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Home My WebLink AboutSunnyside on the Street - 12/31/2021t` (,E, FOR BOARD OF HEALTH USE Ot Date Received Permit Fee Approved By NAY 2 7 Permit # Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1). Establishment Name: ;7 crlr re,ci Establishment Address: Establishment Mailing Address (if diferent):�s�� ji./ ,/yffU2.- /r��G� �Z�� IV Establishment Telephone No: 401--,V,9 �t 2) AppiicanUownerName&Title• ff 4.Y,rjr/,Qpeal,J ,-,we Applicant/owner Address: J y j ,I�ia'di^� /�ls - 191GL 'L � `V 3��l Applicant/Owner Telephone No: 4j/`ff-.7d AppO,cant/owner Email address: ilovJs/,,ie,Ptld LQi 3) Person In Charge of onsite operations & Tale: /,6/- PICAddress /Y�,f'' (f✓�" /tijlfit� f4' Pic Telephone No: 4.ir4%/ J Ze 7 -,2 7 416 Emergency/onsite Telephone No: PIC Email Address: ',A,iV V c:i��iC- Z,��A �44) Event �� Attending: %'�w"r ) •1VP1 ef�!N Date(s): .? /'z 91 .amlrf l /. Event Name. ,, 0w�r�./ -- Event Location: f3% Event time: 5) Check one Food Truck p Caterer rp Other r ca 7', Water Source: IVIRIlemo 6) Solid wasts dispcsai plan: go 4Y.- sjQj'r^ l 9) Sewage disposal plan:.. . dfvl ), f ... 9) Please give a brief description Ctv"ed � � j,,te 4. 0Y f7— J Ems' / f / ✓�}C1 °J 6s4,ac4' i" rae drY� l Z t e 37 I 10 ) Food will be prepared: txa Onslte for immediate consumption iD Onsfie and Maid at proper hot/ cold holding temperatures E3 Offsile and held at proper hot/ cold holding temperatures Cl Oftsite, coaled and reheated on site M Other 11) if PHF Is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager Allergen Awareness: see!y t < e - ripe fn /' rf.�M hand washing facilitiesa+t in be utilized � a rye e11W "MY i= iJ J 13) Please list all sanitizing solutions that will be on site; 15 7eNk1�� G rTBSf S','a°S 14) if applicable, please describe your FOG management plan or attach the written plan: r7WJ '!9 l u ti s fir}rF— ttft4 IJi3 Jew A� 15) For caterers:. C➢tylrown where tood establishment permit is held. Please attach.a COPY of the caterer's permit' For food trucks, please list additional communities where a food permit is heldandattach copies of the Base of Operations or Commissary permit .....,.,D.V7 '(l I, the undersigned, attest to the establishment operation will colt by the board of health on haw to 19) Signature of Appiiewt:.— of the intormatirsnprovided In this application and Iaffirm that the food 105 CMR 590,000 and all other applicable. law. I have been instructed pursuant to MGL Ch. 92C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 20) Social Security Number or Federal ID: �T- �J6 21) Signature of Individual orC'orpofateName: /t.,0 WrAWt�z7e4' 0 TOWN OF MANSFiGLL1 LOCAL OyLAW5 the following twkovi apply to rill food o5tabh+hntonfs pnanitted by the Mansfield llaiilth Ltupartmnent: pla,th: Waste Retht4t rn; poiyatytogo faJntainnr Rodur;tinn; and Plastic 5ih aw/Stirrer R . it tide, A ropy Of each bylaw Is hatludrzd, It is too re pnuslb[Iiry of the applicant to rnadand understand all bylaws. ple, m? indicate by Initialing the following statements that the permitted fund establishment wlli adhnro to all applicable bylaw-,,. The applh not and.rssociato corporation ama subject to Rum associated with viooletions, plastic Waste Reduction No retail aatablishmont In the Town of Marnsheld shall provide thim,fllnn, imithruSe plastic check-out bags to m:uYtumt t ' ` have retoived a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to oresw e that this bylaw fs ;tdhr, red to auto lx runitted rood establishment, I understand violations Of this bylaw will result ill fins. polysWerne Contalner Reduction (effective January 1, 2021) Food establishments are prohibited train dispensing pr opared food and drink in disposable hood service containers made tram expanded polystyrene- All food establishments are strongly encouraged to use reusable fund service containers and eutlary, and when possible biodegradable, compostable alternatives, Campost*alole mater(nis must meet ASTM f Arnadcan SacietY of the hrternatiapa) Assottaton far Testing and Materials). Standards for conapostability, have received a copy of the polystyrene Container Reduction bylaw, I understand my rrsPgnsihilit}+4o ensure that this bylaw is adhered to at the permitted food establishment. I wndnrstamut violations of this bylaw will result in fines, Plastic Straw/Stirrer Reduction (effective January 1, 1021) plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction , em with semile serving by business i i,froa n, or other ins Or beverages event of liquid, ages to the public (or consamption slurry, 419, have receiveda copy of the plastic. Straw/Stirrer Reduction bylaw, I understand my responsibility to ensure that this bylaw is adhered to at the permitted food ostabiishment, I understand violations of this bylaw wilt result in fines. a,ite, 7 Ile j Applicant Signature ' Applicant Namne (please print clearly) fi'•--- —. -�-�- El Food Prote0ion Questionnairie for Catered Events r1wIP1 F'VencrimV Cq,4- rti 60H n� curl in anIVUS N-heating CYOW l(VA I,iq all fbod% that YIAI "lilt be chillinp- h"A(b on Z on Saw) ;w Ye's No Yes ij No ua fOT it leaves yout prelt ti,4 tt",t re,-pixed V-""rat 12k —el ---- Removed Served ------ ---- - -- hand edt4o lnae cart �;�!�W afCXVAIm (7 104-14 ...... I'A.XCEitrIFICATION FORM I (-Lrfify under the penalties of peritiry that I, to my best knolvW900 rid belief, have filed all state tax returns and paid Astate taxes required under law. Offirer, 0,101fddtOtY, Tj-- A3 (,�urjiy No. Wvh4fftaVY) Of Fvderci Nwwber , *Thi4 licens,_ will not be issued unless this certification clause is signed by the applicant. a f **your6 �-,Ccurjty nornber will be furnished to the M— S� Chu';fts r,)epartmerit of , R,�,eljue to (jeteriniDe whether you have met tax filing or tax Payment obligations. Licensees who fail to cOrrect their non -filing Or cleflocitiency will be subject to license suspension or revocation. This request is joade under tleIjjth()rit.y of Gener. it Law Chapter 62C, W,fiov 49A. The Commomvealdt of Massttehusetts "r Department of Industrial Accidents Office of fitvelldgatitim 6h0 Washingion,S°treet Boston, MA 02111 tvtwv.nttuagovtdia 1Vorkers' Couipensatioo Insurance Affidavit: General Businesses Applicant Information Please Print legibly fiuNNinesgOrganization�Naame: Address: city/statelZip:'(--V ' � Phone Am you an emptoyce? Check th • appropriate has: t_ ® I all) a employer wilk, employees (full muV or pan -lime),* 2,0 i lull a Sole pmprictorerparrkership mvl have no employees workigg for like ill ally capacity, INo workans' camp, aisurn ico requiredl 3.❑ We niea cocgwmtionand its officers luwo cavreiecd their right ofescnrpdou per c, 152, A 10), our no luwe rto cayrloyecs. [No workers' eromp, insurance requir0d1*4 4,❑ 1Neare a rnm-profit mytruilxnnou, staffed by vo onlellm whh no curployees. INo wo k t5 comp. insurance rNj Duxan_ws Type (rogniml): 5, ❑ Retail G. ❑ Restaum[wBartf'rtdug 8stnbh"hn m 7, ❑ Office andlor Site" (ind tral cstale auto, etc ) S, ❑ Non-prolit 4, ❑ Eutedaiurncni 10.❑ himurCaeturinl; 1I.❑ Hcldih Caro 12.RIOtIm "� rxe4ele dli uu1 rlw:cceN,m balwvsAmtinrl nrair ixkax'.,vnixa,angar PNic'y au�mnvrm mwlrmx Mn thucratwrnritu has oihcr uurtLx»+�rxxk•ri O,mapmsaiim w.dky ie 2yuirzil nml such an ,N+�Utalia, �uadA diuA aa�lsl, - I aan emplaper that dv provNingx a ,,ke ,v' canyrensrdion instttanrefor lip+ cmryrlayer nelmv is "N galley hxfurntarinn. m huurlince Company Nanlc:_ lmuwr's..Address: Cuyistntelaip; Policy # or SeIC-hr3. Lie. A y+7pG1i",ieiJ"7 EspirtdonDidc: iIJ�>1r}�.-� Anuch a copy oCihe wurlcens' enmpernsvtion lnidicy dcciar^atinn page (ahnwlug the Im6cy numiter and espirvtknn date). failure to suvro cuvemgpasregnia`d andcr Secdan 2SA ol'MOL c. I i2 pan leadto Uu: imposidon of pnmiruti pctnhics of a take up to $i:5dt1,tN):u�or one-year lmprisnimtent, as w�li as civil penalties iu the Conn nl-a STOP tNOtiK ORDER and a D of lip to $250.tx) a day against like rinlaax. Doath•iscd dwt a copy of Wis scriwtunt tmy be fotw•anlcd to tiro t7{lice of (nvestlgntiotn u1' ita 171A for ir>sunwrx: ponemKe virif(eadon I do he eby cettif_i", Under like pains and p� n th yYhe in o vided nbaxc is true anricrrrretx 4lI?/—.3e�'_" t)Jfutal ase aul)t ps not uyite in. this area, ra be ciompleted by ch)r ortauvt elficiat City or Town: PermittLicensel€ 1s,Kuing Aulhoriiy tcirele(lae). l,. pu, rd of licahb 2, Dulldhng Departnumt 3. Chyffown Clerk 1, Licensing lauaMt S-.Sclectmeq's Otree b, other Contact 1 Date: Noveinber 10, 2020 eacon Policy Number: 0000097983 jai Insurance Co. Policy Information Page Account Holder: R,P. Winkdton Inc Agent Name: Wayne G Rouley Address: Sunnyside on the Sircet Agent Address: 117 Eddie Dowling Nighwav 1435 Iron Kline Hill Rd North Smithfield, RI 02896- 7338 North Smithfield, RI 02896,1156 Phone: (401)76,5-6311 Agent Number: 01736 NCCI Carrier Code: 30325 Named insureds R,P: Wink0ton Inc Dec Type: New Group Affilladom Endorsement Reason o..n.... nPldnd 3 A, Wa•kers' ComPensat"m Insurance: Part one applies to the Workers' Compensation law of Rhode island. 'u nr..nlovers' Liability Insurance: Part two applies to work in Rhode Island. The limits of cut- liability are: n. Endorsements & Schedules: En 6 E- Em dorsemen[ Endorsement.._ EndorsLi,ement Endorsement OU OU 01-WCand. EE_OU,.00_OYA- BE 00 Ot) 40-OFACTrde EE_00 00_50-AuditNgn plovers Liability Policy Cancellation EndorsameSa nt Endursemeutice and EndorCompsementance This This is not an Invoice Insured i{e &aeon Elul iat li +tonceC np,10V +:,na e N ap,VhA. RI 89R-t37t$ I biupryinulua+l,cont a 6E 00 00 14 VA ilnoon,ntinrT: 1 Se � Lb,a e7 1 Toll fr,1.888 O6 4450 Pago I of 3 This This is not an Invoice Insured i{e &aeon Elul iat li +tonceC np,10V +:,na e N ap,VhA. RI 89R-t37t$ I biupryinulua+l,cont a 6E 00 00 14 VA ilnoon,ntinrT: 1 Se � Lb,a e7 1 Toll fr,1.888 O6 4450 Pago I of 3 Name of Recipient: Anthony L Soly Date of Completion: May 19, 2021 Date of Expiration: May 19, 2026 I:w�d py: ..-�,: LS. ` s1 D „ t e ✓f, -5�� iDcyrkq.�i{t'i j. drca BFnllL tLlue3tiuiu'nu r. I'iilsitild, \lvachu�tir Mli T - : (401) 462 Faa< (451) 462-9"5 V015ILE FOOO ESTABLISHMENT ReGI T TION rr KNO 4W MAT Ete'abNs OWYWO- ktOwry SOPI 143,5 krif Om Nat7 R4 Piame of A9utils Pstsd 01v oma Nara 9 n� : of rmiassi " ' E - -. : ) EsiabulhmcntlTruc*; or Delm 1 sies¢br Nu of �`dss uialldr+ surd has ro sa ssa 4V fHR S fAr�5 OF ON MAND, Im 0 Immpq it r, I 0 r Food Establishment Inspection Report — Town of Mansfield Establishment: `,AS Date: Page 1 of _ Address: Time in: Time out: Telephone: Permit No.: Number of Violated Provisions Related to Foodborne Illness Risk Factors Owner: and Interventions (Items 1 through 29): Person -in -charge: Number of Repeat Violations Related to Foodborne Illness Risk Factors Inspector: 01-) - -� `� �� and Interventions (Items 1 through 29): a u, iffl4 IN = In compliance OUT= out of compliance NIO = not observed NIA = not applicable COS = corrected on -site during inspection R = repeat violation Compliance Status IN ou NIA Nro COS R Person -in -charge present, demonstrates 1 knowledge, and performs duties 2 Certified Food Protection Manager eu Management, food employee and 3 conditional employee; knowledge, responsibilities and reporting 11 4 Proper use of restriction and exclusion 5 Procedures for responding to vomiting and diarrheal events Proper eating, tasting, drinking, or 6 tobacco use 7 No discharge from eyes, nose, and mouth � I tt 8 Hands clean & properly washed No bare hand contact with ready -to -eat 9 food 10 Adequate handwashing sinks properly supplied and accessible 11 Food obtained from approved source 12 Food received at proper temperature 13 Food received in good condition, safe, & unadulterated ;k— 14 Required records available: shellstock tags, parasite destruction Compliance Status IN OU N/A Nro cos R P.rotectonfrdmCcotamination '. 15 Food separated and protected 16 Food -contact surfaces; cleaned & sanitized 17 Proper disposition of returned, previously served, reconditioned & unsafe food 18 Proper cooking time & temperatures 19 Proper reheating procedures for hot holding 20 Proper cooling time and temperature 21 Proper hot holding temperature 22 Proper cold holding temperature K. 23 Proper date marking and disposition 24 Time as a Public Health Control 25 Consumer advisory provided for raw / undercooked food 26 Pasteurized foods used; prohibited foods not offered 27 Food additives: approved & properly used 2 Toxic substances properly identified,8 stored & used f 29 Compliance with variance / specialized process / HACCP Plan Official Order for Correction: Based on an inspection today, the items marked "OUT' indicated violations of 105 CMR 590.000 and applicable sections of the 2013 FDA Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If you are subject to a notice of suspension, revocation, or non - renewal pursuant to 105 CMR 590.000 you may request a hearing before the board of health in accordance with 105 CMR 590.015(B). Date of Reinspection: Discussion with Person -in -Charge: - Food Establishment Inspection Report - Town of Mansfield Establishment: Date: Page 2 Of IN = In compliance OUT= out of compliance NIOfl= not observed NIA = not applicable COS = corrected on -site during inspection ^ R = repeat violation Compliance Status IN OUT NIA NiO cos R 30 Pasteurized eggs used where required 31 Water & ice from approved source 32 Variance obtained for specialized processing methods w� Proper cooling methods used; 33 adequate equipment for temperature control 34 Plant food properly cooked for hot holding 35 jApproved thawing methods used 36 Thermometers provided & accurate 37 Food properly labeled; original container 36 Insects, rodents, & animals not present Contamination prevented during 39 food preparation, storage and display 40 jPersonal cleanliness 41 Wiping cloths: properly used & stored 42 Washing fruits & vegetables 43 In -use utensils properly stored 44 Utensils, equipment & linens: properly stored, dried, & handled 45 Single -use / single -service articles: properly stored & used 46 Gloves used properly ` �`tltellxils>�gui`pmenkandVelidtii``� ,� Food & non-food contact surfaces 47 cleanable, properly designed, constructed & used Type of Operation(s): ❑ Food Service Establishmen ❑ Retail Food Store ❑ Residential: Cottage Foods ❑ Residential; Bed & Breakfast ❑ Mobile/Pushcart ❑ Temporary Food Estab. 0 Other ❑ Routine ❑ Re -inspection Pre -operational Illness investigation ❑ General complaint ❑ HACCP ❑ Other Compliance Status w OUT NIA alo cos R 46 Warewashing facilities: installed, maintained, & used; test strips 49 Non-food contact surfaces clean 50 Hot & cold water available; adequate pressure 51 Plumbing installed; proper backflow devices 52 Sewage & waste water properly disposed 53 Toilet features: properly constructed, supplied, & cleaned 54 Garbage & refuse properly disposed; facilities maintained 55 Physical facilities installed, maintained, & clean 56 Adequate ventilation & lighting; designated areas used M1 Anti -choking procedures in food service establishment M2 Food allergy awareness M3 ICaterer M4 Mobile Food Operation M5 Temporary Food Establishment M6 Public Market; Farmers Market Residential Kitchen; Bed -and - Breakfast Operation M6 Residential Kitchen: Cottage Food Operation M9 School Kitchen; USDA Nutrition Program M10 Leased Commercial Kitchen M11 Innovative Operation r �L1 u tt ,eME Local law or regulation L2 Other Food Establishment Inspection Report — Town of Mansfield Establishment: Date: Page _ of Item I Location Observations and/or Corrective Actions Violations cited in this reportp must be corrected within the time frames stated below or in Section 8-405.11 of the Food Code Item Section of Code Description of Violation Date to Correct By Number Mansfield Application for Standard Permit FP-006 (Rev. 1.2018) Return completed application to: Permit Number FOOD,21-0002 City or Town: Mansfield, MA Date: 05/25/2021 DIG SAFE NUMBER Start Date: f In accordance with the provision of M.G.L. Chapter 148, as provided in Section 10 A. Application is hereby made by I_3�_ a 7y6 SUNNYSIDE ON THE STREET-ANTHONY SOLY 58t-33�8ne4 (Full name of person, Firm or Corporation) (Pone umber) of 1435 IRON MINE HILL RD NORTH SMITHFIELD, RI 02896- (Address: Street or P O. Box, City or Town, Zip Code for permission to (state clearly purpose for which permit is requested) Issued for the use a food truck at Canoe Name of Competent Operator ANTHONY SOLY Cart. No. Date Issued -rejected: 05/25/2021 by Date of expiration 05/25/2022 Fee 0.00 Amount Paid $ 0.00 The Commonwealth of Massachusetts Town of Mansfield # 4 l w_ `3 FP-oPERMIT (Rev. 1.2018) Permit Number (if applicable) FOOD.21-0002 DIG SAFE NUMBER Date: 05/25/2021 City or Town: Mansfield, MA Start Date: In accordance with the provision of M.G.L. Chapter 148, as provided in Section 10 A. This pemit is granted to SUNNYSIDE ON THE STREET-ANTHONY SOLY for Issued for the use a food truck at Canoe River Restrictions 527 CMR 1.00 at 137 MILL ST Fee Paid $ 0.00 (Full name ofperson, Firm or Corporation) (Give location by street and no., or describe in such manner as to provide adequate identification aflocalion) This Permit will expire on 05/25/2022 Signature of Official Granting Permit Title CAPTAIN y- This permit must be conspicuously posted upon the premises 4=11,