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Home My WebLink AboutMansfield Deli, LLC - 12/31/20211 s FOR BOARD OF HEALTH USE ONLYg3Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) M.R.1gmnImp P air4 Establishment Name 72 PRAT STRgET Establishment Address AN YIELD' MA 02048 Establishment Mailing Address (if different) Establishment Telephone No ;oV ,339- 9.1 f Applicant Name & Title: C Applicant Address 3 Cif Ovc' l-0 - �nb.ryu wr d l Applicant Telephone No.: "1,I`i-s )1 -o a-1 3 24 Hour Emergency No.: Applicant Email — 4 �- aQ I � 1^"! �a��yCrAr9 _.0 m-1 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. • A Corporation Name Title Address El An Individual on oei; mac_ Stj 'j IeM4, C_ (l QNt 0 A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: '(CAMS, Q:' Address: 3 (srovu ts� okho",� 02� 3, Telephone No: 24Hour Emergency No:)2 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: j w� L EWAGE DISPOSAL: T, w [No. of Food Employees: 16 DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests Xn ra 551st ;" 5 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. 0 Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual etail Food $125.00 [Z] Mobile Food Consession E] Temporary good Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 n Manufacture Frozen Dessertstlee 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 El Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 � Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 0 Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (time4emperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no timaltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 0 Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs F1 Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly 9 of 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 and/or HACCP Plan (including bare hand Customer Self -Service Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only E] Ice Manufactured and Packaged for control) I Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of I Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Ej Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for U 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 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 1pq CMR 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 fled all state tax returns and paid stale taxes required under law. J Social Security Number or Federal ID: t� ^'}- Signature of Individual or Corporate Name: Corporate 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. 4 Signature of Individ 1 or Corporate Name 200 1-tY� ci 1 `--- "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if 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:\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' ation Insurance Affidavit: General Businesses mation A" F�® 0Ef.Jy LLC Please: Business/OrganizationN raitJg svla ra�sw rw Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: eb Business Type (required): 5. Retail L ❑ I am a employer with 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. 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, § 1(4), and we have I 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *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 # 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: HD)FOtt4 �- 0,uIt,12:j I_AS, Gs /r2_9 Insurer's Address: on - Pyj)( 01%I Soo 0• Y,i City/State/Zip: (uit �✓y 3 2 ��- Policy # or Self -ins. Lie. # a WNW- 14 111. Expiration Date: 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,(he pains and penalties of perjury that the information provided above is true and correct. 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 Phone www.mass.gowma ACORLIP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 1/09/2020 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 C & S Insurance Agency, Inc. 190 Chauncy St Mansfield MA 02048 CONTACT Lisa Fonseca NAME: plc No Ell: (508) 339-2951 rile No): (508) 3394811 E-MAIL Lisa@candsins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Employers Mutual Casually Company 21415 INSURED MANSFIELD DELI LLC 72 PRATT ST MANSFIELD MA 02048-1927 INSURER B: Commerce Insurance Co 34754 INSURER C: Hartford Casualty Insurance Co 29424 INSURER D : INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER: 2020 Cert of Lien 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDY� MWDDNM LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR NTE PREMISES Ea o=rren«,U_ $ 500,000 MED EXP(Any one person) $ 5,000 PERSONAL& ADV INJURY $ A 5W07628 02110/2020 02/10/2021 GENLAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY ❑ PRO- LOC JECT$ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED !� AUTOS ONLY HAUTOS ONLY BBZQWrJ 02/20/2020 02/20/2021 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccidenl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION S $ C WORKERS COMPENSATION AND EMPLOYERS'LIASILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N/A OBWECTJ1416 04/24/2020 04/24/2021 PER X STATUTE EORH E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 600,000 If yes, describe under DESCRIPTION OF OPERATIONS belayI I Per Occurrence 1,000,000 A Liquor Liability 5W07628 02/10/2020 02/10/2021 PerAggregale 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERT!F!CATS HOLDER CANCFI. 1_ATION 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 AUTHORIZED REPRESENTATIVE Mansfield MA G2048 91988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: MANSFIEl-p N G Arirlracc• 72 PRATT STREET Mailing Phone/Fax Number: S�d-339- 2 i5 Email -7- 61''Oq 9-) C�Mcc�1 ti`l Contact Person/Title for Grease Traps: Name of Company scheduled to pump internal grease trap(s) monthly: Ss`IyiY�i Name of Company scheduled to pump external grease trap quarterly: 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. Date //-f o -2 Print 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 6`'7 Thursday Sunday Tuesday 6- Friday 4' -) 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 Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators 3 Grills or Ovens % Exhaust Hoods 1 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 If yes, at what station/sink? 2 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 ro 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? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: 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 located? How often is this grease storage unit emptied?. Please list the vendor who removes the vOOp NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER.. UNDER THE CONFERENCE FOR FOOD PROTECTION :STANDARDS LAWRP NCE J. LYNCH, CAE *n ISSUE DATE: NJVEMBER 21, 2016 EXPIRATION DATE: NOVEMBER 21, 2021 CERTIFICATE NO: 21293337 TEST FORM:EXES2 9fiis mf<e,e is mii valW for more : ,hm fiveyruv from Jam aL>xue Patriot Services Inc. Invoice PO Box 294 BRIDGEWATER, MA 02324 Bill To MANSFIELD DELI 72 PRATT STREET MANSFIELD, MA 02048 Date Invoice # 10/22/2020 G3B1022201 P.O. No. Terms Project Net 30 Quantity Description Rate Amount 1 CLEAN GREASE TRAP FOR 3-BAY SINK TEST TRAP WITH LOTS OF WATER AND EVERYTHING WORKING WELL RESEALED LID WITH CAULKING 72.50 72.50 Total $72.50 PATRIOT/SERVICES, INC. Your Grease Trap Pro & Drain Specialist P.O. Box 294 Bridgewater, MA 02324 LIKE (508)697-9565 1 (800) 449-4480 (508)759-0979 US ON www.PatriotServicesMa.com Date of Service Customer Invoice # Phone # 4 Address City Zip Job Address (if different than customer) Apt. # DESCRIPTION OF WORK i �. A { n J I hereby auo� rize you to perform the above described services and I agree to pay the amounts indicated to the rightyl eet ify that I am duly authorized to order and approve the work requested. Signature >� I� PARTS r LABOR t 0 Terms: 1, '` Cash PO # �Bi(1 Out This is to acknowledge completion of the above described work which has been done to my complete satisfaction. TAX DISCOUNT TOTAL DUE G Date L") /`.:, - 4, (,) Customer Name Customer E-Mail Address