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Home My WebLink AboutThe NRG Lab - 12/31/2021G 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 V I i c- N P,C--1 k A B Establishment Address L O SCJi06L,I )2 F C- ( HA KISF(F—c-D, (jq { 0;? U -I g Establishment Mailing Address (if different) 3kM(= Establishment Telephone No --,DO _ Y3-7 to -_ 2- Applicant Name & Title: P-, ry N Fb"-t-& i�,Ac I-(v1PC To Applicant Address cla� pI) nvr_tirup_ S. Ajlti°i30✓LiU yy).n c2 7(Sj Applicant Telephone No.: Svy, yo ) ktd"a-() 24 Hour Emergency No.: c,�� p ( �Ha c� Applicant Email A Fy0+a- In^ 0 f�12_'t h.,'kr3 ,CtnY) 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 N An Association partner. WA, Corporation Name Title Address IN An Individual ® A Partnership IN Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: /\j,-At k j'pa t rA �.l( r �71 fZE<_ -(D Address: Telephone No: �,U�-� �24 Hour Emergency No: FAX: nn E-mail: FU(YiA. l nC'C'0 N 2-(� it -R Q .cow) Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: N/ Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: --rb Iu r\l SEWAGE DISPOSAL: V-) h-A DEP Public Water Supply No: (If applicable) No. of Food Employees: Li 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_Rc — [\SSQSIO'�' 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. ® Yes Does this this establishment require a FOG permit? yC?S 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 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream ® 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 ❑id Caterer $35.00 Food Operations: Deftnitions: PHF- Potentially hazardous food (timerlemperaturo controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ® Sale of Commercially Pre -Packaged Non-PHFs ® PHFCooked To Order ® Hot PHF Cooked and Cooled or Hot Held ® Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot And for More Than a Single Meal Service ® Delivery of Packaged PHFs Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly 0 Sale of Raw Animal Foods Intended Susceptible Population Facility ME Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours ®Customer Self -Service and/or HACCP Plan (including bare hand ® Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ® Ice Manufactured and Packaged for control) 0 Preparation of Non-PHFs Retail Sale r,� � Offers Raw Or Undercooked Food Of n Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑rd 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 t � information provided ill t is application And affirm that the food establishment operation will comp) wit _ �CMR 590. 0 and a oth§� applicable la I have been instructed by the board of health on how to obtain cop -d 06- {v1- :federal Food C e. Signature of Applicant�- Pursuant to MGL Ch`.62C,.see 49A, I certify under the ffe}falties df perjury that I, toNy best knowledge and belief, have filed all state tax returns and paid state taxes required under law. vv Social Security Number or Federal ID: L� �O " Z "0 /-7 C_7 I Signature of Individual or Corporate Name: t —t-- 4 c_:- C-7 NI F k C7y L'A 3 1 t�[ C 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 of Individual or Corporate Name 4to 2ai01I "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\sleae\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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: T[�F ( -NR It -IC. Address: 2-00 SC. ft oC_ S50 _.G- i City/State/Zip: IY1NMSn (' i- lit MN- 02 014 (? Phone #: GY� S-) (p Qlp -114 Are you an employer? Check the appropriate box: Business Type (required): 1 I am a employer with 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] g• ❑Non-profit 30 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, 11.❑Health Care 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: b Dot C City/State/Zip: l ,-1^arL 7 `PC_n2 Ac-- C.-F- ao I Policy # or Self -ins. Lic. # 06 W e C. C P O S�o7 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 of the Dh4 for insurance I do hereby cerhi, under tltg,1iakt�s analties ofrjury that the infornmtion provided allove is trueond 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 Person: Phone #: www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: 1 rf Q P-C-7 Address: 2,60 !�.C- {"f-bo t Mailing Address: S f1l"ncO= Phone/Fax Number: G06 2-7 (0 (Ly) H Emai l: I r1 rlru lu h A A fUa-�A r)eA) f)CIA lad C" PR�Fs¢RGD Contact Person/Title for Grease Traps: A f�-1 is-1 F n e tT Ft l r�I t l Iz C fi5 Name of Company scheduled to pump internal grease trap(s) monthly: i77 Name of Company scheduled to pump external grease trap quarterly: 9 A �r f f i - SitJAC� 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 considerati n of a granting of the per it the uncle i ned agrees to the conditions of the permit and acknowle g a thp� o (nation itted in th documents is true, accurate complete. a t i , Signed Date 000-0 Print Name 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 60- — S ThursdayS��o�L - 82 jj Sunday S`- —lap Tuesday Ba —�3p Friday 86t_—g,;� 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 IBar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods L j 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? 3A 12= S I N e ) Pm 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 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 Where is the existing outdoor GRU located? No Size gallons 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? Where is the grease storage unit located? N �— How often is this grease storage unit emptied? /k Please list the vendor who removes the waste: ICI 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 cus mers. 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 Testin 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, fro en, 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 Applicant' Applicant I I � § � ) q■}a \ \\\\ \ �\§A \ \&) \ \ 2}7§ \\\) - \ 42 JA 1 .Q 0 .o N (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Insurance Company of the Midwest ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 20605 Company Code: G Suffix LARS RENEWAL POLICY NUMBER: 08 WEC CP0502 Previous Policy Number: 08 WEC CP0502 1. Named Insured and Mailing Address: THE ENERGY LAB, INC. (No., Street, Town, State, Zip Code) 38 RUSSET HILL RD FRANKLIN MA02038 FEIN Number: 46-2870170 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Fitness and Recreational Sports Centers Other workplaces not shown above: 280 SCHOOL STREET, BUILDING F MANSFIELD MA 02048 2. Policy Period: From 11/01/20 To 11/01/21 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: DOWLING & O'NEIL INS AGENCY/PHS PO BOX 1990 HYANNIS MA 02601 Producer's Code: 08088233 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (8661467-8730 Total Estimated Annual Premium: $3,332 Deposit Premium: Policy Minimum Premium: $286 MA (Includes Increased Limit Min, Prem.) Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by T'YA� 09/22/20 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 09/22/20 Policy Expiration Date: 11/01/21