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HomeMy WebLinkAboutMansfield House of Pizza - 12/31/2021#�l 36 - &_ 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 11 �f4t V1 SL o f Establishment Address Establishment Mailing Address (if different) Establishment Telephone No - 3,59 - 7 7 & Applicant Name & Title: 2`v_1 KVN6� _/ rt 5) de o-\-. Applicant Address 2 t/ gyp))) e_w5 Y 11're_ I C KA `' �n -0 Applicant Telephone No.: 570$_33 G) - 17 & S' 24 Hour Emergency No.: 5V $ -,2ZC c%- t/ 3 Applicant Email c 2 zot zef bf hay J e ;/t h o o - Ui Y) / 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 0�v An Association partner. XA Corporation Name Title Address C7 An Individual So me o sa b MVP Ed A Partnership N Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: O� m Address: Telephone No: 24 Hour Emergency No: 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: —ro(s,p Y1 SEWAGE DISPOSAL:-1 O (,J in DEP Public Water Supply No: (If applicable) No. of Food Employees: ,.1 DAYS/HOURS: 7 D o 5 — � •--t / 1 Ili' q ( 6Z j - f o 50* ( f : 30 -y 5 \A Y)' Name of Person(s) In Charge Certified in Food Protection Management: rizz70 znkz_1-)Ar/ Name of Person(s) In Charge Certified in Allergen Awareness Training �- zZ of Z0, r� �� ►�� 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? S If yes, please attach the FOG permit application. Length of Permit: Establishment Type: I)(Annual `r❑''=" Retail Food $125.00 L-flMobile Food Consession i Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 0 Manufacture Frozen Desserts/ice Cream Temporary Start Date:,,.:- Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: iFood Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 E-] Residential Kitchen $100.00 Rain Date: .` Mllk &Cream $10.00 ®Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food (timartemperalwe controls required) (Check all that apply): Non-PHFs - non -potentially hazardous lood(no timeltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) C Sale of Commercially Pre -Packaged Non-PHFs ] PHFCooked To Order _ Hot PHF Cooked and Cooled or Hot Held l Sale of Commercially Pre -Packaged PHFs (`Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs old Holding For Single Meal Service ',]. PHF and RTE Foods Prepared For Highly ry 9 Susceptible Population Facility ❑-° Sale of Raw Animal Foods Intended eheatin of Commercially 9 y to be Prepared by Consumer Use of Process Requiring A Variance rocessed 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 Ice Manufactured and Packaged for control) Preparation of Non - Retail SalePHFs � Offers Raw Or Undercooked Food Of [I Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑�,`+' Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities [�Z] Prepares FoodlSingle Meals for ® 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 a(I other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 ap the federal�Food Code. Signature of Applicant:'7`j'"j"1�/ Pursuant to MGL Ch.62C, sec. 49A, I certify under the and paid state taxes required under law. of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal l D: 22 pp Signature of Individual or Corporate Name: ® LJ 3J 2 q I'Llr-1��q ti 0 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. eiS 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. t-3 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 r ponsibility 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) 1 - & -AD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Address: % 75- Nei, Mpi'n T - (l)ohsI t e Ic h_N Mailing Address: 171'1 et- Phone/Fax Number: X' 3 9 — tl 00 Ema Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: 12 tS I Pl ff �'L 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 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 information submitted in these documents is true, accurate and complete. Date I I —/P— 19-0 Print Name %7 7 l4---y 4 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): 1-;2 9 Seating Capacity (Actual Count): 'a;y Normal Hours of Food Preparation/Service: Monday Thursday (j — Sunday Tuesday ( j — q Friday j ( - 10 Wednesday I r- q Saturday (—Ol 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 Grills or Ovens `j 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 station/sink? 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 51rn j< 5 Mand Welsh 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 Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? _I C, Where is the grease storage unit loca How often is this grease storage unit Please list the vendor who removes t o�K�s omn1od,1 � 3 �1C 9 TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or or rate Name By r orate Officer (Mar a 6rV if Applicable) (19tl 9- Ili9 1 "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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetis Department of Industrial Accidents Office of Investigations 600 Washington Street o Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: i T , AL - 11 11 • V1 S l - City/State/Zip:o ryb Soelj t (�j�_0 A(2 Ilj7 Phone #: 0 $ a00 Are you an employer? Check the appropriate box: Business Type (required): 1.[,2!kI am a employer with c2 employees (full and/ 5. Retail or part-time).* 6. MRestaurant/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] 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 I0.❑ Manufacturing no employees. [No workers' comp. insurance required]** 1 I.❑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 #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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: W1oj2f-_91 K al VtA-3n A f L t l,S • �Q Insurer's Address: City/State/Zip: P - n pp� M 11 U '� 0 Policy 4 or Self -ins. Lie. #J,ll F 1 7 ,� (00 9 A 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 the pains m:d penalties ofperjury that the information provided above is true and correct. 9 -5 —t — 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 #: rNnvw.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS' LIABILTY INSURANCE POLICY ---- INFORMATION PAGE i, INSURER: NORFOLK & DEDHAM MUTUAL 222 AMES STREET DEDHAM, MA 02026 FIRE INSURANCE COMPANY ITEM 1. NAMED INSURED AND MAILING ADDRESS: MANSFIELD HOUSE OF PIZZA INC 175 N MAIN STREET MANSFIELD, MA 02048 POLICY NO: WE172629A RENEWAL NCCI Company No: 21059 Account No: FEIN: 04-3291697 AGENT NAME AND ADDRESS: SALHANEY INSURANCE AGENCY 5264 WASHINGTON ST WEST ROXBURY, MA 02132 AGENT NO.: 20121060 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 11/05/2020 To: 11/05/2021 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 500,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 211 Annual Premium: $ 1,008 Audit Period: ANNUAL Additional / Return Premium: Issued At: Date: 09/28/2020 Comments: Countersigned by WC000001A Copyright 1987 National Council on Compensation Insurance INSURED COPY Day State Sewage Disposal, Inc. P.O. Box 886 • Lakeville, MA 02347 508-947-2636 • 1-888-822-0766 Middleboro Cesspool 508.947-0560 Lakeville Sanitary 508.947-6525 AcUshnet Cesspool 508-995.3196 Lakeville Cesspool 508-947-9275 Anytime Septic Service 508-697-8500 Rochester Cesspool Service 508-763-2029 Eveready Pumping Service 508-238-6241 M&G Sanitation 401-624-9457 Action Sanitation 508-646-9900 DATE: P I © I -� PHONE: TO: MgV\S��e1�' NeuSe �'� �i 22,�A, Pumping: �a T CMG S P-ill J �1 Service: TOTAL S� Driver / Date / Chk No / Amount Type / Gal Filter: Oyes ONo Truck / Hoses Dump: OYes ONO Notes Cover Location / Exposed 'Thank, You Baystatesewase.com Sfafe Sewage Disposal, P.O. Box y 9 Lakeville, MA 02347 1 r r r r Middleboro Cesspool508-947-0560 AcushnetCesspool 508-995-3196 Anytime Septic Service 508-697-8500 Eveready Pumping Service 508-238-6241 Action Sanitation 508-646-9900 DATE: qoa /)-0 TO: Pumping: (;Yq-% Q +r u Service: . vt , Driver / Date / Chk No / Amount Truck / Hoses Dump: ❑Yes ❑No Cover Location / Exposed Lakeville Sanitary 508-947-6525 Lakeville Cesspool 508-947-9275 Rochester Cesspool Service 508-763-2029 M&G Sanitation 401-624-9457 PHONE: A TOTAL / Gal Filter: ❑Yes ❑No Notes 5 ' AC,\,\ C) (L `}G f, ■r Thank, You www.BaystateSewage.com