HomeMy WebLinkAboutTrattoria Romana Pizzeria Bar & Grill (Lazio Corp.)- 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit# Issued x
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name 44,40 �O,-P d1l.% -
Establishment Address k" 0.4,,1,0W,
Establishment Mailing Address (if different)
Establishment Telephone No -/I,( . •119 -
Applicant Name & Title: *6077 yrri a.�
Applicant Address to7 &AoV,*$M1.J e f 174u)7ddt-C-7 4;r d2"
Applicant Telephone No.: //6� h"F�j >/ 2- 24 Hour Emergency No.: �d 'y g4�— Zt �2 -
Applicant Email 7�a(f �i y�R-rtyrb�t$�f(DvtA^'G /27+�!
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
Fail An Association
WA Corporation
H An Individual
O A Partnership
partner.
Name
G ot_4AA__0 G' 'gvrt' __
�e'&ly *kk y.✓
Title Address
`t7c /
brr c+'� W 7
4-P-4 C-L- '4q'01/
llrvA-fl-
ij°j jF '/'e; S7 _
E Other legal Entity
Person. Directly Responsible For Daily operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 4 d e✓
Address: 2.7 !h*d.y+'wt /n- OY yU'd rrcrL F? 0>-J-6f
Telephone No; gr-d-f--. yQ'r - Zt ?2-- 24 Hour Emergency No;
FAX:
E-mail: A4 0i nG eip A4
I Alt E-Mail: _
District Or Regional Supervisor (if applicable)
Name & Title;
Address:
Telephone No;
FAX:
E-mail:
24 Hour Emergency No:
WATER SOURCE:
DEP Public water Supply, No: (if applicable)
DAYS/HOURS:
Food Establishment Information
SEWAGE DISPOSAL;
No. of Food
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
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. WYes _.
Does this establishment require a FOG permit?If yes, please attach the FOG permit application.
Length of Permit:
[M(Annual
R Temporary
Temporary Start Date:
Temporary End Date:
TemporaryTime:
Rain Date:
Establishment Type:
[3 Retail Food $125A0
Q Food Service up to 100 INCLUDING
FOOD TRUCKS $175,00
[Food Service up to 101 .200 $250,00
R Food Service up to 201 + $300.00.
Q Supermarkets. $400
Milk & Cream $10.00
i❑-.'. Mobile Food Consession
NO PHF PREPARED ON. SITE $100.00
Manufacture Frozen Dessenslice ,Cream
$25,00/freezer
ut Pushcart $50,00 # of Pushoartw
Q Residential Kitchen $100.00
n Caterer:$35.00
Food Operations: Definitions: PHF Potentially hazardous food (Nmefiereperature controls required)
Non-PHFs - non -potentially hazardous lood(no time/temperarum controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches,salads, muffins Which. need no further processing)
2 Sale of Commercially Pre -Packaged Non-PHFs Q. PHFCooked To Order
sale of Commercially Pre -Packaged PHFs
R Delivery of Packaged-PHFs
® Reheating of Commercially
Processed Foods for Service Within 4 Hours
x~� Customer Self -Service of Non PHF and Non -
Perishable Foods Only
dt Preparation of Non-PHFs
Other Food Operations
ig Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to. be Prepared by Consumer
R Customer Self -Service
0 ice Manufactured and. Packaged for
Retail Sale
R Juice Manufactured and Packaged for
Retail Sale
m Offers RTE PHF In. Bulk Quantities
Fa Retail Sale or Salvage, out -OF -Date
R. Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service.
is PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Q Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Offers Raw Or Undercooked Food Of
Animal Origin
Vacuum Packaging / Cook Chill
Prepares Food/Single Meals for
Catered Events or institutional Food Service
I, the undersigned,.altest to the accuracy of theinformation provided in this application and affirm that the food
establishment operation will cc ply with 1 5 CMR 590.000 and all other applicable law, I have been instructed by the
board of health on how to obtaAcopi s 91105 CMR 590.000 and the federal Food Code.
Signature: of Applicant: r—
Y
Pursuant to MGL Gh,62G, sac, 48A,. I certify under the penalties of perjury that I. to my bast knowledge and belief,. have feted all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID: /6j `
Signature of Individual or Corporate Name: * �'T,
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.
. i
ignature of Individual or Corporate Name By: Corporate Officer (Mandatory, i(Applicable)
F413 5-76 "f
"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.
CAUs,cn\s1eite\Dexktop\Sco¢'s DocumeutsTood Establishments- Temp\TAX CHRTTFICAMN FORM.doc
t�\ 3Ilfi YVIIi IIt V/!/YIL.MLL/4 Vir lI1 /IJJH..I4!^4J�iW
Department oflndustriai Accidents
Office of `Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation. Insurance Affidavit: General Businesses
Applicant Information Please Print Leaib(v
Business/Organization Name: 64 ,7,ze 4Ke 7W-,-0-7uZ,,At- 40-t�°--
Address:, 44 0 A1V_ Lr /D frl
Are you an employer? Check the appropriate box:
111 1 am a. employer with employees (fall and/
or part-time),*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in say capacity.
[No workers' comp. insurance required]
3� We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
�--i no employees. [No workers' comp: insurance required]'
4. n We are a non-profit organization, staffed by volunteers,
with no employees. iNo workers' comp: insurance req.]
me #: 77't.. 1l I 14 SZ—
Business Type (required):
5. []Retail.
6� Restaurant/Har/Eating, Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. Non-profit
9. ❑Entertainm
I I.0 Health Care
box #1 must also fill out the: section below showing theirworkers' co
ave exempted themselves, but the corporation his other employees, a
policy is required and such an
[ant an employer that is providing workerscompensation insurance for my employees, Below is the policy information.
Insurance Company Name: 7�#lle_
insurer's Address: A /'ictiL /I//70
City/State/Zip:_ tZegLwG�k bed ifl
2 u.)6 C A e, //4- Expiration Date: ;Y/
Policy # or Self -ins, tic: # � � p
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 ofa
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 $250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to die Office of
Investigationsofthe DIA for insurance coverage verification.
[do hereby eru nder the pains and penalties ofperJury that the information provided above is true and correct
) n�+... /Z , * r 00
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License
issuing Authority (circle one),
1. Board of Health 2, Building Department 3, City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6, Other
Contact Person: Phone
www.ma,is.gov/dia
CERTIFICATE OF LIABILITY INSURANCE ,g02O "
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS. UPON. THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGEAFFORDED BY THE POLICIES
BELOW.. THIS. CERTIFICATE OF INSURANCE DOES. NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING. INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,.
IMPORTANT. It cmtiflcate holder Is an ADDITIONAL INSURED, the polley(les) must have ADDITIONAL INSURED provisions or OR endorsed.
if SUBROGATION IS WAIVED, subject to the terms and conditions of the pollcy, certain policies may require an endorsement. Astatement on
this Certificate does not confer rights to the Certificate holder in lieu of such endamement(s).
PRODUCER
Oceanpoint Insurance Agency
WOWest Main Rd
Middletown RI 02842
AnaAttErgafia
PMONe (401)8475200 No Ne: (401)848-.5071
AcnoAss, aalbargada®awanpoinl(ns.wc,
INBURERa AFfDRDIND COVERAGE
NAIC0
IN.URERAZ Hanford(ACH)
INSURED
Lae10 C.T.
80 Oakland S1
MensOeW MA 0204tl-14N
INSURER e:
INSURER m
INSURER 0:
NSURER E:
INsaRER F,
COVERAGES. CERTIFICATE NUMBER: CL2011413901 REVISION NUMBER:
THIS 15 TO CERTIFY THATTHE POLICIES OF INSURANCE USTED'BELOW HAVE BEEN ISSUED TO'THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED, NOTWFIHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICHTHIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AUTHE TERMS,.
ENCLUSION$AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN WY HAVE BEEN REDUCED BY PAID CLAIMS.
IA
S IORTYPE
OF INSURANCE
POUCYNUMSER
MMN
MMID
LIMITS
CPMMEflCMLOENERALLMBLLnY
EACH PCCURRENCE
S I,000,000
4 1,000,000
CLAIMS-fitADE OCCUR
EMI
RSES EaawY —
S 5'000
MED E%P M au artw,
A
02SSAAJ2CGY
1012W2020
10121D2021
1ER111L 111VWNRY
g 11008;000
GENLAGGREMTELPIRAPPLIEB
PEA:'
GENERALAGGRE6AM
$?,000,000
S 2-000.000
POLNiY ❑ %& ❑ LOU
PROnI1CT6-COMPIDP AGa
Properly damage-ain918-
5
OTRER:
AVTOMOSY.fi
LWBMRY
Enaru'Ne RIG LIMIT
$
BODILY INJURY (Per pe.,zpn)
$
ANYAUTO
aDDItYIN1URT IPenmietln0
$
UWNEO 6CHEDUUU
AUTOS ONLY AUTO.
HIRED NONAWNIM
POPE dtt D E
S
AUTOS ONLY AMR ONLY
UZUM9PEOA LNO
OCCUR,
EACHOCGURRENCE
S 1'000A00
AGGREGATE
$ 1,000,ODU
A
CMR=AL
culus.MAPE
02$BAAJ2CGY
10128/2020.
102812021
DED I I RETENTION $
$
WORMERS COMPENSATION
p
STATNIE Efl
A
ANO EMPLOYEgB'LMeIOD' YIN
k WNiREMeE CLNUOE➢iECtnIVE
NiA
02WECA12CHR
1027/202A
1027)20?1
EL EACNAcCInENT
s 500;000
EL DISEA96Er'EAIPLOYEE
g 500i000
(Mnndelpry In NM)
ELOIEEASE-POLIGYLIMIT.
S 500,000.
DE5!dezoicNewdOFwOPERATIONS bobs
DESCRIPTp'
oath wmman cause
51i000,000"
A
Liquor Llebllity
02SBAAJ2CGY
1012812020'
10/2tl2D21
aggregate
$2,000,000
eESCNPTa1N OFOPERATroNB /LOCATIONe1YEHMLEB (ACDRD im,AdSiliorol Remarie ENeUSM, may tie oNONNd ilmem Reece b NRUI,SdI
SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE' THEREOF, NOTICE WILL BE DELIVERED IN
Town of Mansfield
ACCORDANCE WITH THE POLICY PROVISIONS.
500 East St.
AUTHORIZED REPRESENTATIVE
Mansfield MA 02048
-C a. ' 9lA+1.
01988.2015 ACORD CORPORATION. Art rights rsaereco.
ACORD 25(2016103). The ACORD name and logo are registered marks of ACORD
lntormaton and Instructions
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."
An 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 or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartinents 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 1.52, §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 not 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 tine.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at die bottom
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/licensenumber which will be used as a reference number. In addition, an applicant that
must submit multiple permittlicense 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
trust be filled out each year. Where a home owner or citizen is obtaining a license of permit not related to any business
or commercial venture (i.e. a dog license or permit to burn 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 # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www,mass.gov/dia
irm.Revised 5-26-05
Town of Mansfield Health Department
APPLICATION FOR FATS OILS, and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: 4"t17 426!� EA& 7a-o TowA- /lo--BA yr -
Address: 6,2 42k4-L -0-0 01
Mailing Address: GO 044e(,!ftp 5? rN/—AK-J 94',P 0" ""V - -
Phone/Fax Number: 77Y '7r9 R 3 7—
Email: l666 /f' 6d 1-r - eo-- p j o..,ra a� Ao + 4
Contact Person/Title for Grease Traps: '5, & #- Qs So.-.i
Name of Company scheduled to pump Internal grease trap(s) monthly:
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 considerat' n of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowilees that the information submitted in these documents is true, accurate and complete.
Date IDS*✓. 910
Print Name Gp 1 �!5 5 traJ
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 e-ze%j <�v
Thursday 90-- /d
Sunday 174,-- 1,04
Tuesday P *yyy r loe..y
Friday 94;,nt — fy,o
Wednesday 4di.
Saturday Qa -1,0e
Please indicate the NUMBER of kitchen fixtures used In your establishment and if It is attached to a Grease
Removal Units (GRUArap)
Number in
establishment
Attached to
GRU
r
3 compartment sink
Handwashing sink
/
f
Commercial Dishwasher
Bar sink
Mop Sink
+!%
Garbage Disposal
Ice Making Machines
Fryolators
3
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? ✓ Yes
If yes, at what station/sink? z,z 6W
r
No
Grease Trans and Grease Removal
Internal Grease Traps
How many Indoor Grease Removal Units (GRU/trap) are on site?
2
Please list fixtures attached to each grease trap
Grease Trap 1
Grease Trap 2Ott
Grease Trap 3
Grease Trap 4
Grease Trap
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? 1/5/10SA-4--yx-
Where is the grease storage unit located? pOs?e,jf�t,044 -
How often is this grease storage unit emptied? /t2 o'Y37-
Please list the vendor who removes the waste: bk.4 it;
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.
Al I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered tout 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. 1 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
Applicant Name (please print clearly)