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HomeMy WebLinkAboutWhite's Bakery - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued 8 4L,, FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name UJKJrQ L� Ke Establishment Address 3 Q 1 SGI t 0 i /1/lQ it S Fj 2 p/j Q a (J uj Establishment Mailing Address (if different) i b LI 1 PLa V 1 S+ I �roc'k_+vn, Mft pa2U) Establishment Telephone No Applicant Name & Title: 170.Ntd kUti;+t / 1�f2�iLCxM1�} Applicant Address 16 `l1 Peck,( I S4 . 13 rz O,IC-h n Applicant Telephone No.: 5-0 $. 24 Hour Emergency No.: a5 t)8 ApplicantEmail 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 NO An Association partner. XLA Corporation Name Title Address O An Individual Dow; a AA &q. P a-8i&z!!j `i o garnab_as IZd • Fa_.Q nn aLA-k M © A Partnership 9 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Tt q Gy coaq fr\ M0_� Address: 3a2[ 2CVu01 >i. M"S1'Le�ld, AAA 0'd04Y Telephone No: SO 33`I ga3 O 24 Hour Emergency No: -)-%4 - a°t 70 la $ 7 FAX: E-mail: YNA an 9-Ri W MCUlc,Qe_r(� tA, VN J0, bWker�14L/ cIC4-Fe . Cu.-r., Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: \ a / fY /�ALUl XI Lx l SEWAGE DISPOSAL: - DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Mfm-t—ri -]am _7Prvti r SG�f �S P= Surf 73000tn=ta PP-h Name of Person(s) In Charge Certified in Food Protection Management: ir�c� Care. Name of Person(s) In Charge Certified in Allergen Awareness Training - - r& CI CG"rI -PP\ 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? _jg S _ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [Annual Fs Retail Food $125.00 E Mobile Food Consession on Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 9 Manufacture Frozen Dessertslice Cream $25.00/freezer ® Food Service up to 101 -200 $250.00 Temporary End Date: MN Food Service up to 201 + $300.00 IM Pushcart $50,00 # of Pushcarts: Temporary rime: Supermarkets $400 ❑H Residential Kitchen $100-00 Rain Date: Milk & Cream $10.00 E Caterer $35.00 Food Operations: DefinNons:PHF- Potendallyhazardaus food(Ilma4empersfure controls required) (Check all theta I Non-PHFs- non -potentially hazardousrood(no limadempersture controls requffed) apply): RTE- ready4o sat foods (Ex. sandwiches, salads, mutilns which need no f etherprocessln9) © Sale of Commercially Pre -Packaged Non-PHFs ® PHFCooked To Order ® Hot PHF Cooked and Cooled or Hot Held Q Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot And for More Than a Single Meal Service ® Delivery of Packaged PHFs Cold Holding For Single Meal Service © PHF and RTE Foods Prepared For Highly ® Sale of Raw Animal Foods Intended Susceptible Population Facility no Reheating of Commercially to be Prepared by Consumer ® Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand Q Customer Self -Service contact alternative, time as a public health ® Customer Self -Service of Non PHF and Non- P Perishable Foods Only Q Ice Manufactured and Packaged for control) ® Preparation of NomRetail Sale PHFs ®Offers Raw Or Undercooked Food Of no Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ® Vacuum Packaging / Cook Chili E Offers RTE PHF in Bulk Quantities E 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 ap icable law. I have been Instructed by the board of health on how to ?"Tin copies of 105 CMR 590.000 and the (ed�F l Food Code. Signature of Applicant: V VV Pursuant to MGL Ch.52C7se' 49A, I certify under the penalties of and paid state taxes required under law. 1� Social Security Number or Federal ID: Of -3 Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Sign4ae of Individual or Corp o Name By: Corporate Officer (Mandatory, if Applicable) ()L'I --30S(P8,V "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:\Uscts\sleite\Desktop\Scott's Documents\Food Esmblishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization S Address: t C)q I Ve&(1 S+ , City/State/Zip: O K Lh {l IAA 8 Oa 3 0 ( phone #: i (0y __ Are you an employer? Check the appropriate box: Business Type (required): L M I am a employer with 0 employees (full and/ 5. [KRetail or part-time).* 6. ❑ 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. [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 lunteers We are a non-profit organization, staffed by vo, 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: OV e 'k I S k Insurer's Address: PO 130X 8-S9aaa-�laaa City/State/Zip: (A I fA+-- 1? 2 Policy # or Self -ins. Lie. # D 1.4 C 0 5 0 3 513 91 a, P Expiration Date: O I O 1 a 0 a l 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, render the pains and penalties ofperjury 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 www.mass.gowma Phone #: CoveRisk. Services, LLC March 30, 2020 White's Pastry Shop, Inc. 1041 Pearl Street Brockton, MA 02301 RE: Workers' Compensation Insurance Policy Number: 014005035138120 Policy Period: 04/05/2020 to Ol/01/2021. Dear Member, Thank you for giving us the opportunity to provide you with your workers' compensation needs. Enclosed are the following items: 1. Workers' Compensation certificate 2. Claims Procedure Manual, which outlines what to do in the event of a worker's compensation loss. Claims forms are included, please make copies as needed. 3. Posting Notices to place in a common area of each location. 4. The business cards for your claims manager and policy services representative. 5. A copy of the estimated bill and invoice will be sent under separate cover. Your service team is as follows: Policy Services: Elizabeth M (781) 353-2110 ext.2110 esavoia@coverisk.com Savoia Claims: Mark Erdody (781) 353-2096 ext.2096 merdody@eoverisk.com Safety Services: John Hazzard (603) 321-5777 ext.0 jhazzzard@coverisk.com Should you have any questions after reviewing this information, please contact us or your Broker. Sincerely, Elizabeth M Savoia Policy Service Dept Ext. 2110 esavoia@coverisk.com. CC: Morse Insurance Agency, Inc. 285 Washington St. N. Easton, MA 02356 P.O. Box 859222-9222 Braintree, MA 02185 800-79"877.800-382-8991 Fm w .coveriskxam Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PER RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: � 1 V "I Address: S cho D IS A M (3,n S R eJ J AAA-U "Q q7 Mailing Address: i og I Pe -art >T 6 a c kr6 yl AAA 0 a3 0 1 Phone/Fax Number: 45-bg' 3 3 1 - 8 a3 o Email: W6Lr1S-Pi906M001a-*r- Oe whiteS\ u.ken411II&Cale. cam Contact Person/Title for Grease Traps: 1-L C� Gan -f-CA Name of Company scheduled to pump internal grease trap(s) monthly: 1 Name of Company scheduled to pump external grease trap quarterly: PAA— Yip 0'1 S Qy- I c� 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 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 sukmitted in these documents is true, accurate and complete. Date 10 1 oZ ad Print 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, 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. 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. 4on Ihave received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my sibility 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 clearly) to a & I '�_a _ FOM 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 j aM -zn Thursday 7 p- 7 pin 7 pinn Sunday !l�n"—Fm Tuesday %aryi -�Pyp Friday Wednesday &w -%pin Saturday ':'JD 'LM -719m 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 f 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? 1Yes No If yes, at what station/sink? , a L4A 0 Grease Traos 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 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap S 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? /y a' Where is the grease storage unit located? How often is this grease storage unit emp Please list the vendor who removes the w w O H V w OM4 W V 0 z OWO 0-00 t do cn w Z F Y !KKKM�}F z s O z Y � a A