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HomeMy WebLinkAboutWendy's #166-2286 - 12/31/2021r�V boot Cv,o •- 3C0. FOR BOARD OF HEALTH USE ONLY wermit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION ,. � ' C (Application must be submitted at least 30 days before the planned openintdate/ Establishment Name Establishment Address U4 COmd Drive. Establishment Mailing Address (if different) oj%R, pa�/� _"'lOYYVU- w� DkJoItn, Establishment Telephone No - Applicant Name&Title: r`Wpx MRISI'1¢�► '�v�{J r, t"" Applicant Address t YplAa I V A - Applicant Telephone No.: �I �- }{Q "?j 100 24 Hour Emergency No.: i Applicant Email . bu.Sinas hu'nv2 W Owner Name & Title (If different from applicant) • Wi' dj1 Is 4PrciP� h eS, LLC, J 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 - A Corporation partner. Name Title Address An Individual Set �(X� A Partnership Other legal Entity _ Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Tdle. En oa/I I Address: U 4 c0fe «I id 'DY, Telephone No: s ufr- �?q 24 Hour Emergency No: FAX: L041r1 E-mail: is -orb nCX1C� '. Alt E-Mail: _ -- District Or Regional Supervisor (if applicable) Name &Title: ft1SSA ICI O �71))Si n(A ManW Address: 3 Gan-(i SI.Q. Rd 24 Hour Emergency No: Telephone No: �yf � �� �L t Na1- �Q I l iS�9D' t µµ FAX: E-mail: ftIsc Ci_JGiGI 1' i U YV ., S. C o n W Food Establishment Information WATER SOURCE: {�ub1 SEWAGE DISPOSAL: DEP Public Water Supply No. (If applicable) No. of Food Employees: DAYS/HOURS>_ a • Sal_ )_—� Name of Person(s) In Charge Certified in Food Protection Management: J�nil�jl AN&VIO;V - U A Name of Person(sj in Charge Certified in Allergen Awareness Training Eyjqd ftwefto-Go --------...-...-.--- Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 pegple 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? Length of Permit: Y Annual Temporary Temporary Stan Date: Temporary End Date: i Temporary Time: Rain Date: ✓ If yes, please attach the FOG permit application. Establishment Type: Retail Food $125.00 ✓Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 Food Service up to 201 + $300.00 k Supermarkets $400 Milk & Cream $10A0 Mobile Food Consession NO PHF PREPARED ON SITE $100,00 116anufacture Frozenpgssens/ice Cream S25.o0Rreezer Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 Caterer $35.00 Food Operations' Oehmhons PHF-Polenhaltyhazardaus food (hmaRemperarure controls required) Non-PHFs - non-potenbaly hazardous rood(na emersemperafura controls Bgmred) (Check all that apply) RTE - ready -to -eat roods (EX/ sandwiches. salads, muffins which need no runherprocessimg) Sale of Commercially Pre -Packaged Non-PHFs allFCookeO To Order - Hot PHF Cooked and Cooled or Hot Held / for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs ✓Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours ". Customer Self -Service of Non PHF and Non - Perishable Foods Only reparation of Non-PHFs Other Food Operations Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer use of Process riance and/or HACCP Plan (in Requiring gabs a hand Customer Self -Service contact alternative, time as a public health Ice Manufactured and Packaged for control) Retail Sale - Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Retail Sale Vacuum Packaging I Cook Chill Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Oul-Of-Date or Reconditioned Food Prepares Food/Single Meals for Catered Events or Institutional Food Service 1, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply vdth 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, sea 49A, I cedity, under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid statetaxes required under lawt l2-��"� Social Security Number or Federal ID'. i 7 Signature of Individual or Corporate Name: IluI 1 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix In Conjunction with Food Establiahment Permit To the 13oard of Health at the Town of,tlansfield: in accordance with the provisions ofsecdon 65H of Chapter 91 of the General Lmvs. as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license for a 1141OLES.4LE RGT,411, manufacture of frozen desserts and ice 1`Yf1cret am mix and subntils the foil owing information: �M 1. Food Establishment Name , ndq S 2, Establishment Address: Q4 toc+ro byly l 3. Location of Plants/ dessert machines: 4. Names of brands and trade or corporation name, if any, under which the products are to b VIinnc j`.4 re/t n�5, L �-C freezer) $ #Type! 5. Number and capacity of freezers and f _ 5 _ Fee: (535.(1t)per`^ r`` ,, . j r2 Is the mix purchase If so, from whom purchase __ W'kW�+ f M — p Is the mix pasteurized? "i_ $ Number of gallons of frozen desserts and/or ice cream mix sold in Massachusetts during the previous licensing period 9. Is the plant/ dessert mcachine constructed and equipped as provided in the regulations 10 Certified laboratory used for monthly testing 11. Regulations can be found at https://www.mass,gov/regulations/105-CMR-50000-good-manufacturing-practices- for-food. Please indicate if you would like a copy of the regulations emailed to you I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and true and be manufactured under sanitary conditions. I attest that the information stated in this application is :,,, ,:.,-. hies of perjury. (DATE) ,�,.,,1'i (C)jM�p.�(a+n/y�o'wnerlotficer's signature) 7y� DU W ✓'1 � l (City or Tovm) (Title) 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—W Wal- M�SS C0M`t��PU—(i� ) �a ,(h�at� (� t Signature of individual or Corporate Name dytorpb6e Officer (Mandatory, if Applicable) **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 tllxrs151eae1Desktup\Scntt's [)ucumems+Food Finabhshmenrs "remp\TAX CER I -IV ICA riON FORM dtx Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: v-r s nn Address: l �Q� �.v� �cw� k_k4 c �t1 Mailing Phone/Fax Number: ( S(3F) ^S Sq -7) N Email: Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: KX+41;�d((s Name of Company scheduled to pump external grease trap quarterly; _ Lr<L ` 1,r1li c1-S— 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 ----. — --- Farh arpaap interceptor/trao over 3 $50 ($200 max) i 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. Signed _U�`' c 7�V�'"jp Date �� 7 �� IfIRMor-TTFIM-Mill! 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): GsnLeri sC C2n S—L _ V Seating Capacity (Actual Count): ! O tY`a (Uc ',eas Normal Hours of Food Preparation/Service: tt �,} `���� � A�A Monday ; " � Tuesday rj,W $t' � Wednesday ILA—" [� Thursday �V� Friday ( Saturday' Sunday I Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) 1 Number in establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink l Mop Sink Garbage Disposal Ice Making Machines Fry olators 3 i Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3j bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? Yes No / NI 1( Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? one - Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 Grease Grease Grease Extemal Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size Where is the existing outdoor GRU located?_��Ca! 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? 4s Where is the grease storage unit located? W t+Jak\ S ' I How often is this grease storage unit emptied? 6afo1 rr Lk4 nnta a fn&dA\ Please list the vendor who removes the waste: V ns ( DMCY-C�%�� e S I j VMS f a Z w m p M Q r Z aC C O 0 x w 0 i Q ec Q O o X C) X �g ¢ LO w w `k I 0 z M--i z ry JJ v J W z z rW W a a) M 0) CD N Iq N N T L d .Q L r Z z .;j d o m c a, o c U "- a Q x W m Z ) o ge 5 0 C N O N y� u O ti o zi AMERICAN ■SAFETY& HEALTH INSTITUTE Dear Engelberth American Safety & Health Institute 1450 Westec Drive Eugene, OR 97402 800-447-3177 Congratulations on successfully completing your American Safety & Health Institute Basic Life Support (2 year) /BFA Only (G2015). The digital certification card below is identical to a printed version of the card and documents that a properly authorized ASH[ Instructor evaluated your knowledge and hands on skills in accordance with the program standard. You may duplicate this page as needed to provide proof of your training. Register for refreshers or download the Passport App at www.hs[ com/passport! Use the registration code BLS: I 57762/BFA: 153477 to register. Hockomock Area YMCA 300 Elmwood St North Attleboro, MA 02760 Basic Life Support BLS for Healthcare Providers and P Brian Janney Authorized Instructor (Print Name) 3053696 Engelberth Menendez Registry No. s successfully completed and competently performed 02/12/2020 02/12/2022 the required knowledge and skill objectives forthis class Completion Date EvpRatlon Date Basic Life Support (CPR and AED) program. " 508.643.5229 Y2837 Training Center Phone No. Training Center l.D. AMERICAN SAFETY&■ ...Ei-mas ®HEALTH INSTITUTE Basic First Aid Engelberth Menendez has successfully completed and competently performed the required knowledge and skill objectives for this program, AMERICAN SAFETY&■ LEI aug�„ce ®HEALTH INSTITUTE TNs card onti las the have nomad indlWdi al has succewh19y completed the required oblectNes and hand.. All edaluallone to the satlafedion of a omrently authorized ASH instructor. Title p,ogaln conforms to the Wits MA Donations update for CPR and ECG EspI ation done may not exceed two years from month of class campieflon. Brian Janney Authonzed Instructor (Print Name) 3053696 Registry No. 02/12/2020 02/12/2022 Class Completl. 5;N apdarboo Date 508.643-5229 Y2837 Training Center Phone No. Training Center I.D. This card cedifiea the above named individual has successfully completed the required objeck do and hands-on skill asaivatis to the sahsfaoticn of a cunantly aNM1amed ASHI InaWdor. This pmgmm conkmms to the 2015 PHA and ARC Ouldeffnas Update for RatM. This p,ogam Is not designetl to meet pediatdo flret a" (reining regulatory requirements and Mould not be used Ior than puryose. Evpimtlah data may net exceed Iwp years boom month of class completion. The Commonwealth of Massachusetts WDepartment oflndustrialAccidents Ofce of Investigations Lafayette City Center 2Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information Please Print Legibly Business/Organization Name: The Wendy's Company One Dave Thomas Blvd City/State/Zip: Dublin, OH 43014 Phone #: 614-764-3100 Are you an employer? Check the appropriate box: Business Type (required): 1. K I am a employer with —30 employees (full and/ 5. ❑ Retail or part-time).* 6. M Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. ❑ Non-profit [No workers' comp, insurance required] 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 4. ❑ no employees. [No workers' comp, insurance required]** We 1 ] ❑ I health Care 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 kl. t am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Willis Insurance Services of Georgia, Inc. Insurer's Address: c/o 26 Century Blvd P.O. Box 305191 City/State/Zip: Nashville, TN 372305191 Policy # or Self -ins. Lic. # WC 023095927 Expiration Date:, 1/1 /2021 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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. www,mass.gov/dia Page 1 of 1 "1LC RV CERTIFICATE OF LIABILITY INSURANCE 120/30/2012019 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(les) 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 andorsement(s). PRODUCER rNA TAT Wallas Iowa" Watson Certificate Centex Willis Insurance Services of Ceoxgia, Ind, PHONE P.O. Hoz cex_t_i_£leatea8w_ill-ae.eom FAX ' 8 c/o 26 century Blvd .a C.c FXO,-1 877 945 7376 �.NpL1-88 467-2378 _ E4MAIL 305191 _ _. B• r,d:_. Nashville, TN 372305191 USA INSURER(S)AFFOft01NG COVERAGE NAICq_� National Union Fire Insurance Company of P 19445 Wendy. Company Dave Thomas Blvd in. OR ,-nveRAncc r1FRTIGICATP NI IMRER• W15018443 REVISION NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 BEEN REDUCED BY PAID CLAIMS, INSR—AODZ GerYi---��_--� POLICY Ew. POLICY LTR TYPE OF INSURANCE POLICYNUMBER MIOONYYY MMIDD.. LIMITS COMMERCIAL GENERAL LIABILITY f EACH OCCURRENCE S CLAIMS MACE El OCCUR Dx AGErDeO MED UP (Any one person) S PERSONAL A ADV INJURY $ GENL AGGREGATE LIM IT APPLIES PER: GENERALAGGREGATE $. COMPIOPAGG..S POLICY �_I PRO. L.OG ECT _PRODUCTS _. $ OTHER: AUTOMOBILELIABIDtt OMBIN ) SINGLE LIMIT g CANY AUTO BODILY INJURY (Per person) LEI` S ( I DAMED SCHEDULED AUTOS ONLY _ AUTOS � HIRED NON AUTOS ONLY AUTOS ONLY NLY ' BGDILY INJURY (Pot accident) S PROPERTY O>MMAGE ......_..___._ $ UMBRELLALIAe __ OCCUR EACHOCCURRCICE $ AGGREGATE8 8 L EXCE9IAR DEA ' _m�CtA1MS-MADE RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANVPROPRIETORIPARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? LJ (Mandelary in NH) .NIA WC 023095927 01/01/2020 01/01/2021 x -§ TUTE ER-.._._—._..,_._._...�____, E.L, EACH ACCIDENT 1,000, 000 rS EL DISEASE: EA EMPLOYEE_ 1,000,000 If yes describe under OES�RIPTION OF OPERATIONS FgIPw E.L. DISEASE - POLICY LIMIT 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may he attached IF more space Is required) The Wendy's Company One Dave Thomas Blvd SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, V ©1988-2016 ACORD ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD as xD! 19044145 macs: 1507175