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HomeMy WebLinkAboutSubway - 12/31/2021j FOR BOARD OF HEALTH USE ONLY Permit# Is: FOOD ESTABLISHMENT PERMIT APPY18ATION4 (Application must be submitted at least 30 days before the planned opening k Establishment Name Establishment Address pefa urt? !�(• Y' ,S�.�(�� Gt (En D 21Ocf Establishment Mailing Address (if different) Establishment Telephone No 0 6 DU !Applicant Name & Title: oLg- pS J NA e't �q �/ Applicant Address (S 60-L ktio (( �S �' 4111ebOV6 M4 9 Z 16 p Applicant Telephone No.: , ZS y. 3i16 24 Hour Emergency No.: Applicant Email r _// 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 V An Association partner. �KACorporation Name Title Address `ol/ An Individuan , _ __ I e�� p � T e 5 �Q y -__ , C✓VlC'e tr _�-PS1' J f J A Partnership-�_ �+f 4-- IN Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (,e_C SGu Address: C�iL Jh. lekj✓©. "4 ©Z (D Telephone No: Lt w 24 Hour Emergency No: t(� Z,� (( -3 Lf / FAX: E-mail: L'kL)clLL'wl Ijlq 23(nEj�k4Cti Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: ���� �29 t✓ I DEP Public Water Supply No: (If applicable) l26)0 46 No. of Food Employees: DAYS/HOURS: Y`r, t`" FAO\ - QPA( 564 (y4 ' -7— A—_ : fit) 1644 :7 Pl Name of Person(s) In Charge Certified in Food Protection Management: 0)(C-Y.1.es &.,;- k, S4,(P0&v( De C� lks Name of Person(s) In Charge Certified in Allergen Awareness Training ,\ // C40"V-l'Cs S""t� J.kp�'",l6 Name of pest control company routinely inspecting the premises for evidence of 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. Iml Yes N (A Does this establishment require a FOG permit? �\L_�erz If yes, please attach the FOG permit application. Length of Permit: Annual !mil Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Establishment Type: Retail Food $125.00 Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 f&31 Food Service up to 101 -200 $250.00 ILi Food Service up to 201 + $300.00 10, Supermarkets $400 Milk & Cream $10.00 Lffil, Mobile Food Consession NO PHF PREPARED ON SITE $100.00 >i Manufacture Frozen Desserts/Ice Cream $25.00/freezer 91 Pushcart $50,00 # of Pushcarts: 91 Residential Kitchen $100.00 Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous two (time/lemperature controls required) (Cheek 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 itel PHFCooked To Order IW Hot PHF Cooked and Cooled or Hot Held Ili Sale of Commercially Pre -Packaged PHFs jl Preparation of PHFs For Hot And for More Than a Single Meal Service ', jDelivery of Packaged PHFs Cold Holding For Single Meal Service NI PHF and RTE Foods Prepared For Highly Reheating of Commercially [?i Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer r] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand WI', Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only '&2. Ice Manufactured and Packaged for control) [j Preparation of Non-PHFs Retail Sale l Offers Raw Or Undercooked Food Of ( Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ii Vacuum Packaging /Cook Chill la Offers RTE PHF in Bulk Quantities A Prepares Food/Single Meals for [c,ll 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 o ply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to tain op' s of 10 R 590.000 d the federal Food Code. Signature of Applicant: C ' . 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: Signature of Individual or Corporate Name: '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 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:\tlsers\sleite\Desktop\Scott's Doeunients\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department o f Industrial Accidents [Ulf Office of Investigations 600 Washington Street Boston, MA 02111 wn,mmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information / Please Print Legibly Business/Organization Name: ✓JJ/% %®5� Address: C9ae ld--CC ®ti0Phone#: /DF_ ✓Z�g-06 Dy Are you an employer? Check (J)le appropriate box: Business Type (required): 1. Fj I am a employer with rf- 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 (ilud. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit rporation and its officers have exercised 9. ❑Entertainment In We are a co . their right of exemption per c. 152, § 1(4), and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]" 11.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 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 mgpnization should check box #I. I ton an employer that is providiIworkers' fompensation insurance for my employees. Below is the policy information. Insurance Company Name: )IA4 EA? � CL insurer's Address 6 ®o 6J! 5YA44 l 3)Vd. y City/State/Zip:._.�,, Z Policy # or Self -ins. Lic. # ���-6 0:7 Expiration Date: /� C.J`✓ 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 j 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 j Investigations of the DIA for insurance coverage verification. h do hereby er 'fy, ur er the pau . nd penalties of peieajury that the information provided above is true and correct. Si,namre--�i.,,f,.='�/" _Date: �l �-O 2 0 Phone �� Z- � 2 -t 6 0,Tcial 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.gow'dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Address:i 1► 1,4, ._ Awakelej Mailing Phone/Fax Number: J/ / D 6 o o Contact Person/Title for Grease Traps: l r'' Sa't IJ/'I ® 6.dAJ.P . Name of Company scheduled to pump internal grease trap(s) monthly: �uiRJd- %'yey- Name of Company scheduled to pump external grease trap quarterly: 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 acknowle s that the information submitted in these documents is true, accurate and complete. Signed /� Date 11 z) &r� Print Name Facility Onerational 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): G y Seating Capacity (Actual Count): - 2j Normal Hours of Food Preparation/Service: Monday x — 97/q Tuesday J{d - g?X Wednesday`rAA(— ?Pla Thursday � 9�j/Ii Friday i'fil�i- %FW Saturday Sunday ID AM 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 I 3 compartment sink C' 2 Handwashing sink i% U Commercial Dishwasher J/ Bar sink I Q Mop Sink D Garbage Disposal Ice Making Machines C> 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): Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes &k-- No 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 be'&- rj �' J ( (�Gc rc(�k 5tA, ti 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 V No Size gallons Where is the existing outdoor GRU located? INA 5; /' kV (i 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? 0 Where is the grease storage unit located? How often is this grease storage unit emptied?. Please list the vendor who removes the waste 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. Ob(� 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. Cb_�_l 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 L/ � /� )) --T Date: b LTO Applicant Name (please print clearly) ( / h6eC /rr S ` r �-" :R Rl D 0 Z L Win �o 611 r • f o S � MW S (Q (U 0 n m t4'. Z 00 m C 0 r / \ \ aƒ\* \ ` } ƒ ) (}(222 !<,®— ± ; [ t / r \ !z\ ) «� \ \/:: 2\& . 9 z � Un (A I � z � z C) � � � � � � � / . \ \\\{ 5 &\ƒ! \ /() \ \\) \ \ ~® « / \!, )10 / }jam \ §/�f\ ^®o.� 2 e F \/ \ ƒ \ \ �I � � � pt t7l z � � L4f) 0--� z � z C) � � � � � { \\2\ \ \ / (( 2= ) J / U � �71 z rTi CA CA 0-� � � z � z C) � � I 5 @ *; y a\!\ ~\§\ \ % { ƒ HIM , �E( f ( f \ 2�4 ~c`0\? ��m M � ► e z ml � � � z �M* z C) � � 0 ON" 2 the Always FoodSafe company StephanieDThe Always Food Safe Company - Allergen Awareness Approval lr: 163594 Employee Food Safely Online Course & Exam Date: 9/25/2019 (valid+ until 9/25/2022) course reference: AA Learner reference: 245347 This training is approved for 1 continuing education hour toward the initial or recertification application for ACF certification \ r r Nick Eastwood The Always Food Safe Company #1203 President 899 Montreal Circle, St. Paul, MN 55102. The Always Food Safe Company www.alwaysfoodsafe.com ti Congratulations! Go ahead and frame the big copy-- you've earned it! Keep in your wallet for anytime, anywhere proof you passed! the Always Foodsafe company Stephanie Decelles The 4lwdya Food Sale CpmppnY mod, Allergen Awareness Employee Food SatelY Online Course b ham 9/25/2019 (validr unlil9/25/2022) eeur:o rore�aeee: Aq - xeamernmrenn: 245347 This training is approved to t contiion appdscene hour toward the initial or recsrtdloation application for / onW, 'lwwe Prea�sOM ACF certification meaw,n fees sare<arePam a98 Man4¢el Cti[te, S1. P0uI,MN 551o3. nxos The Nwa/i f0008a(e <ortipany wMvn'wayrsloOfah cOT For your manager to keep and admire 0 the Always FoodSafe company Stephanie. Decelles Me M,s., Foal Solo Company h»a wee Allergen Awareness Ernployne Food Safety earns Cous" b ham oaro: 9/2512019 (validr until 9/25/2022) cou.s¢rehran[d AA t arner�eMren[e: 245347 This paining is approved for t continuing education f hour toward Lisa initial or recertification I c camn application IG Iwooa Oiw lv: ACF certification - me uw,n Seed 5".C. Vunr ySa Cqn l Mu ellox. e. m faoOsah comPam .aWry51W0:aie / E&�! ; \ \®y! »\7 \ \ \ {}}( }�{�\ |' \r\ 's ; ( I �W* z �-o z C) r) � � � � 0 )011 (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 GC0709 Previous Policy Number: 176WEGGCO709 1. Named Insured and Mailing Address: CSS SUB INC (No., Street, Town, State, Zip Code) 74 TAUNTON AVE SEEKONK MA 02771 FEIN Number: 27-1418387 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 2. Policy Period: From 12/09/20 To 12/09/21 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: COMPLETE BENEFIT SOLUTIONS/PHS 1 CARANDO DRIVE SUITE 1 SPRINGFIELD MA 01104 Producer's Code: 08081352 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (866)467-8730 Total Estimated Annual Premium: $1,773 Deposit Premium: PMicv Minimum PrPmlum: $211 MA __... Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 10/29/20 Policy Expiration Date: 12/09/21 INFORMATION PAGE (Continued) Policy Number: 08 WEC GC0709 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states 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 $100,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A, OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium $1,332 Expense Constant $338 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 1 ,$5$5 Estimated Annual Premium (before Surcharges) $1 Total Estimated Surcharges 721 `See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $1,773 Deposit Premium: Policy Minimum Premium: $211 MA Interstate/intrastate Identification Number: Refer to Schedule of Operations Labor Contractors Policy Number: NAICS: 722110 SIC:5812 Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 10/29/20 Page 2 Policy Expiration Date: 12/09/21