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HomeMy WebLinkAboutTasty Ray's - 12/31/2021FOR BOARD OF HEALTH USE Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening d Establishment Name G s 41/?w i S 1 Establishment Address a () 3'0u*A niG,� �rcc� q�sr:<r4 S tm>a W014 Establishment Mailing Address (if different) Establishment Telephone No (50 7 - 0 73-3 Applicant Name & Title: � ay ✓h 0 A n e �yrc �v ® La ne, t�n Applicant Address Q 5' W ejbu(F")ic4 ,54- (fn:f )7 A/or44 l9 i {12 vbr0,lr`a ( 7�� Applicant Telephone No.: (5-0 `) g (05'-7 a 52 24 Hour Emergency No.: (6 D-2� Q 6 5--'-� aA Applicant Email r c,(p ,i 5 r, c (y 4 40 o- c o M 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 ❑ An Association partner. e❑l A Corporation +�Anlndividual /Name �1 Title Address IltymflnJ Q�Istit l7iaw43rr as w I U-11I 1I r ❑ A Partnership t) 44 l�bli✓a /11>9 Other legal Entity Ur Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: y,Mond 0,A5r.,14 ocincr Address: QI S t,Jej4 8u1C'n ,,Skcc4 Cho 1-7 IVor-4 /i-iA,be, MAoxno Telephone No: Oro i) n S _ 7 D s-- ? 24 Hour Emergency No: FAX: 11 E-mail: pc%�e.�t4 �yq�l00.C6m Alt E-Mail: f � i 4 g 0 0, c 0 M District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: (� DAYS/HOURS: hcejcd Name of Person(s) In Charge Certified in Food Protection Management: Name ofPerson(s) In Char Certified in Allergen Awareness Training ��a RC ✓yl,brl4 UG4'aTGjy Name of pest control company routinely inspecting the premises for evidence of pests F' 14 ey.1-) rbn- a l 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: Annual la Retail Food $125.00 ❑ Mobile Food Consession ❑ Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ❑ 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: �. Iilk & Cream $10.00 .Caterer $35.00 Food Operations: Definilions: PHF-Potentially hazardous food(tinxdremperature contra/s required) (Cheek all that apply): Non-PHPS- non -potentially hazardous(ood(no timeRemperatum controls required) RTE- ready -to eat foods (Ex.. sandwiches, salads, muffins which need no tunherpmcessing) ❑ Sate of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order Vof PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meat Service Delivery, of Packaged PHFs Cold Holding For Single Meal Service g ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ 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) VI Preparation Sale Preparation of Non-PHFs ❑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 P 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 59pp.�000 and all other applicable law. I have been instructed by the board of health on how to obtain ¢spies of 105 CMRnS{t0.p00 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have fled all stale tax returns and paid state taxes required under law. (� e) �C Social Security Number or Federal ID: 7 1.— 05 f 6 &3-� ,t Signature of Individual or Corporate Name: 4A , 4 . 4 A /\ 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. -7-C4J4 4 L C �r Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) y4 o,y 4 j35. '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:\Uscm\sleite\Desktop\ScoMs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe 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: G spy tS a v t L L C Address: 00 '5 0 i j41, ✓ ,, n jirc4 City/State/Zip: Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/ or part-time).* 2.10 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] In We are a corporation and its officers have exercised their right of exemption per c. 152, §I(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone Business Type (required): 5. ❑ Retail 6. ❑ RestaurantBar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I LF1 Health Care 12fDAther Gg4cr:n`] *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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: A Insurer's Address: Na t'_✓ndGiee- 1/ /l 2t/"4—r Cco0ccieq City/State/Zip: Policy # or Self -ins. Lic. # 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 free 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 of perjury that the information provided above is true and correct. Signature: ✓ J w-N Date: j i la l 1 111 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 Phone www.mass.gov/dia wlk z O Um cG W u 0 Q W 0 R h. z W p S F- ❑ In 0 I $ � 2 ~ cm 2 k 2 2 § ° z cr CO) � E z B % §CL � w & � � 2 � � R ( \ ( /\\ƒ ! p (\ \ \ \ \$§) m � � i # � � 0� 0 / \ © / 0 4- / \ / LL 0 � a • LU LEARN2SERVE FOOD PROTECTION MANAGER CERTIFICATION This certifies that RAYMOND DEAGRELA has achieved the title of Certified Food Protection Manager with Online Proctor Issue Date: 11/23/2020 Certificate number: L2SC-3-006314 i® Test Name: Form A21 #0975 o Samantha Montaibano, Ch f Operating Officer THIS CERTIFICATE IS NON -TRANSFERABLE & VALID UPTO 5 YEARS FROM THE ISSUE DATE DEPENDING ON YOUR LOCAL HEAL TH DEPARTMENT'S REQUIREMENTS. 6801 N Capital of Texas Hwy, Bldg], Suite 250 1 Austin, TX 78731 1 877,881.2235 1 www.360lraining.conn 1Q (CIIT HE. . _ _ _ _ _ .._ _ _ _ _ _ (CUT HEflE) _ _ _ _ _ _ { C xa This certifies that RAYMOND DEAGRELA has achieved the title of Certified Food Protection Manager with Online Proctor Issue Date: 11/23/2020 Certificate number: L2SC-3-006314 Test Name: FOMA21 _ #0975 Samantha MOntalbano, Cf el Operating Officer THIS CERTUICATEIS NOWIRJN3EEBABLE B VALIOUPTO SYEARS MOM THE ISSUE UATE Congratulations on becoming a Certified Food Protection Manager. Learn2Serve also provides training courses in: Food Safety Handler, Alcohol Seller/Server, HACCP, and Sexual Harassment Please contact us today to learn more about how you can take advantage of these quality courses, or visit www.Learn2Serve.com. Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Mailing Address: 5 c. Y? C Phone/Fax Number. is o1 — �'� `i () r! s Email: 1 0D COYn Contact Person/Title for Grease Traps: A", d_ d Be!21 ck Name of Company scheduled to pump internal grease trap(s) monthly: &1 4 n4c, se t—mi is 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) 1 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 information submitted in these documents is true, accurate and complete. Date jII/ai/LIB Print Name 114, rvio4 1—«=y%rG� 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): y 0 SS Normal Hours of Food Preparation/Service: C'q 4cr' ) Monday Thursday Sunday Tuesday Friday kourj Very 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 Bar sink ' Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods f Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): 'V__ L,. C'__L /—. 1, C•'! _ ,.-A 1/. --L,,h„ Llgfe Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes No -IV 0 %n 41er vvtir 3 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 3 b aJ lJ elj t e! r> > • n k J Grease Trap 2 `� mac--..._..... Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes 1/ No Size 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: Property Owner's Name: /i4n in #IP-'( (pt Property Owners Address: Po Rnx 4�$G W e i� Rr.'d�ec,_ 0-V77 Property Owners Telephone Number: 17 % Yellow Grease Waste Ui�Don� 1C Do you store yellow grease waste from fryolators? s i 0 b - d • �, • t tom �n ljhr Where is the grease storage unit located? O si cie. nrx 4d 6Q,jrh 03&r- How often is this grease storage unit emptied? o -.? f,'0:2 e r n if u Please list the vendor who removes the waste: /Vec-Cse 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. RD 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. 10 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. A_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 — 414 / f - Date: I ( /'?. D p Applicant Name (please print clearly) rD \ A / ( aRl CD \ » - - CD I:D \/\- CL-% f �o rD} 7§%( ,.} $ ( � \ } 3CL ® ( 0 ( / - ( } ` \ / } rT �