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Home My WebLink AboutMooyah Burgers & Fries - 12/31/2021`f° FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION I6d ©—G (Application must be submitted at least 30 days before the planned opening dke). Nop 1,9 _412 Establishment Name M 0 Q Y k \4 -j v Y- r " - r� 2S - S'k', V_ e- EstablishmentAddress$91 Sc'AvoL. tV, 5o4e_ 41HO MAMSni�EI N HA, a�o'fB Establishment Mailing Address (if different) Establishment Telephone No sag - 47 $ - 3 0 95 Applicant Name & Title: FARtrp R I Fp f Co - 0 W t4EQ- _ Applicant Address 400 FoXBo2o AL-vC> j,4rr Go,t •FFvyOoQo (KA, p�°ah Applicant Telephone No.: 50$' a9q- ?VY 24 Hour Emergency No.: aO0-3 Applicant Email l` WAM S, CVM )�oTrl /J m l.L. c 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 El Association partner. A Corporation Name Title Address , ❑An Individual F�Pro RIFAi �csi�c„� MEt5A_G0V- ❑A Partnership or'�t ZCi�ah rr��✓[ 3jo4D Lo oLru wpy IJA!�n'�(h ❑ Other legal Entity r 2e1�ay\ a NEQ 341 Pl,,% 6. f0.(4, MA, Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: MAQIJAt-I 2e-iA4,v\ Address: Telephone No: �� - $35 - y�s� 24 Hour Emergency No: 617 — `d 3S _ y t ,'O FAX: E-mail: II t AltE-Mail: Gi)o I"/ lteck cohN _ District Or Regional Supervisor (if applicable) jatn'e_ 'r5 A boue- Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 11 f' hp, 0;V4 a19y 11 f' hp, 0;V4 a19y Food Establishment Information WATER SOURCE: 70%. h SEWAGE DISPOSAL: svr7 No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: F r�;r9rp P./ I 5li nt0aJ_ '�"14V (LS A-`t I�r'Do - 77tiAy} LSifT(f O. E>A'r Name of Person(s) In Charge Certified in Food Protection Management: OftP.WA" et ko Name of Person(s) In Charge Certified in Allergen Awareness Training pip «, _ NTVINr ZiF#o - ARwA0 e'fnAn!_ �Dt✓ABf� SAS 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. M 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 W/ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100,00 ❑ Temporary LVJ FOOD TRUCKS $175.00 m4anufacture 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 ❑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(time/temperature controls required) Non-PHF's - non -potentially hazardous food(no fimeltemperature controls required) (Check all that apply)' RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing) ❑ Sale of commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ 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 Q Self -Service contact alternative, time as a public health ❑ Customer Self -Service of Non PHF and Non- control) ) Perishable Foods Only ❑ Manufactured and Packaged for ❑ 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 I 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 establishment operation will comply board of health on how to obtain c pies of 5 I Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I ce and paid state taxes required under law. D' provided in this application and affirm that the food and all other applicable law. I have been instructed by the 0 and the federal Food Code. the penalties of perjury that I, to my best knowledge and belief, have filed all slate tax returns Social Security Number or Federal I . �' _. �' ' I O Signature of Individual or Corporate Name: 'I fl. 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. TiiQe� (rsor� %Uy5 2;4,1e• — Signature of Individual or Corporate Name By: dorpoAte Officer (Mandatonj, if Applicable) �I— MR-140go "Social Security No. (Voluntnnj) or Federal Identification Nutnber 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 Documents\Food Establishments- Temp\TAX CERTIFICATION FORMdoc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address:3o1] scAvoL 4Shire 41140 City/State/Zip: 0 q6 Phone #:_ r�(p % $ - 30 9 5 Are y an employer? Check the appropriate box: l.i r am a employer with 8 employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. ❑Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.❑ Other *Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information. **1f 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 41. I am an employer that is providing/ workers' compensation insurance for ntp emplovees. Below is the policy information. Insurance Company Name: 'M' - it'a My Rt) Insurer's Address: 4 j4&9Thy9b MZA City/State/Zip: t i n L(ak o cT 0 0 55 q y Policy # or Self -ins. Lic. # � G1iF� L{G 1/2 /� Expiration Date: U l - D 4 - orOd 1 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 Investieations of the DIA for insurance coverage verification. I do hereby certify er1 e pa its and penalties ofpenjury that the information provided above is true and correct. _ lJ.--dt7 Official use onlp. 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 #: www.mass.goa/oia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: VIVO i fg 1 FS "t L12 av "-j %-�5 v ?/ 2 �/"k-' _T ' Address: 3011 SC VOL 61,SU;fc-41(4d M(rK-e,�IEL, MA Oo`Oy�jj Mailing Add Phone/Fax Number: 1 boY) at) Y5%Vk 6Of%10� Email: C9OOP � I#ka j no'r�L Cl W\ Contact Person/Title for Grease Traps: KA 1 1 J V MOIJr RU H P Il.JG EeV I Cu- Name of Company scheduled to pump internal grease trap(s) monthly: IyH6&1r PdH�)n!4 niaV ICE ' Mo r4nwy EL b> �" Name of Company scheduled to pump external grease trap quarterly: 4yft � "PWXAA 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 t t e information submitted in these documents is true, accurate and complete. Signed Date Print Name VAP I N 1 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 II ;vo - g roa Thursday ; 01) _ f ; Oy Sunday j5,,, S;, Tuesday 11 : eo - to, Oa Friday 11,'C AJj- 9%no VIM Wednesday I I` v o — 6 %oo Saturday 7L'30 - `CO 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 Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): 1='✓E2V �'ov� Mort'tV1 by P��u� t!r C�►�'s�Ah� Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes we 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 CV Vn1 pa,t m n 1 ht Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap S External Grease Traps 11 I Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Dta T�C f'O Yes No Size gallons Where is the existing outdoor GRU located? Fr --AP— o F- ` t" V- �&J l L b j f-f c1 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: pN3 FICLi7 C_0 vNT2y ..40. 4 Property Owner's Address: J 1-91Je71,,14TDnI Wao05 Vr. IZuw4fwryod � NIA , o I903 Property Owner's Telephone Number: 791— 143 — S55 S Yellow Grease Waste Do you store yellow grease waste from fi Where is the grease storage unit located How often is this grease storage unit emptied? n Please list the vendor who removes the waste: �(Eltiltl�ok=1 D(O N9:6C YDI THE 4THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 Town of Mansfield MA 6 PARK ROW MANSFIELD MA 02048 Account Information: Policy Holder Details : Three Good Guys Inc DBA Mooyah November 17, 2020 %P Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (877) 287-1316 Fax: (888) 443-6112 Email: aaency. services(�thehartford.com Website: https:Hbusiness.thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 .AE-C t CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 11 /17/2020 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 be endorsed. if SUBROGATIONIS 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 CONTACT NAME: ECOMP PAY AS YOU GO INS SOLUTIONS 76250865 PHONE (925) 462-8400 (AIC, No, Ent): FAX (925) 462-8868 (AID, Not: 6600 KOLL CENTER PKWY STE 100 E-MAIL ADDRESS: PLEASANTON CA 94566 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Hartford Accident and Indemnity Company 22357 INSURED INSURER B : INSURER C: THREE GOOD GUYS INC DBA MOOYAH 4 RIVER ST SOUTH EASTON MA 02375-1286 INSURER D: INSURER E: INSURER F : 4V V GRFiVCJ 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 CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. INSR TR TYPE OF INSURANCE ADDL IN SUBR MD POLICY NUMBER POLICY EFF MIOD POLICY EXP IDDIY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE❑OCCUR DAMAGES) RENTED PREMISES Fa occurrence MED EXP (Any one person) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG POLICY PRO LOG JECT OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY A Ea accident) BODILY INJURY (Per person) ANY AUTO BODILY INJURY (Par accident) ALLOWNED SCHEDULED AUTOS AUTOS HIRED NON-ONMED AUTOS AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAR JOCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAR CLAIMS- MADE DED RETENTION $ WORKERS COMPEN5ATION AND EMPLOYERS' LIABILITY ANY YIN X PER STATUTE OTH- ER E.L. EACH ACCIDENT $1,000,000 A PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? NIA 76 WEG AC5VZM 01/07/2020 01/07/2021 -EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS hot. DESCRIPTION OF OPERATIONS /LOCATIONS/ VEHICLES (ACORO 101, Additional Remarks Schedule, may be aaached if more space is required) Those usual to the Insured's Operations. CER tI H L;A I E HULUEK Town of Mansfield MA I P SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 6 PARK ROW BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD MA 02048 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD DUMONT PUMPING SERVICE an Advanced Waste Company 246 East Main Street, Norton, MA 02766 Phone (508) 285-7783 dumontpumpingservice.com Customer Service Report System Owner' 9 (O F: \`a fJ ` ft i $10 Off Next Service * Re -Book for next year to lock in current pricing 1 & 2 Year Service Contracts Available Services Description i o_a.....r1..1 Cnlu+lone! Quantity ti l System # Hoses Unit Price Subtotal Tax. Total ❑ System Operating Fine We suggest these 4 keys to keep your system healthy: a) Regular Servicing 2) Bacteria "Boost" at time of service 3) Use Dumont Pumping Service Bacteria Additive 4 Use a filter ❑ Excessive Solids Utilize Dumont Pum in Service Bacteria Additive bacteria via Dumont Pumping Service Program ❑ Heavy Sludge Introduce additional Utilize Dumont Pum in Service Bacteria Additive ❑ Tee Missin /Broken ❑ High Liquid Level Repair/Replace Tee Could bean indication of system in hydraulic failure, Suggest a system evaluation and/or a custom cleaning. Call the office as soon as possible at 508-285-7783 ❑ Distribution Box Issue We observed the following issues: ❑ Missin Filter Use of a filter is one of the 4 ke ys to keeping ours stem health ❑ Other The observations and solutions identified may require additional treatment. Please tall 508-285-7783 for our Customer Solutions Specialist for additional information or Customer Service with an guestions. Tech Notes: Previous Date of Svc. Ext Price 141 4'f � t Payment Details Payment Type Credit Card* Card #: Security Code Exp. Date *Credit cards accepted are: MasterCard, Visa, and Discover. Additional Notes: Time Arrive Time Left Tech Initials Customer Signature WO-00: Grease Cleaning Log (Less than 100 gallons) 4th Quarter Business Name: Address: Phone: Size of Trap (gal): Date of Service Initials of Employee Inspecting Cleaning Name of Cleaning Service or Employee Initials of Cleaner Gallons Pumped Comments 4 L ci� ( Cl l U (Osy v 0 I oAo 5 0 tit -70 c"o I certify that this document was prepared under my direction or supervision. The information submitted is, to the best of my knowledge and belief, true, accurate and complete. Name: Title: Signature: Date: Schedule Reminder: O October CD November O December DUMONT PUMPING SERVICE (508) 285.7783 ian Advanced Waste company ; i P.O. Box 292, Norton, MA 02766 www.dumontpumping.com Customer Service Report r _.._ ' ' - ' ' ' - - - - - - - - - - - - - - - - - - I $10 Off Next Service * NOW OFFERING 1 and 2 YEAR SERVICE CONTRACTS * PRE -BOOK FOR NEXT YEAR TO LOCK IN CURRENT PRICING Services "y'lun ! Quantity Customer Since Time Frame—. I Service Date Scheduled # Hoses Unit Price Subtotal Tax Total Ext Price Date of Svc. Tank Observations: Potential Solutions: Payment Details - r ❑ System Operating Fine We suggest the;keyso keep your system healthy: Payment Type1) Regular Servi2) Bacteria "Booof service Credit Card*3) Use Dumont Pvice Bacteria Additive Card #: 4 Use a filter❑ Excessive Solids Heavy Sludge Utilize Dumont Prvice' Bacteria Additive Introduce additiia via Dumont Pumping Service Program Security Code❑ Utilize Dumont Pvice Bacteria Additive Exp. Date ❑Tee Missing/Broken Re air/Re lace Tee *Credit cards accepted are: MasterCard, O High Liquid Level Could be an indication of system in hydraulic failure. Suggest a system evaluation and/or a custom cleaning. Visa, and Discover. Cards will be assessed Call the office as soon as possible at 508-285-7783 a 2 /o convenience fee. ❑ Distribution Box Issue We observed the following issues; Additional Notes: 508-285-7783 for our Customer Tech Notes: for additional information or C r:a" Time Arrive Time Left TeckThitials White - Original Customer Signature WO-001 Yellow - Customer Couv n/r AiiA DUMONT PUMPING SERVICE P.O. Box 292, Norton, MA 02766 www.dumontpumping.com Customer Service Report i��iC�C:s�C�-�l ��-iiC C✓' CCLS Approx. Gal. Custom Clean Customer Home Zabel Filter System Type Aid Ox Frequency Title V Previous Service Service Date Build Up Depth Below Grade Services Description (508) 285-7783 Customer Since Time Frame— t Service Date Scheduled # Hoses Quantity Unit Price Subtotal Tax Total Tank Observations: Potential Solutions: ❑ System Operating Fine We suggest these 4 keys to keep your system healthy: 1) Regular Servicing 2) Bacteria "Boost" at time of service 3) Use Dumont Pumping Service Bacteria Additive 4 Use a filter ❑ Excessive Solids Utilize Dumont Pum in Service Bacteria Additive ❑ Heavy Sludge Introduce additional bacteria via Dumont Pumping Seri Utilize Dumont Pumping Service Bacteria Additive ❑ Tee Missin /Broken Re air/Re lace Tee _ ❑High Liquid Level Could be indication of system in hydraulic failure. 5uoaest a system evaluation and/or a custom cleaning. 508-285-7783 for our Customer Tech Notes: may require oamtmnm TreaTmem. pease is Soeclalist for additional information or Previous Date of Svc._ Ext Price Credit Card Card #: Security Code Exp. Date Terms: " CC Customer Signature WO-0 White - Original Yellow - Customer Copy D/TP , �lpt c O O c OW c p ,o `u `oo v Z W U o m N 0 ~ < m c2 z O o U N O v a 1 o s p z 2 N w CDLO Q ~ fO c 9 ry i— w Oi 0 . o L.L! � � 7 N �jy •C � may. ?n, �L� 45'u� 75 az 3 a v 4 itn i r s L i u d 1 -lam Ji $r� w U �'• � � U C. iJ' � LL 2 �{p'• .� U p gJ'w � Oo m7 W d 2 • RR �I"^ W Q 3 ., li..�M_i_,U 0 VJ IL j tM d oz O a N �W 00 Mwa W a. zw O tL d� zo 0 IL m Q 0 Q Q U �x0 as waoo A � LL w U z a w w z 0 U W U U z oin -n 00(D UU) N .o vw vn� �mNK m 03 LL wwZtn N in .. W iw r ooW =ZU N 0 k w 0 u z z r z f w N o N N O m z0 Zct¢ � h l M � M P„ v F'4 abf py kb, a' I z !-- z z �1 w CL W J W 2 z Z O N N O 0 Q v N ,a a S It ti K � y A + b b HEARTSAVER e rtsave ' Heart Karst Aid CPR AED Association° Marwan Zeidan has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsavero First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Recommended Renewal Date 1217/2018 12/2020 Training Center Name Instructor Name Emergency Medical Teaching Svcs Tony Jordan Instructor ID Training Center ID - 12150392300 MA00640 eCard Code Training Center Address 186008871434 201 Oak St OR Code Pembroke MA 02359-1980 USA Training Center Phone Number (781) 826-2011 0. To view or verify authenticity, students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. m Me American Heart Assoclation. Ail rights reserved. 15-3002 3/16 � z � z � � � z W4 Q� P4 � � \ \ \ \ \ pq L911 1.0 )7§_ ¢ _& q� §@] [ \ � \�\ \ 3A(\ & �\\\ \ \\}\ y . \ \ !{\> \//\ \ a HEARTSAVER Heartsaver° First Aid CPR AED 00 American COHeart Associationo Farid Rifai has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Heartsaver° First Aid CPR AED Program. Optional modules completed: Child CPR AED, Infant CPR Issue Date Recommended Renewal Date 12/7/2018 12/2020 Training Center Name Emergency Medical Teaching Svcs Training Center ID MA00640 Training Center Address 201 Oak St Pembroke MA 02359-1980 USA Training Center Phone Number (781) 826-2011 Instructor Name Tony Jordan Instructor ID 12150392300 eCard Code 186008871433 QR Code To view or verify authenticity, students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards. O 2016 American Heart Association. All rights reserved. 15-3002 3/16 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. --S(—1 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. __q/ 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 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 r Date: 0"c7 Applicant Name (please print clearly) t A- Q IN �A f Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts andlor Ice Cream Mix To the Board of Health at the Town of Mansfield: In accordance with the provisions ofsection 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license for a WHOLESALE/RETAIL manufacture offrozen desserts and ice cream mix and submits the following information: 1. Full name of applicant: eA21 n (� i f MadYA 14 Qr5TAV IZA,.rfl- 2. Business address 5 [1 0 o L m nl s;I b�b L V l 3. If applicant is an individual: Full name: Residence: 3a. If applicant is a partnership, ftdl name and residence of all partners: _MAKw4tl it bRtJ A. If applicant is a cmporation: State of incorporation: 'TN-2InE g;, oa,) (�d y5 1 7tG Date of incorporation: 08 - 1 a - l9 Full name and address of: Principal office: President FA# 0 Rlfa Y" &xBOQ-a gl ✓D t%MA Oi-l034' UNi G0,2 Treasurer: 4,4TVtNE Ze'IDA / Clerk: 1'I,AJ&1Rif 26_lD&v 4. Location of Plants: 5. Names of brands and trade or corporation name, if arty, under which the products are to be sold: 6. Number and capacity off •eezers and fees: I Fee: ($25.00 per,freezer) $ #Type! Z Is the mix purchased? y CIfso, from whom purchased? U 5 Jso p 8. Is the mix pasteurized? 9. Number ofgallons offrozen desserts and/or ice cream mix to be sold in Massachusetts during the licensing period 10. Number ofgallons offrozen desserts and/or ice cream mix sold in Massachusetts during the previous licensing period Soo q 11. Is the plant constructed and equipped as provided in the regulations? X S 12. Is the water supply public or not? I", tlf/ r, 13. Have you received a copy ofthe regulations? ye I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all taw of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of .t ealt made thereunder and will be manufactured under sanitary condidons. I attest that the information stated in this appl/ • do true a accurate under the pains and penalties of pejury. /I- )9 �o (Cornifan owner/officer's signature) (DATE) P✓'es �010 , (Title) (City or Town)