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HomeMy WebLinkAboutPrimrose School of Mansfield - 12/31/2021UG ��° 25. FOR BOARD OF HEALTH USE"ONLYpermit # Issued FOOD EST (Application must be submitted at least 30 days before the planned opening date) Establishment Name pi,..IW11 St+4vot-of HAWSOC Establishment Address 2,01 torvcAwD De- , mANtfiro, I_4A 0*2-4 1 Establishment Mailing Address (if different) Establishment Telephone No Applicant Name&Title: 146MA fo%,CL, 0trNtrL- ApplicantAddress I 44,1LLoa: PAtrtr wfu*SLLYMA, O'2VV+ 01-04t Applicant Telephone No.: , G 1 "1- 8 ► 24 Hour Emergency No.: Applicant Email to p Aka @ f ri wo U W%".1k'Qd - to nn Owner Name & Title (If different horri'applicarit) Owner Address Owner telephone number Owner email: Establishment Owned By: if a corporation orpartnership; give name, title, and home address of officers or ® An Association partner. ® A Corporation Name Title Address ® An Individual P VAS/ tLL•v kEic' WA Partnership ^Pwbt1 �— --- pwnti ,, 9 Other legal Entity SPA ( He*A!4(+':0 3 '' Q3fi' r+ flArt H Person, Directly Responsible For Daily Operations (owner, person in, charga, supervisor, manager etc,.) Name & Title: NCkA' JAW O W A V Address: ($ WILIAW QAttk. WEuEb'W-41 IIAA 01481 Telephone No: (o t 7 - g P$-4 Y$ S 24 Hour -Emergency No. 11, $ t b - 4 f t 13 FAX: E-mail: nfAJtA 61P•t�+rou..+Gw)d:LAi(e.++' Alt E-Mail: ne4 Ak ( District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: it' Town of Man ield 6 Park Rom, Mansfield, Massaduisetts 02048 Health Department Amy Uanovan-Palmer, MPH, AS, Healtb Agent October 13, 2020 Food Service Establishment Permit Holders: Your current food establishment permit in Mansfield will expire on December 31, 2020. To renew your permit, please submit the following documents and payment to the Health Department NO LATER THAN NOVEMBER 25, 2020. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. V /1. Food Establishment Permit Application (Attached) ,-7. ServSafe / Food Safety Manager Certificates �. Allergen Awareness Training Certificates f4. Tax Certification Form (Attached) .� Workers' Compensation Insurance Affidavit: General Business (Attached) /. Workers' Compensation policy declaration page ✓T. Completed FOG application (attached) t4. Town bylaw sign off sheet (attached) Please note, the Health Department is communicating with permit holders mainly through email. Please be sure to include a valid email address for all positions. if there are any changes in contact information (i.e. new PIC, new email address), the Health Department must be notified within 10 business days. As a food service establishment seating for up to 100 people, the following fees may apply: • $175 Food Service Establishment • $10 Milk and Cream • $50 3 grease interceptors/traps or less and/or 1 yellow grease collection container There is a new requirement based on the Town of Mansfield's Food Code, Food Regulations attached to this package, which went into effect on October 1, 2020: • 'Section 5. All food service establishments shall have a certified food protection manager who has completed Food Allergen Awareness Training as required by 105 CMR 590.000 available on the premises at all times that the food service establishment is in operation." Phone (508)261-7366 Fax (508)261-7425 Exiailadpalmet@max�6eldma.com Food Establishment Information WATER SOURCE: wrow#J of Mlr SEWAGE DISPOSAL: To i,t o of kA N�rf e4b fro rtboto No, of Food Employees: DEP Public Water Supply No: (if applicable) DAYS/HOURS: 1444 �o �4' %i G: $<�ON M g..s` 6.s d ii '3' Name of Person(s) In Charge ertifled 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'n.-q_ye Pti+ e"lh-j If there is seating for 25 peop or more, a person trained in manual choke saving procedures will be onsite at ali times food is being prepared. es Does this establishment require a FOG permit? If yes, please attach the FOG permit application. th of Permit: Establishment Type: Annual ® Retail Food $125.00 9 Mobile Food Consesslon Temporary ,,--,,!! .vIJ-rood Service up to too INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 H Manufacture Frozen Desserts)Ice Cream Food Service up to 101 -200 $260.00 $25.00/freezer Temporary End Date: (] Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts: Temporary Time: ® Supermarkets $400 ® Residential Kitchen $100.00 Rain Date: A -Milk & Cream $10.00 ® Caterer $35.00 Food Operations; Definitions:PHF - Potentially hazardous two flimMenperature conbulsrsquired) (Check all that apply): Non-PHF's- non-pofen0a/ty hazardous lood(w time((emparature contrdsrequved) RTE-ready7oeat (duds (Ex. sandwiches, salads, muffing which needno hitherprocessing) Efl Sale of Commercially Pre -Packaged Non-PHFs (iff'AFCooked To Order %Fiot PHF Cooked and Cooled or Hot Held n Sale of Commercially Pre -Packaged PHFs DoP reparation of PHFs For Hot And for More Than a Single Meal Service W Delivery of Packaged PHFs Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly RE ® Sale of Raw Animal Foods Intended Susceptible Population'Fac0lty Reheating Commercially to be Prepared by Consumer ® Use of Process Requiring A Variance F for Service Processed Foods for Service Within 4 Hours am1)or HACCP Plan (including bare hand Customer Self-service of Non PHF and Non- ®Customer Self -Service contact alternative, time as a public health Perishable Foods Only 0 Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of ® AJuice Manufactured and Packaged for Animal Origin. Other Food Operations Retail Sale ® Vacuum Packaging /Cook Chill n 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 copies ofAl05 CMR 590.000 and the federal Food Code, Signature of Pursuant to MGL Ch.52C, sec. 494,, 1 ce" under the penalties of perjury that I, to my best knowledge and belief, have flied all state tax returns and paid state taxes required under law. Social Security Number or federal ID: 24 ee e Signature of Individual or Corporate Name: g Z.' 6d2J Im % .p. � a� � \ \� \ . � . /MM \ � 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 4state taxes required under law. 1tltwyac �'tG�,.l � ti.4a+r�ttA _ Signature of Individual or Corpo `rate Name By: Corporate 'car wandatory,'ifonf if Applicable) $2-•2416$vr -So"Security No (VANAnj) or' Federal Identycation Number s A *This license will not be issued unless this ceitification 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,£ail.to correct, their;rtgn-•tiling or, delinquency'will be 'subject to license suspension or tevocatibn: This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. Q\US cs\* te\DuktnP\SCOtrs DOCwaWOF¢.d E'sta6lisl=m - Temp\TAX CERTIFICATION PORMAx The Commonwealth of Massachuseffs Department of Industrial Accidents Ogee of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: HIWD3 LLL 'D 6A QIG.ImUi.0 S Gn,ei. of Address: 2 C 1 C., pc tw.tn 'h L City/State/Zip: Phone #: 5 01 - 3 4 4- 4 16 3 Are yyu an employer? Check the appropriate box: Business Type (required): 1.9 1 am a employer with employees (full and/ 5. ❑ Retail Tr part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no 6. QRestaurantBar/EatingEstablishment employees working for me in any capacity. ?, ❑ Office and/or Sales (ael. real estate, auto, etc.) (No workers' comp, insurance required] 3.0 S• ❑ Non-profit We are a corporation and its officers have exercised 9. Q Entertainment their right of exemption per c. 152, §1(4), and we have ]0.0 Manufacturing no employees. [No workers' comp, insurance required]* 4.� We are a non-profit organization, staffed by volunteers, I 11.Q Health Cara with no employees, rNoworkers' comp.insurance real 120Other k4t0lfen (eA+,fr• *My applicant that checks box NI must also fill out the section below showing their workers' compensation polioy information, "If the corporate careers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 41, lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ...Mayget Insurer's Address: ` e. Pa,kw+p.,y Nool % t City/State/Zip: ell �'ttJ�i IL 4eotc Policy # or Selfirt-1 ie. # M VJ G 0 ) 4 ` 7- 6*7 — O 1 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury Phone#: 15y$- Lq-�i63 Official use only. Do not write in this area, to he completed by city or town qffciat City or Town: PermittLicense d above is true and correct Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's office 6.Other Contact Person: Phone WC000001A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Original Printing issued April 1, 2020 Standard NCCI Carrier Code:35513 Type: Stock Policy Number: FirstComp Insurance Company WCO206052-01 222 South 15th St. Ste 150ON Omalm,NE 681021680 Renewal of Policy: 888-500-3344 Rewrite of Policy: Fain # I Risk ID #: 822916525/ 1. The Insured's Name and Mailing address: DBA. Name:Primrose School of Mansfield Inspirational Minds, LLC SIC CODE: 18 Willow Park Wellesley, MA 02481-5609 Phone:61781841.11 Other work place not shown above:See Attached Location Schedule Type of entity: ILimited Liability Company 2. The policy period is from 04/01/2020 to 04/01/2021 [12.01 AM Standard Time] at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the states listed here: MASSACHUSETTS B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A . The limits of our liability under Part Two are: Bodily Injury by Accident: $ 1,000,000 each accident Bodily Injury by Disease: $ 1,000,000 policy limit Bodily Injury by Disease: $ 1,000,000 each employee C. Other States Insurance: Part Three of this policy applies to the stales, 9 any, listed here: All states except those listed in Item 3A of the Information Page and the following states or territories: AK, AL, CA, CO, DE, District of Columbia, FL, GA, ID, IL, KY, LA, MD, ME, MI, MT, NC, ND, NJ, NY, OH, OR, TX, UT, VT, WA, WI, WY, Puerto Rico and US Virgin Islands D. California Endorsements and Schedules Other State Endorsements and Schedules: MWC 1201, WCOOOOOOC, WC000308, WC000406A, WC000414, WC000414A, WC000422B, WC000425, WC 20 03 01, WC 20 03 02 A, WC 20 03 03 D, WC 20 04 01, WC 20 04 05, WC 20 06 01 A, WC 20 06 04, MIWCI000, MIL 1214, MPIL 1083, MPIL 1007 0120 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating. Plans, All Information required is subject to verification and change by audit. Minimum Premium: $258.00 Deposit P remium:$393.00 Total Estimated Annual Premium:$2,541.00 Pay plan: 10-Pay-15 % Producer:DMS Insurance Agency Of Texas LLC countersigned By: 12400 Coil Road, Suite 1100 , 972419-7568 Dallas, TX 75251 Date: 04/02/2020 Servicing office: Markel Service, Inc., (888) 500-3344 Central Park Plaza, 222 South l5tb Street, Suite 150ON Omaha, NE 68102-1680 (See extension of information page for class code, rate and premium detail) THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY II�IIIINIUIIIIIIIIIIhII�IIIIIIIIIIIIIIIIIIiIINll�lllllllllllllllllll 1 of 31 I�IIIIII�IIIIII�IIII�III�IIIIIIIVIIIIII�IM8111111111111111 DOM 1,013681A146231 i-04022020 W0020605"I Town of Mansfield Health Department APPLICATION FOR FATS, OILS, and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/Food Establishment Name: pRIHta1 Sgl-Ob OF IRAta1FIE0 Address: MA6 6lta /LR.41O 101 C.n/Btgtrop 'D,t MANlf"I! HA o243?r Mailing Phone/Fax Number: 50 4 - 3b 9. 616 3 Email: rnl%J�(pl Pri►aro)C�mIIant,f�{j( &*eO Contact Person/Title for Grease Traps: h Gv f.D Name of Company scheduled to pump internal grease trap(s) monthly: I w S i o k S g4., j?,`o V.4 J A+C Name of Company scheduled to pump external grease trap quarterly: V Bw 0 a•J Inr 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 $SO 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 thg permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date Print Name NENR Q{raE1.- 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): ) f 9 6 o6_/y (S hie% ( n c✓tc n �t Normal Hours of Food Preparation/Service: Monday 7', pb 6;10dct Tuesday' "y'("tb : 6; '3b�v+ Wednesday ' 1, v+ • b!3* fm Thursday i':rNA.,. 6 3i+Pr' Friday q;yyy„ (;low Saturday Sunday 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 Dishwo, asher Bar sink Mop Sink Garbage Disposal / d ice Making Machines Fryolators ; Grills or ovens , Exhaust Hoods: Floor drains .Other: How are hood vents cleaned? (Le., in three (3) bay sink, off site by private company): NI A - Is dinnerware pre -rinsed before being washed? ✓/ Yes No If yes, at what station/sink? -ff&A k . 1 ix' . GWL Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Grease Trap I Please list fixtures attached to each grease trap �n Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap S Fxtemai Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Vl� Yes No Size ( OW 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: PropertµOwner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? P A Where is the grease storage unit located? N%h How often is this grease storage unit emptied? 01 A. Please list the vendor who removes the waste: d) A 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. V 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. 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 Date: 1125 Applicant Name (please print clearly) 0 6NA F AIca- W--q 0 �. � � � � � � � W-4 u (M� z � z I V) Q*n W-4 z. 9:4 � � � z W4 � 44 � � \04 04 04 k ??Lm. /^ Co 2� ^ §CL «@ ° a »©~ \� » y » x Q x >© w % CD E 2 0 � R 7 a Q \[aZ \ »7\\ } < ƒ to / r