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Home My WebLink AboutVillage at Willow Crossings - 12/31/2021FOR BOARD OF HEALTH USE ONLY,, Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening d Establishment Name The Village at Willow Crossings y Establishment Address 25 Cobb Street, Mansfield, MA 030484505 Establishment Mailing Address (if different) c/o Benchmark Senior Living LLC 201 Jones Road, 3rd Floor West Waltham, MA 02451 Establishment Telephone No 508-261-1333 Applicant Name & Title: Lynda Maryanski, Vice President and Assistant Secretary Applicant Address 201 Jones Road, 3rd Floor West, Waltham, MA 02451 Applicant Telephone No.: 781-489-2825 24 Hour Emergency No.: 978-9444902 Applicant Email compliance@benchmarkquality.com Owner Name & Title (If different from applicant) KRE Husky Willow Crossings Operations LLC Owner Address 201 Jones Road, 3rd Floor West, Waltham, MA 02451 Owner telephone number (781)489-2825 Owner email: compliance@benchmarkquality.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. 0 A Corporation Name Title Address 1-1 An Individual N/A -------- ---------- El A Partnership C Other legal Entity LLC Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Florence Botti, Senior Director of Dining Ser vices Address: 25 Cobb Street, Mansfield, MA 02048-4505 Telephone No: 508-261-1333 24 Hour Emergency No: 978-944-4902 FAX: E-mail: compliance@benchmarkquality.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: James Hourihan, Regional Director of Dining Services Address: 201 Jones Road, 3rd Floor West, Waltham, MA 02451 Telephone No: 781-489-7100 24 Hour Emergency No: 978-944-4902 FAX: 781-235-01368 E-mail: compliance@benchmarkquality.com Food Establishment Information WATER SOURCE: Ne4w"e TO SEWAGE DISPOSAL: Np*kange , DEP Public Water Supply No: (If applicable) No. of Food Employees: 5 DAYS/HOURS: No Change Name of Person(s) In Charge Certified in Food Protection Management: Florence Botti, Jean Faulkner, Thomas Sroka, Erik LeBlanc, Chad Bunger 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. D Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Ex] Annual ❑ Retail Food $125.00 Mobile Food Consession Temporary [ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 El Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: f_] Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: [3 Milk &Cream $10.00 Caterer $35.00 Food Operations: Dentitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs-non-potentially hazardous food(no ttrta/temperatum controls required) RTE- ready -to -eat foods (Ex.. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑x PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs N] Preparation of PHFs For Hot And for More Than a Single Meal Service C] Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly 0 Reheating of Commercially El Sale of Raw Animal Foods Intended 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 Customer Self -Service of Non PHF and Non- and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only U Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale P ❑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 El 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 gopies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C7'9&Z�'1`9A,'r6eirlify my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. - Social Security Number or Federal ID: 84-2115543 Signature of Individual or Corporate Name: KRE Husky Willow Crossings Operations LLC 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. KRE Husky Willow Crossings Operations LLC Signature of Individual or Corporate Name Corporate Offic(t ( andatory, if Applicable) Lynda Matyan§ ', Vice President and Assistant Secretary 84-2115W "Social Security No. (iVoknntary) 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:\Osem\sleite\Uesktop\Scott's DocmneWsTood Establishments- Temp\TAX CERTIFICATION RORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwtv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name KRE Husky Willow Crossings Operations LLC d/b/a The Village at Willow Crossings Address: 25 Cobb Street City/State/Zip: Mansfield, MA 02048-4505 Phone #: 508-261-1333 Are you an employer? Check the appropriate box: Business Type (required): I.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑K I am a sole proprietor or partnership and have no g ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for 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]*'1 L❑Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other Assisted living and memory care facility *Any applicant that checks box #I 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 # I. I ant an employer that is providing worriers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lic. # 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 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. 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 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: KRE Husky Willow Crossings Operations LLC d/b/a The Village at Willow Crossings Address: 25 Cobb Street, Mansfield, MA 02048-4505 Mailing Address: 201 Jones Road, 3rd Floor West, Waltham, MA 02451 Phone/Fax Number: 508-261-1333 (t) 781-235-01368 (f) Email: compliance@benchmarkquality.com Contact Person/Title for Grease Traps: Daniel Corvelo, Director of Plant Services Name of Company scheduled to pump internal grease trap(s) monthly: Wind River Envrionmental Name of Company scheduled to pump external grease trap quarterly: Wind River Envrionmental 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 acknowledges that the information submitted in these documents is true, accurate and complete. Date Print Na 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): 150 Seating Capacity (Actual Count): 130 Normal Hours of Food Preparation/Service: Monday 6am-8pm Tuesday 6am-8pm Thursday 6am-8pm Sunday 6am-8pm Friday 6am-8pm Wednesday 6am-8pm Saturday 6am-8pm 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 1 3 compartment sink 1 Handwashing sink 1 1 Commercial Dishwasher 1 Bar sink 1 Mop Sink 0 Garbage Disposal 1 I Ice Making Machines 1 Fryolators 3 Grills or Ovens 1 Exhaust Hoods 4 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? X yes No If yes, at what station/sink? Dish rinse station F1 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 3 Bay Sink 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)? X Yes No Size 2,000 gallons Where is the existing outdoor GRU located? Main Entrance 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? Yes Where is the grease storage unit located? Located in dumpster area How often is this grease storage unit emptied? Quarterly Please list the vendor who removes the waste: Bakeus Commodity N c� W U Z W (Ir V LL J L I Mwo 201 Jones Road, Suite 300 West Waltham, MA 02451 tel: 781-489-7100 ivHrvv.benchniarkseniorlii,ing.com November 23, 2020 FEDERAL EXPRESS Amy Donovan -Palmer, MPH, RS Town of Mansfield 6 Park Row Mansfield, MA 02048 Re: The Village at Willow Crossings - Food Permit Dear Ms. Donovan -Palmer: In connection with the above -captioned, enclosed please find the following: 1. Food Establishment Permit Application 2. Tax Certification 3. Workers Compensation Insurance Affidavit 4. FOG Application 5. ServSafe Certification of Florence Botti 6. Allergen Awareness Training Certificate of Florence Botti 7. CPR Certification of Florence Botti 8. Check in the amount of $235 to cover the cost of the permits. Should you need anything further, please let me know. Thank you. Sincerely, 8 Sheila M. Morabito Senior Corporate Paralegal Enclosures