HomeMy WebLinkAboutPushkart Cafe, Inc. - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued,' ` ^4
FOOD ESTABLISHMENT PERMIT APPLICATION �4
(Application must be submitted at least 30 days before the planned opening date
Establishment Name �t,t S �1 �G(({ C- (k { J�r) c-`
Establishment Address I\J , 01 a j ✓I Ylq 0 11 S fl -e— I Cm H
Establishment Mailing Address (if different) (� V (' o-ie V / I v c l a o ll Ic yt rn o
Establishment Telephone No
Applicant Name & Title: I <t to vV�- C)
Applicant Address (()A V Irv-vo �- Ave
Applicant Telephone No.: "S-Ub-qr(?-qo,,2 24 Hour Emergency No.:
Applicant Email -�� U (r CC)VI—)
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
11 An Association
partner.
4A Corporation
O An Individual
Name Title Address
0 A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: I Q GV rA Vic.- Hb Cc v-\ (-(—
Address: t(YLVC
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r
Telephone No: �(� �� - (f y L- o'i 24 Hour Emergency No:� o- 2 - 1/0 >> S
FAX:
E-mail: _�I rl' o l'( <S ( �4 L C� �£/ (___
Alt E-Mail: +c� u n (A_chc U- 1) b\ % d (d a V 1 6 o, U ry1 _
District Or Regional Supervisor (if applicable) '-
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
rn
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS: () `) {—)
Name of Person(s) In Charge Certified in Food Protection Management:
V I
Name of Person(s) In Charge Certified in Allergen Awareness Training
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5 k Le L l � Vi a_ _
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Name of pest control company routinely inspecting the premises for evidence of pests f �)
If there is seating for 25 p,e9pple or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. 6kYes
Does this establishment require a FOG permit? f = If yes, please attach
the FOG permit application.
Length of Permit:
Establishment Type:
nnual
❑ Retail Food $125.00
Mobile Food Consession
El Temporary
IXl Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100,00
Temporary Start Date:
Y—'FOOD TRUCKS $175.00
Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Dale:
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
El Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous food(no time/tempemture controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs 4PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs E] 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
Sale of Raw Animal Foods Intended
Reheating of Commercially
Susceptible Population Facility
to be Prepared by Consumer
Processed Foods for Service Within 4 Hours
❑ Use of Process Requiring A Variance
and/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 ❑ Ice Manufactured and Packaged for
control)
of Non-PHFs Preparation Retail Sale
P
❑Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
El 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 copies of 105 CMR,590.000 and the federal Food Code.
Signature of
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID: Q- ( I ,
Signature of Individual or Corporate Name: (� /I
-P_.J-4'"1 C
C Cif'
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.
r1nut(d-oculd— l&6ya vf-
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, 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:\Users\sleite\Desktop\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
1ne uommonweattn ofmassocitusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
If wrvw.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: c G1 K) �% i o
l
City/State/Zip: i)� 60 �'%1 `2 f C� � i 0 hoonte
191 l `� )
kre yop an employer? Check the appropriate box:
Business Type (required):
l . I am a employer with employees (full and/
5. ❑ Ret it
or part-time).*
>_. ❑ I have
6. \ estaurant/Bar/Eating Establishment
am a sole proprietor or partnership and no
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ Non-profit
[No workers' comp. insurance required]
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]*
A. ❑ We are a non-profit organization, staffed by volunteers,
11.❑ Health Care
12❑ Other
with no employees. [No workers' comp. insurance req.]
1ny 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
ganization should check box #1.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
tsurance Company Name:
tsurer's Address: 2* 0 U ���� it )�1l�) �� ✓�
ity/State/Zip: r% �T��j� 6r'd�jt(� �
olicy # or Self -ins. Lic. # � ` p-ki �zC/o� Expiration Date: I c:9-1
ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
F up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations of the DIA for insurance coverage verification.
do hereby ce(rtitit, under the pains an]d� I1penalties o�f}perjurry/ that the information provided above is true and correct.
innahnr- ` I (it.�t../t�-(11 I \S1I cl1i,, c( Pate• I I `t 0or-�-()
hone#: �i)�-a�i2~ �_(03S
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
www.mass.gov/dia
Phone
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: -
Address: �)-1 r( N . M C-k 0 v � MCx r\ S f 'e- ( Cl p Y 1 n 6)w (<S
Mailing Address: U9 k �- ( wy--� V AV -c' —( C�- U� n+oy-) ✓`() A
Phone/Fax Number: �� C/ _ Z scr - 9 (-1 i- O
Cc'--fe. Co%- --�
Contact Person/Title for Grease Traps: ci 0, V-'\ c� - )c, (`Gr N of
Name of Company scheduled to pump internal grease trap(s) monthly: c � CA � .(-
Name of Company scheduled to pump external grease trap quarterly: Y1 ,e" �S
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 that the informati s bmitted in these documents is true, accurate and complete.
LA -Signed t A, i1�ti 01 Date ( � L,U
Print Name
VA
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 G( 0
Thursday 6,\ (2i (2
Sunday r q - 10
Tuesday ,P-
Friday (p 2
Wednesday (C)
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
ff
J
Bar sink
Mop Sink
�>
Garbage Disposal
lIce
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� Cl o v k_3 r--'
Is dinnerware pre -rinsed before being washed?
If yes, at what station/sink?j
/Yes No
f r-y--,�rV � `' I V\ L�_
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
V-A UCCs— MCiCI-1"K-)e_ C—
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?
✓vIGC �t rLC
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? LK
Where is the grease storage unit located? 0U { ,l d (, r-�
How often is this grease storage unit emptied? c� x L I �` G ✓� l
Please list the vendor who removes the waste: �� x �J�r �ci es-e
f l tULrl 01 [r] S Ji /t1 kl6i 913 A 71161Ife14 :l l W AY5.1
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.
_\ ,
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.
TI have received a copy of the Polystyrene Container Reduction bylaw. 1 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.
--T—W 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.
1
Applicant Signat re Cl luYv¢, (1 Date:
Applicant Name (please print clearly) TCl kA � � -\AU I O � CA
I I- iA-ZU
DATE (MMIDD/YYYY)
.4.'
CERTIFICATE F LIABILITY INSURANCE
09/11/2020
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 INSURERS , AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) 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:
AUTOMATIC DATA PROCESSING INS/PAC
76250816
71 HANOVER ROAD
FLORHAM PARK NJ 07932
PHONE (800)524-702A
FAX (800) 524-4013
EMAIL ADDRESS:
INSURER(S) AFFORDING COVERAGE NAICIX
INSURERA: Twin City Fire Insurance Company
29459
INSURED
INSURERS:
PUSHKART CAFE
INSURER C
219 N MAIN ST
MANSFIELD MA 02048-2211
---
INsuRERb:
INSURER E:
INSURER F :
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
..............
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 WITH 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,
INS
7'R
TYPE OF INSURANCE
ADbL
SUM
POLICY NUMBER
POLICY EFF
MMIDD YY
POLICY EXP
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$1,000,000
CLAIMS MADE OCCUR
General Llabillty
X
DAMAGE TO RE14TE 81 D
$1.000,000
MEO EXP(Any one person)
$10,000
A
76 SBW BG2800
11M8/2020
11/18/2021
PERSONAL&ADV INJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
GENERALAGGREGATE
$2,000.000
POLICY❑PRO- LOC
PRODUCTS - COMPIOP AGG
$2.000,000
JECT
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
ANY AUTO
ALL OWNED SCHEDULED
AUTOS _ AUTOS
HIRED NON -OWNED
BODILY INJURY (Per accldenq
PROPERTY DAMAGE
AUTOS AUTOS
(Per ecoident)
UMBRELLA LIAR
EXCESS LIAB
OCCUR
CLAIMS
MADE
��
EACH OCCURRENCE
AGGREGATE
DED
RETENTION $
WORKERS COMPENSATION
PER
OTH-
-
AND. EMPLOYERSYIABILITY
--_-
-- --
—
STATUTE
F
E.L. EACH ACCIDENT
ANY YIN
PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
NIA
E.L. DISEASE -EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
(Mandatory In Ifyes, describe under
If
DES TI OF OPE ATIO slow
A
EMPLOYMENT PRACTICES
LIABILITY
76 SEW BG2800
11/18/2020
11/18/2021
Each Claim Limit
Aggregate Limit
$10,000
$10,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Those usual to the Insured's Operations,
ffbgt�tmmW010.1+ no
........ _
The Town of Mansfield
- __
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
6 Park Row
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
mansfleld MA 02048
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
d4ea Coat �
ACORD 25 (2016/03)
i
01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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Name:
Tauna Holland l� merican-
a Health Care Academy
' tYegovlde uvoN c!dgan'
Adult, Child, Infant CPR & AED
Training (BLS)
This card certifies that the above individual has successfully
completed die requirements in accordance with American Health
Care Academy's curriculum.
10/22/2019. 10/22/2021 _
Issue Date Renewal Date
Instructor's Signature
Holder's Signature
... _................
Call 911 in case of a medical emergency
Call 1-800-222-1222 in a poison emergency
For CPR/AED or First Aid training informadon,
call 1-888-277-7865 or visit cpmedcuurse.eme
American Health Care Academy
Renewal recommended every 2 years 8003823-1503462.,
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