Pushcart $50.00 If of Pushcarts: Temporary Time: (tslj Supermarkets $400 op Residential Kitchen $100.00 Rain Date: ® Milk & Cream $10.00 Lim] Caterer $36.00 Food Operations: DeIInillons;PHF- PolantlaWhazardous foodffimeHemporalum eonlroisrequired) RonPHF's-non-porenflairy hazardous twor(no flmetlomperaWre confmis required) that (Check all apply): RTE-reedydo-sal toads fEX. sanoWlches, salads, muffins Which needno furlherprocessing) Q Sale of Commercially Pre -Packaged Non-PHFs F101 PHFCooked To Order ❑91 Hot PHF Cooked and Cooled or Hot Held ® Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service alive of Packaged PHFs Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly ry 9 Susceptible Population Facility [a Sale of Raw Animal Foods Intended , RReheating of Commercially to be Prepared by Consumer log Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand ® Customer Self -Service ❑m Customer Self -Service of Non PHF and Non. contact alternative, time as a publlc health control) Perishable Foods Only I] Ice Manufactured and Packaged for EM] Retell Sale Preparation of Non-PHFs Ila] Offers Raw Or Undercooked Food Of fa Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale IDEAVacuum Packaging /Gook Chill ❑® Offers RTE PHF In Bulk Quantities (`,prepares Food/Single Meals for "Catered IN Retail Sale of Salvage, Out -Of -Dale Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the Information provided In this establishment operation will cor 1y-wltF�105 CMR 690.O0 µhd gll othe board of health on how to obtain`coplese _ of�OC�Cjv1F�690.f(OJJ ary(}11�a to Signature of Applicant: v Pursuant to MGL Ch.62C, sec. 49A, I certify u der he penalties of and paid stale taxes required under law. Social Security Number or Federal ID. Signature of Individual or Corporate Name: lion and affirm that the food law. I have been Instructed by the Code, my best knowledge and belief, have filed all state tax returns -- Mansfield Board of Health Request for Fee Waiver for Food Permit Date � /� We, ��f MS Ft�.�(� C&Yt 1 CM WCX1 n'K (restaurant/ organization) request a waiver of the Food Service Permit Fee for the following reason: his is a request from a town department. {{ N Please list the department; b(( ()V) k i ire ❑ We are a 501(c)(3) organization and ALL proceeds earned will g directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. * Please list the organization: ❑ We are not charging a fee for food/drink being served, ❑ We are a religious organization. ❑ Other: Thank you, Signature V i V 2(°�t7/1% Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: Town of Mansfield 255 Hoye Sheel, Maosflehl, Ma saelmsells 02048 Mansfield Council on Aging December 31, 2020 Members of the Board of Health; Enclosed is an application for the 2021 renewal of the Food Establishment Pernieant Application package for the Mansfield Council on Aging. I respectfully request that any fees are waived to the agency is a not for profit government establishment. Thank yoihfgr your Cotln-dl on AginktSilailigervices Director Mansfield Council on Aging Pborre (508)261-7M8 Fax (508)3394886 Er»ail jniadraZa t�i rrrwtafrelrlivn.cam 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. V 0&.Q,,(J k l K WA kJ (k 7A Signature E udivid lal or Co porate Name By: Corker (Mandatory, if Applicable) "Social Security No. (Volmltary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security munber 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, CAUsem\sleitellJesklop\Scolt's DocumentsTood L>stabllsknlents-'remp17'AX CERTIFICATION FORKdoc The Commonwealth of Massachusetts Department of Industrial Accidents Office ofluvestigations 600 Washington Street IV Boston, MA 02111 wlpw,niass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Are you an employer? Check the appropriate box: Business Type (required): ,employees 1 � I am a employer with (ftill and/ 5. Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I 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 3.❑ [No workers' comp, insurance required] We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §l (4), and we have 10.❑ Manufacturing 4.❑ nc employees. [No workers' comp, insurance required]* We organization, staffed by volunteers, 11 ❑ Health Care are a non-profit with no employees. INo workers' comp, insurance req.] 12:0Othor fAiY(il l I *Anyapplieaottlmtehecks box#1 must also all out the section below showing tbeirworkers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation Ims other employees, a workers' compensation pol ley is required and 12 n organization should check box#1. I am till employer that is providing workers' colgpensation Insurance for apr employees. Below is the policy irrfororation. Insurance Company Insurer's City/State/Zip: Policy # or Self -his. Lie, Expiration Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dote). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a time 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. ofpetYmy that the information provided abovq is true and carrec4 r• nnr zs.,o Ofelal Ilse only. Do not write ire this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle ore); 1. Board of Health 2. Building Department 3, City/Town Clerk 4, Licensing Board 5. Seleetnnen's Office 6, Other Contact Person: Phone www.mass,govtdin Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/Food EstablishmentN,ame: Y'(�/ I.vur/cA g�YIv Address: ' -5 bp t°_ Mailing Address: r QU__Q( ✓�� _ Phone/Fax Number: ' h� % (a ' % 3�ii Contact Person/Title for Grease Traps! Wild 'Cl L41-- Name of Company scheduled to pump h3ternal grease trap(s) monthly: I I / / % (i��� Name of Company scheduled to pump external grease trap quarterly: �Y d ��jj�Y )ae— 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 Mansfleld) Food Establishmenb Fee 3 grease Interceptors/traps or less and/or 1 yello.vv 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 in r ation su rnitted in these documents is true, accurate and complete. Signed _ f! Date j ��- Print Name _ ti/ - n j W 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 Thursday Sunday 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) Numberin establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher 0 Barsink d Mop Sink % Garbage Disposal Ice Making Machines V Fryolators / Grills or Ovens / Exhaust Hoods 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? If yes, at what statlon/sink? (O�IS14 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 �(h 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 1 7j No Size gallons Where is the existing outdoor GRU located? 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? h d ^ ui,2 (� not ill: Ufa 1 r Where Is the grease storage unit located? How often Is this grease storage unit emptied? Please list the vendor who removes the 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. I have received a copy of the Polystyrene Container Reduction bylaw. I understand my res onsibility 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 res onsibility to ensure that this bylaw Is adhered to at t ermltted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature Applicant Name (please �In Mansfield Board of Health Request for Fee Waiver for Food Permit Date I`G' ( D We, organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: ❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. * Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. Thank you, F `h i rho FW- Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: