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HomeMy WebLinkAboutTrattoria Della Nonna - 12/31/2021( O6 .5-y S FOR BOARD OF HEALTH USE ONLY oPermit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name Establishment Address ��� �.�(�(�� •��\3 CL��� �����'� Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: �e nh;�Yi �� o� �— ' �W • C�� v�� Applicant Address Applicant Telephone No.: ��- _ ���<� 24 Hour Emergency No.: Applicant Email \ 14�t_ 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 El An Association partner. O A Corporation Name Title Address 11 An Individual�Cp��� [] A Partnership 0 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: \�� \� • ��z.�,(\ S'\ . ��0.� .w\� �'<\�\ l�l!\ D Telephone No: 24 Hour Emergency No: k FAX: __� 50�- `\W i 3 �iC1 E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title:��\ili��c�—t;� Ste\ Address: Telephone No: d�c\t)_ 24HourEmergencyNo: FAX: �---- 0 E-mail: \\ l f� Food Establishment Information WATER SOURCE: T e vP� SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) InCharge Certified in Food Protection Management: A Vil 1 mf 10 Name of Perso (s) In Charge Certified in Allergen Awareness Training — — Name of pest control company routinely inspecting the premises for evidence of pests 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. gth of Permit: Establishment Type: Annual E] etail Food $125.00 E] Mobile Food Consession E] Temporary - Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Q 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: 0 Supermarkets $400 E] Residential Kitchen $100.00 Rain Date: [] Milk &Cream $10.00 0— Caterer $35.00 Food Operations: Definitions:PHF - Potentially. hazardous food(timellemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no timeRemperature controls required) RTE- ready -to -eat twos (Ex. sandwiches, salads, muffins which need no fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs 4 PHFCooked To Order PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs E] Preparation of PHFs For Hot And -lot for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility [] Reheating of Commercially to be b Prepared p y Consumer Use of Process 0 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) 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 Q Offers RTE PHF in Bulk Quantities 0 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 Applicant: 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: i.�j�? - :,'�- ��:-1 �/01 ' / j 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. S' nature of divi ual or Corporate Name "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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. C:\Users\sleile\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORMAoc 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: Address: \U� fie\ Phone Are you an employer? Check the appropriate box: Business Type (required): 1. `l I am a employer with employees (full and/ 5. ❑ Retail o -time.* 6.E! Restaurant/Bar/Eating Establishment �Q—I am a sole proprietor r partnership and have no I, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working or me in any capacity. [No workers' comp. insurance required] 8• ❑ 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 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 organization should check box #l. Ian: an employer that is providing workers' compensation insurance for any employees. Below is the policy inforination. Insurance Company Insurer's Address: -k") • v�\C City/State/Zip:` \�\\Cep \Ay. Policy # or Self -ins. Lic. # \ \, `����0��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 of perjury that the information provided above is true and correct. J� 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 Person: Phone #: www.mass.gov/dia KENNAND-01 MDEPILLO ACORO" CERTIFICATE OF LIABILITY INSURANCE �/ DATE IIIMMIOD/YYYY 11113/2020 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS 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 Deland, Gibson Insurance Associates, Inc. 36 Washington Street Wellesley Hills, MA 02481 CONTACT �acNNo, EzO: (781) 237-1515 (,A' .o ((781) 237-1805 EMAIL ADDRESS info@delandgibson.com INSURER(S)AFFOROING COVERAGE NAtC4 INSURER A: Mass Bay lnsuranCe Compan 22306 INSURED INSURER B: INSURER C: Kenneth and Yvonne Defazio INSURER D: 88 High Street Mansfield, MA 02048 INSURER E: _ INSURER F : CERTIFICATE NUMBER: REVISION NUMBER: VVYGRIIV GJ CERTIFICATE - ----- 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 E BEEN REDUCED BY PAID CLAIMS. INSR WOOL SUBR POLICY EFF POLICY EXP LIMITS L TYPE OF INSURANCE g POLICYNUMBER Dp A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS -MADE OCCUR ZONH128285 12/1512020 12115/2021 PREMISES E occunence._ _S_ MED EXP An one arson $ _ 10,000 PERSONAL B AOV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ _ 2,000,000 POLICY ❑ jECOT- 1XI LOC PRODUCTS-COMP/OP AGO $ 2,000,000 LIQUOR Included OTHER: COMBINED SINGLE LIMIT A AUTOMOBILE LIABILITY Ea ccident $ ANYAUTO ZDNH128285 12115/2020 12/1512021 BODILYINJURY Per arson $ -, OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accitlent $ X HIftED X NON -OWNED PeOr acc,tlent AMAGE $ AUTOS ONLY AUTOS ONLY - UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I RETENTION$ $ A WORKERS COMPENSATION STA E ETH AND EMPLOYERS'LIABILITY YIN WDNH156207 1/1512020 1/15/2021 500,000 OFFICEOPRIETOWARTNOED? ECUTIVE NIA E.L. EACH ACCIDENT (Mandatoryin NH) E.L. DISEASE EA EMPLOYE 500,000 It yes, describe under 500,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT A Property ZDNH128285 12/15/2020 12/1512021 BPP 289,625 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Trattoria Della Norma 160 N Main St #162 Mansfield, MA 02048 Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ACORD 25 (2016103) U 1988.2U15 AUUHU GUKPUKA I IUIN. An rlgnrs reservea. The ACORD name and logo are registered marks of ACORD Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED ACORD 25 (2016103) U 1988.2U15 AUUHU GUKPUKA I IUIN. An rlgnrs reservea. The ACORD name and logo are registered marks of ACORD Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Tf r'fl'oV v a Address: 16 0 AAJI--ft� V14 A-1 A/ -)l - VYL/+^l'5 r/e�� Mailing Address: `{� %— S ��� +4 n/j F ' e `d w& Phone/Fax Number: I— S 0 %--5 -3 6 cl 9 Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: ) ay 5 r6 4 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 container $50 Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date I t— 2*) — Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): _ Seating Capacity (Actual Count): 6 Normal Hours of Food Preparation/Service: Monday Thursday Sunday Tuesday Friday Wednesday X Saturday 10 Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher Z Bar sink Mop Sink Garbage Disposal ( Ice Making Machines -$ 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): Is dinnerware pre -rinsed before being washed? I/ Yes If yes, at what station/sink? 0, (n LA/ ^ 9 Wotn r No 19 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 A/k 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? 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? tj0 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. 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. XI 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: G G" 01 J Z© Applicant Name (please print clearly) 6«wwy V/I 1)_ I Z C O z w C /(F z_ W n W I N c- %1 w O w U w 0-4 w U V z MCI z W Qi Y Z W_ Z M � N N N W � o- a u o (U U U w 0 q w 0 did ox� h ' � V V l � y Massachusetts Department of Revenue MT-1 Data Integration Bureau g p� 100 Cambridge Street U Boston, MA 02204 CERTIFICATE NUMBER A e ® e ® e e e The vendor herein named is registered to sell meals and all beverages pursuant to the General Laws, Chapters 620 and 64H. This registration is effective only for the registrant at the location specified herein. Any change of name or address renders this registration null and void. 04. ®fie 61 w O 7 6 IDENTIFICATION i�1i"L.1- ri it L)ti AZ10 NUMBER /+*F rJRIA LA CUCIN,A 01, ,l14A lv�- ii)tTH fIA1tJ ST OS127t00 ISSUE DATE {1:1 ilia {=if_Li1 %12 Q 4 3 fRcUcftICX A. LASKEY This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE z O LLM Pom — w W V O N H W n z z W Z O a �P a Sim LO O N ii N I c ,o V uz z Con w z lW j� 11 3 z w w .... N0 LL � 0 ^ N N Z o m m Z M o U w U Q W Z Q A u ZON o N O[ O ^ 33Y ¢F¢(nU) oco 3 ZC4 0 Env M N a O N eq� 42 �o O l � y