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FOR BOARD OF HEALTH USE ONQ*-4 Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening
0-
Establishment Name L_<i
Establishment Address „* r,,,tti
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title: P -.arit. N,s b ".}
Applicant Address
Applicant Telephone No.: C��fl x`ti i ->�2t 24 Hour Emergency No.:
Applicant Email r_1
Owner Name & Title (If different from applicant) tr-w .
Owner Address
Owner telephone number (e.v
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
1,1 An Association
partner.
N, A Corporation
Name Title Address
El An Individual
eh t� ` s, :�� , i $ .•_=5 ^U c' _1 c,r„ t,. r t€ t..
ro- t t ��t si is r vet' J ^r' r fj1 C, �>i Cyr �_ ara_ C tE, t�tst
El A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title €> C,t er tcx
.
Address: zc 10e,
Telephone No: c# , y 2 ra t , Vo-1 24 Hour Emergency No: t do-6 `i3_ _
FAX:
E-mail: Ac-vc.1�s1. ,-rE� r;fvrirr�Eezrs. :,-
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name &Title: C1� t4,ee �v-
Address:
Telephone Nor, , j }, t , �' t .3 24 Hour Emergency No:
FAX:
E-mail:
r0,
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL
Y r_
DEP Public Water Supply No: (if applicable)
No. of Food Employees: {_r
DAYS/HOURS: i'ta.) _ c
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 ('Jr
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 establishment require a FOG permit? If yes, please attach
the FOG permit application.
Length of Permit:
Establishment Type:
❑X Annual
❑K Retail Food $125.00
Mobile Food Consession
Temporary
I Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00
ElManufacture Frozen Desserts/Ice Cream
Food Service up l0 101 -200 $250.00
$25.00/freezer
Temporary End Date:
0 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
0 Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required)
(Check all that apply): Non-PHF's - 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 0 PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
is Sale of Commercials Pre -Packaged PHFs
�� y g � Preparation of PHFs For Hot And
for More Than a Single Meal Service
0 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
b
Processed Foods for Service Within 4 Hours to be Prepared y Consumer
❑Use of Process Requiring A Variance
Customer Self -Service
C Customer Self
and/or HACCP Plan (including bare hand
-Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only ❑ Ice Manufactured and Packaged for
control)
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 / Cook Chill
Offers RTE PHF in Bulk Quantities
7] Prepares Food/Single Meals for
E] 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 Applicant. A_p'_cy�Pi
Pursuant to MOIL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled 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
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corpmat Officer (Klanatoiy, if Applicable)
*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.
CAUsers\sleiteADesktop\Scott's DocnmentsTood Establishments- TempyTAX CERTIFICATION FORNI.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofrice of Investigations
600 Washington Street
Ulf
Boston, MA 021H
wtviv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: C,S `> eke: V kr t<_
Address: C'
City/State/Zip:
Phone #:
Are yen an employer? Check the appropriate box: Business Type (required):
1.Q I am a employer with %-I employees (lull and/ 5. ❑ Retail
or part-time)."` ice, Mrs 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] S. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, $1(4), and we have I0.❑ Manufacturing
no employees. [No workers' comp, insurance requirecl]x'
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 01 most also till out the section below showing their workers' compensation policy infonnation.
**If the corporate officers have exempted themselves, but the coq>omtion has other employees, a workers' compensation policy is required and such an
organization should check bo.e #I.
I run an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: `4-tV-;rr $tt
Insurer's Address: A" t` , *Q' e K�(, V `,-Wee
City/State/Zip:
t`,6os 0 Z%l u,
Policy # or Self -ins. Lie. # i ts2 L,`t.b - rk'kr k `c _ - z``Z> 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 e. 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 andpenalties ofpetjtny that the information provided above is true raid correct
f t;" (2s
Offteial 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 Cleric 4. Licensing Board S. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.govidm
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
Ali employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association of other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below, Self -insured companies should enter their self-insurance license number on the
appropriate line. -
City or Town Officials -
Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple pernnit/lieense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses, A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.inass.gov/dia
Donn Revised 5-26-05
WORKERS COMPENSATION AND EMPLOYERS LIABILITY 10 Li 0Y L� MUiUdI.
INSURANCE POLICY
INSURANCE
INFORMATION PAGE 175 Berkeley Street Boston, MA 02116
Issued byLiberty Mutual Fire Insurance Company(a stock company) 16586
Policy Number WA2-64D-444507-070 Issuing Office Lewiston, ME
Renewal Of WA2-64D-444507-079 Issue Date 07/22/2020
Account Number 4-444507 Sub Account 0000
1. Insured and Mailing Address FEIN 44-0652560
Omaha Steaks International, Inc. NJ TIN 440652560000
11030 O Street Risk ID 917128308
OMAHA NE 68137
MI Risk ID 0701300A
Status Corporation
Other workplaces not shown above:See Item 4. Premium - Extension of Information Page
2. Policy Period: The policy period is from 07/01/2020 to 01/01/2021 12:01 A.M. standard time at the Insured's
mailing address.
3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: AZ CA CO CT FL GA IL KS KY MD MA MI MN MS MO NE NV
NJ NY NC OK PA RI TN TX VA
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 $ 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 the policy applies to the states, if any, listed here:
All States except those listed in Item 3.A and the States of:
ND OH WA WY
D. This policy includes these endorsements and schedules:See Item 3. Coverage D - Extension of
Information Page
4, Premium:. 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.
Classifications Code Premium Basis Total Rate per $100 Estimated Annual
See Extens
Minimum Premiumium
$1,443 (CT)
Premium will be billed Monthly
Producer 0002 007662
ARTHUR J GALLAGHER RISK MANAGEMENT
SERVICES INC
10050 REGENCY CIR STE 300
OMAHA NE 681143721
Total Estimated Annual Premium $ Z3 i'Zoo
Deposit Premium $ 231,266
Deposit Tax/Surcharge/Assessment $ 2,878
Countersigned by Authorized Rep. (FL)
WC 00 00 01 A 01987 National Council on Compensation Insurance, Inc. WC 00 00 01 B (CA)
Ed. 07/01/2011 All Rights Reserved Page 1 of 1
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.
x 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.
X 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.
x 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 � "b(O"' 1 uJ Y'_ G � I Date: I" (h' ( 1`"
Applicant Name (please print clearly) �f.; ic- �. F zk "Fdc.