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HomeMy WebLinkAboutMansfield Lodge of Elks #2633 - 12/31/2021e e q( I �- f 11130110 FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name I-1Atj,5ftgL_p /_bDGb o r L1LS {32W Establishment Address (yp A. • m itlj ST r1�tNJf l t �i tjA di oqy Establishment Mailing Address (if different) Establishment Telephone No S pk- (_ S Applicant Name & Title: Applicant Address Applicant Telephone No.: 24 Hour Emergency No.: Applicant Email 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. M A Corporation Name Title Address 1H An Individual d A Partnership ® Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: TAMES r2U p-Kc Address: 10 CA"66 Rt v&(L "DRIvE /�RnSFrlt,D /'lA o-60 (f Telephone No: 24 Hour Emergency No: FAX: E-mail: T9ufz-KC'e:C(LL(- -9viCl(E, f 0 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: TD-W J SEWAGE DISPOSAL: T01.3,J DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: J /i ✓'? f S e u fR-I < E; Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests 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 Retail Food $125.00 Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $176.00 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 0 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 i?a Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 [_=l Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food (fimeRempereture controls required) apply): Nan-PHFs - non -potentially hazardous food(no timellemperelum controls required) (Check all that pP y): RTE - ready-to-eaf roods (Ex. sandwiches, salads, muffins which needno fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ;4.PHFCooked To Order TJ Hot PHF Cooked and Cooled or Hot Held CJ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service 1;i Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ ry 9 0 PHF and RTE Foods Prepared For Highly Susceptible Population Facility 25:{ Sale of Raw Animal Foods Intended 0 Reheating of Commercially to be Prepared by Consumer Ed Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours [Ed Customer Self -Service and/or HACCP Plan (including bare hand 0 Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) 1 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 1 Cook Chill Offers RTE PHF in Bulk Quantities ,�4 Prepares Food/Single Meals for 3a 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 CMIvjR 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain cooieaiff 1A5 ER 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 filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 1 Mansfield Board of Health Request for Fee Waiver for Food Permit Date We, ,IA J,5Y)&�D L-op(( of 6Lk-5 # 2.03 (restaurant/ 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. Other: rM7Zf✓✓A'- OV-� tJcLA to 0 (Po'.S- Pgorl-r Thank you, /%/Y/ Signature S Fc 4TIKY Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES JAMES W BURKE HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER' UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PR SIDENT' -40-A LAWRENCEJ,LYNCH, CAE i® 110656 Notification of Test Results ID#: XXX-XX- Scaled Test Score: 89 Candidate Status: Pass Pest Date: February 5, 2019 Congratulations! Attached is your certificate and wallet card. Please notify :he National Registry of name or address changes at the address below. preventing Contamination and Cross Contamination (Mastered) nsuring Personal Hygiene and Employee Health (Competent) fictively Managing Controls in a Food Establishment (Competent) Monitoring the Flow of Foods (Competent) Ensuring Product Time and Temperature (Mastered) conducting Cleaning and Sanitizing (Mastered) Managing:Physical Facility Design & Maintenance:Preventing & Controlling Pests (Mastered) ISSUE DATE: FEBRUARY 5, 201 £ EXPIRATION DATE: FEBRUARY 5, 202d CERTIFICATE NO: 2154487( TEST FORM: EZT 1 i This certificate h nor valid for mo ,Wa five y.. from dale of in, National Registi y of Food Safet) CERTIFIED FOOD SAFETY JAMES W BURKE' JAMES W BURKE 10 CANOE RIVER DR MANSFIELD, MA 02048 '.. Ccnificate Nu -- issue Dale: Febrm Expiration Date: Febm National Registry of Food Safety Professionals® 1 6751 Fonun Drive Ste 220 1 Orlando, FL 32821 1 Phone: 407,352.3830 1 Fax: 407.352.3603 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. VCR Signature of Individual or Corporate Name oq- Z 7,i-11i 1 "Social Security No. (Voluntanj) 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:\Users\sleite\Desktop\Scotts Documeno\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents } Office of Investigations Lafayette City Center _ 2Avenue de Lafayette, Boston, MA 02111-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Nt3 JS fjj -1) 1--o P6 ( O F 61A Address: ! L10 N , Phone#: ,-09-7-�(-YS S_ Are you an employer? Check the appropriate box: Business Type (required): 1.A. I am a employer with 2 employees (full and/ 5. [-]Retail or part-time).* 6. ❑ Restauram/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 [No workers' comp. insurance required] 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]** 11 ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. jNo workers' comp. insurance req.] *Any applicant that checks box #1 must also till 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: I rJ 3u�A JC6 Insurer's Address: ��I L O /� 1C �/ 7 Oy � �7 t/F SU 7 -(i I ll y City/State/Zip: O /L LA ID b FL 3 ZO � Policy # or Self -ins. Lie. # (6 NUQ a 13 -1- 2.0 } Expiration Date: / / / 2.2.L2- i Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 the 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: Issuing Authority (check one): LE]Board of Health 2.❑ Building Department 50 Selectmen's Office 6. ❑Other Contact Person: Permit/License 3.0City/Town Clerk 4.❑Licensing Board Phone www.mass.gov/dia TRAVELERS J* WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6HUB-1 K05813-1 -20 ) RENEWAL OF (6HUB-11<05813-1-19) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA A STOCK COMPANY NCCI CO CODE:13439 1. INSURED: PRODUCER: MANSFIELD LODGE OF ELKS 2633 ROBERT W EAMES INSURANCE 140 NORTH MAIN STREET 12G NORTH MAIN STREET MANSFIELD MA 02048 P 0 BOX 289 MANSFIELD MA 02048 Insured is ASSOCIATION, LABOR UNION, RELIGIOUS ORG. Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 11 -22-20 to 11-22-21 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE; Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA a� 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: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee a= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB o= D. This policy includes these endorsements and schedules: o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information Is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 11-04-20 WC ST ASSIGN: MA OFFICE: RMD POOL 161 PRODUCER: ROBERT W EAMES INSURANCE 73M9B 000541 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: 1111dv1 JFl (-,L) LoVO 6( 6GK3 1+ Z 03 Address: 1 q D N, tiA l J 6r r0n)YrILD )7 ,, W O-Z'oq? Mailing Address: -'5A M G Phone/Fax Number: S-0�_Zbl—)S"r1SJ Email: 17LlaZt33 5.0IMC4,7-.WT' Contact Person/Title for Grease Traps: QA✓`10 f3u'f-1Z.(T Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: SO A lZ0 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 l 1 h I (z0 Print Name M'4yzl< w`gLJA Facility Ooerational 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): % () b Seating Capacity (Actual Count): 100 Normal Hours of Food Preparation/Service: Monday L) — / 1 Thursday -I- )) Sunday ) — Tuesday Friday ) ) Wednesday _t-i_ 11 9 — ) ) Saturday L1-- ) 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 2, 3 compartment sink 3 (7 Handwashingsink 1 0 Commercial Dishwasher (� Bar sink Mop Sink Q (� Garbage Disposal Z Ice Making Machines Z d Fryolators 1 0 Grills or Ovens ( 0 Exhaust Hoods C� Floor drains 0 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? XYes If yes, at what station/sink? A 77,h-cH (-V -Tp (Y kj) 2 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 3 BAY SInlK Grease Trap 2 Grease Trap 3 Grease Trap 4 1 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes X� 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 Owners 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 Soares Sanitation Pumping, Inc. 285 Thrasher Street • Taunton, MA 02780-1505 (508)824-8370 & 1-800-464-8370 DATE OF SEPTIC TANK ('%'j ES6F9Br FIND &DIG OVERFLOW PIT PAID AMOUNTDUE ,,�**SERVICE /AMOUNT Thank You For Being Our Customer, And For The Confidence You Have Placed In Us. 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. to 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. LI 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. LI 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 4& Date: / 1 / )) Z-6 Applicant Name (please print clearly) / '�AQ T�)e 0 h LSu W-� 0 w � � u � � � � � W-4 u ('4� z Ono z � � � z P4 - f i z W-4 (4� � � � � lu 0�. ©/ .? \ 4 * $ NO04 . ) a�) \ \t\\ ) \ ))ƒ\ \ |\\§ � /