Loading...
HomeMy WebLinkAboutMansfield Service, Inc. - 12/31/2021-456o 3 FOR BOARD OF HEALTH USE ONLY, _ Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION C, '` e 1? ?4r: , (Application must be submitted at least 30 days before the planned opening date) Establishment Name ar C' (r'� ® M qq (,`lAblFltlr S'�. MrtillS�+ MCA, 01010 Establishment Address � Establishment Mailing Address (if different) l( Establishment Telephone No W) Applicant Name & Title: EL I 4-_5 K Az' AtVi e- p Applicant Address /,? VbAt /Q(m b;ltl�©d1l AR. oas- Applicant Telephone No.: 24 Hour Emergency No.:•� Applicant Email t? t�) tA (i v0aI Q , ,fU YVI 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 Ed An Association partner. VA Corporation Name Title / Address �" EL &( k4uty N_f F] An Individual I i\dw c w � o kl 10: M & L EJ A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �r A '0f9 /uf �nAfe/v / / 2 / �Il � Address: 3G J4tAlle S 1 p /* , /� �Ga<z /Vo Telephone No: `J I S `0 `1 24 Hour Emergency No: FAX: E-mail: POµ/k � S Akvelef to Lr't/e _ Gv4w Alt E-Mail: Mll S fir!/ &141hfzr / . 6 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: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Zy Name of Person(s) In Charge Certified in Food Protection Management: a4 A 'Ife/ul Name o Person(s) In Charge Certified in Allergen Awareness Training ✓ P4 All,, & r Name of pest control company routinely inspecting the premises for evidence of pests r e-S aA 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. O Yes Does this establishment require a FOG n permit? /✓ O If yes, please attach the FOG permit application. Length of Permit: Type: � �,1- Annual r�Esttablishment S rt�, Retail Food $125.00 [1] Mobile Food Consession Ed Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 iyt Manufacture Frozen Desserts/Ice Cream Temporary Start Date: s1 Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 !E' Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions: PHF-Potentially hazardous food (timeltemperature controls required) Check all that apply): Non-PHFs- non -potentially hazardous food(no timerfemperature controls required) (RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 4ale of Commercially Pre -Packaged Non-PHFs F1 I PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held 0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service 0 Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility t1 Reheating of Commercially Sale of Raw Animal Foods Intended to be Prepared by Consumer G Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours $-Customer Self -Service of Non PHF and Non- customer Self -Service and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) 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 /Cook Chill Offers RTE PHF in Bulk Quantities Prepares Food/Single 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 all other applicable law. I have been instructed by the board of health on how to obtain c ies oof�105 Cj�1R 590.000 and the federal Food Code. Signature of Applicant: �f-J Pursuant to MGL Ch.62C, sec. 49A. I certify under and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: penalties of perjury that I, to my best knowledge and belief, have filed all slate 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. Signature o Individual or Corporate Name By: Corporate Officer (Mandy j, if Applicable) **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:\Osers\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORMAw The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Are you an employer? Check the appropriate box: Business Type (required): I. DI am a employer with 10 employees (full 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 (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, I I .❑ Health Care urance with no employees. [No workers' comp. insreq.] 12.❑ Other *Any applicant that checks box #1 must also fit 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 ant an employer that is providing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Insurer's Address: T t i. L Y. S60 U City/State/Zip: C Policy # or Self -ins. Lic. # 6S669 UA—q 7 O f L Expiration 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 and penalties ofperjury 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.mms.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GS60UB-9701 L8776-20 ) RENEWAL OF (6S60UB-97011-87-6-19) INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY A STOCK COMPANY 1. INSURED: MANSFIELD SERVICE INC 189 CHAUNCY STREET MANSFIELD MA 02048-1355 Insured is A CORPORATION PRODUCER: R D MURPHY INS AGENCY 75 HANCOCK ST BRAINTREE MA 02185 Other work places and identification numbers are shown in the schedules) attached. NCCI CO CODE:10456 2. The policy period is from 11 -25-20 to 11 -25-21 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 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: $ Bodily Injury by Disease: $ Bodily Injury by Disease: $ 100000 Each Accident 500000 Policy Limit 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 066 D. This policy Includes these endorsements and schedules: 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 verifigation and change by audit to be made ANNUALLY. DATE OFISSUE: 11-13-20 WC ST ASSIGN: MA OFFICE: RMD HTFD 05G PRODUCER: R D MURPHY INS AGENCY 75TBC 004743 z a a _ u _ W V I W. 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 //J� Y'K 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 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. 15k_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 (ple