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Home My WebLink AboutDel's Lemonade - 12/31/2021FOR BOARD OF HEALTH USF ONLY Date Received Permit Fee Approved By Permit # Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: ' Establishment Address: 60 9 " f-- t y 6z- _ V Establishment Mailing Address (if different): Establishment Telephone No: 5t�( —1 2) ApplicantiOwner Name &Title: al�I11"��t 'rt5+1G'4" Applicant/Owner Address: � ApplicantlOwner Telephone No: L) ,95-..3 —57&( Applicant(Owner Email address: d 3) Person In Charge Ons�kje Operations &Title: 'i „tew j�'e L nC� . ,y,f— PIC Address: -toff' PIC Telephone No: Emergency/onsite Telephone No: PIC Email Address: 4) Event Attending: i(L'r✓'�'d� Date($): Z Event Name: Event Location: N' Event time: 5) Check one O Truck E3 Caterer p� f� E3 Other. tJW T 6) Solid waste disposal plan: ,_ • t j� ir- ✓ r'L'ir.O-� 7) Water Source: (Q 6) Sewage disposal plan: HA 9) Please give a brief description of the food to be served: jr7�C C' i 7-0 ,evwtj'/&A 10) Food will be prepared: L7 Onshe for immediate consumption M Onshe and held at proper holl cold holding temperatures ,, !1"Offsite and held at proper hoV cold holding temperatures M Ofisite, cooled and reheated on she o Other. 11) If PHF is being served, please list the person who has completed the following trafnings and attach appropriate certificates: ...r Food Safety Manager. �Wy( Pj4)��i J� Allergen Awareness: rl'If}r/ t �l l0(t"" l `f S 12) Please describe on site hand washing facilities thaat will be utilized: K/ -Q L4 13) Please list all sanitizing solutions that will be on site: Sort - ,slat 14) if applicable, please describe your FOG management plan or attach the written plan: N(tt 1 For cafe re; CttylTown where food establishment permit Is held. Please attach a copy of the caterer's permit: r�rh kf +ta For food trucks, please flat additional communities where a food permit is held and attach copies of the base of Operations or Commissary permit: I, the undersigned, attest to the accuracy of the information provided in this application and I 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 ob eg�aF10�S R 590.000 and the federal Food Code. 19) Signature of Applican , .4 Pursuant to MOIL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax rectums and paid state taxes required under law. 20) Social Security Number or Federal ID: 65 ` %lO 01 /Gof 21) Signature of Individual or Corporate Name: V,, .ih14, 126A- IN-11 ��t?li3^tid`C Date of Event: — Location of Event: List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location: On ice/Refrigc ut Cooking Reheating Food Manager Certification Person Trained On Site? .1 ° ' es c:j No Allergen Awareness Menu Label Present? 7es o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: N/4. How will the PHF be kept at or below 41°F? How will the PHF be kept at or above 140°F? Time of PHF? Setup Served Removed Please describe hand washing and sanitizing supplies that will be provided on site: List all equipment that will be supplied for an event, including but not limited to food ermometers, cleaning wipes, utensils, non -latex gloves, heating utensils, ice etc. Cl tin t t tl _ 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. Sign ture of Individual or Corporate Name * Sodal Security No. (Voluntary) or Federal IdentiJlcalum Number By: Corporate Officer (Mandalonj, if Applicable) *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. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2617 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information p S Please Print Legibly Business/Organization Name: J T -1 k)C 'Di7A :b?�1 Are you an employer? Check the appropriate box: l.�I am a employer with _O employees (full and/ or part-Gme).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 1 ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §I (4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We arc a non-profit organisation, staffed by volunteers, with no cmplovccs. [No workers' comp. insurance req.l Phone #: 5-ov '6 V — 54 Business Type (required): 5JRRetail 6. QRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (met. real estate, auto, etc.) R. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I I.❑ Health Care 12.❑ Other *Any applicant that conks box 41 must also Gil out the section bolmv showing their workers' compensation policy inrormation. --If the curpomme officers have exempted thcmulvev, but the enrpmetion has other employees, a workers' compensation policy is required and such an organization should check be. #1. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy informadom lusssrance Company Name: S�A-6 1 11 fv✓'kM r2. �U"�G%4.r Insurer's Address: 809 0/J I �n�tr+�"`- !t r/A C+/�i.f _�,1 'ie ZZ4 CitylstatetZip: /il a rt LV' / a p 1i7 6t 2/ Policy # or Self -ins, Lic. # O t t k — f 1 182-1 b t_0 0 Expiration Date: -� 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 MOL 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OtTtcc of Investigations of the DIA for insurance coverage verification. I do hereby cjeZ r"' fir and penalties ofperjnry tl+at the info rmnfion provided obese is true and enrrect Phone #: t NFo U 6 K I- 5y67 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 9. City/Pown Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Phone #: Town of North Attleborough, MA; of Hopilh 41 SouthWaaita@pon Si. 4^SI:MMbaeyAl{.4:tti0 Pub ��.�L�tc Hiy Yd PWIi IEI tvalth Few Pimers ➢Ac INC Opa Delia Cemmone L'nbm 2a u^oa!x Loaaled aL 80 N WASHINGTON $T THE COMMONWEALTH OF MASSACHUSETTS Town at Nadh Altieboraagh, MA, Health Depadment FOOD SERVICE PERMIT Permit No FS-20.23 Few S200 Issue Deia: November 19, 2020 !n arcrdanc,e wah the yravisicns of the statutes retailing thereto in the Town of North Attleboro and in accordance with the rules and regulations made under authority Of said statutes a Food avoica Permit is hereby granted lo'. Del's Lemonade Local Manager: Paul Platelli TO sell Food at: 80 N. Washington St Parialf Ea14hun December 31, 2021 This Permit Includes: Frozen Desserts RybaH«-;.r:v'::nx..,•...:.:.�,mnm:sce c,onee�r.<wmr.<sa�.urwryu+ecuaarmxnca<rc>eve p Food Establishment Inspection Report— City/Town of Establishment: { c' Date 1 (j Page 1 ai , _--- Address: )T�f . T a_ _1. ... ---- Time in: �� Time out. Telephone: Permit No.: Number of Violated Provisions Related to Foodbome Illness Risk Factors Owner:, _ and Interventions (items I through 29): Person -in -char ge: Number of Repeat Violations Related to Foodborne illness Risk Factors — } Inspector;-.- �p (,(,,. YAJ -� , t and Interventions (Items 1 through 29): = 04i9$ IuK,PA Tpf45 ANp Rt7811 HEAL7HANTERVENTJONS .' '. _ IafE7t.1-NESS IN=yin compliance OUT= out of compliance NIO-not observed NIA=not applicable C09=corrected on -site dung inspection R=repeat violation Compliance Status a our wA wa cap a x Person -in -charge present, demonstrates 1 knowledge, and performs duties 2 lCertified Food Protection Manager Management, food employee and 3 conditional employee; knowledge, responsibilities and reporting 4 Proper use of restriction and exclusion Procedures for responding to vomiting 5 and diarrheal events Proper eating, tasting, drinking, or sI 6 tobacco use No discharge from eyes, nose, and 7 mouth T 'Ws 7ttn11 1 `.P+tn?adDni�Jf�"�.T?d�sa C.tt v.k , 8 Hands clean & properly washed No bare hand contact with ready -to -eat y 9 food Adequate handwashing sinks properly 10 supplied and accessible 11 Food obtained from approved source 12 Food received at proper temperature Food received in good condition, safe, & 13 unadulterated Required records available: shellstock 14 tags, parasite destruction Compliance Status s ar ars. uro Cos a Protection from Contamination 15 Food separated and protected 16 Food -contact surfaces; cleaned & sanitized 17 Proper disposition of returned, previously served, reconditioned & unsafe food ��:� .� ;,Tama%T'ernper'akura-Cejrtruifar,Safety „, - 18 Proper cooking time & temperatures 191 Proper reheating procedures for hot holding _ 20 lProper cooling time and temperature 21 jProper hot holding temperature 22 Proper cold holding temperature 23 Proper date marking and disposition 24 Ime as a Public Health Control 26 Consumer advisory provided for raw 1 undercooked food u^ ON`F VIM-1 Fii hl .. pb18196ptttnttons 26 Pasteurized foods used; prohibited foods not offered ��fiinnilif"PforaAlililaaiirtTatticSubsl=rrrces-, 27 Food additives: approved & properly used 28 Toxic substances properly Identified, stored & used t - ;` �..,.,. Can(snnatla�X:l+pjinoveig3+l>7cedu, 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 (his report may result in suspension or revocation of the food establishment permit and cessation of fond 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 590A15(B). Date of Rolnspection: I Discussion with Person�ln-Charge: ServSafe Nd[ianatflei[aNdnCA seCiaflon � . a PAUL PIATELLI for successfully..P.6 g the standards set fords lof the ServSolax toori Fmlxiion Manager Cmffiml cn Eaoin nman which h aaredhd by fba Amenwn Nciioaal Slandmds 100. (ANSI {onfcrence for Food Pmk Lion (CFP). 10748 ERA EXAM FORM NUMBER 1/18/2021 11181202E DATE OF EX DATE OF EXPIRATION { t«ul ivxs apply. Che ry for re yrti(iwlian M1gVil:mnlh. ,13tZ RO866 Sher elation Solufiom v v v _wnm..Art�'nan lJbE Wa6eglw.:3�9N/A frsl.ala.t A5J5SA9 w`mlaAA'Ma�waY Name of Recipient: Paul Piatelli Date of Completion: January 19, 2021 Date of Expiration: January 19, 2026 9u abo-or-name=tperson ithereby usual W, wth�Tfe for mmplding un all<rgm awwznm ha iningprogrom remgnivd by th"Ilm""hntetm Depnrhnentaf ArblkFlmhh in attardan. mi[h w GMR 59a009(C)(J)(a). this rertomre will be a a/id jor fe've (S) yews from date ofwmpldien. t,<'::r lterkshirn MC .rt Ilnhhfat.'W"CM- PIZOd, Alssmdmxcus w�v`vm=faxlalkgpiruning.n�; A� & CERTIFICATE OF LIABILITY INSURANCE °"'E`�OeN" O4/0712021 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 INSURERS), 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. It SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement A statement on PRODUCED Westwood Insurance Partners Inc. 1408 Providence Highway Suite 0224 INSURED PAP Inc. OBA Dees Lemonade cJo Paul Platelli 33 Hope Street MA f:lIVFRAf:FR f:FRYIFif:ATF NIIMRER• RFVIRInM 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. INIM TYPE OF INSURANCE AODL SUER POUCY NUMDEIR PDIKYEfF 111111001fryn I�YOa�� 1.ifare A cOMMERGMJ. GENERAL LiABRRY cwMs-NAnE � occuR A OHN4418276"0 04/10/2021 04/10/2022 EACH OCCURRENCE _gREMISES LEa-�mP�i MEU EXP�Antmmyvmul) is 2,000,000 i_S 300000 FERsoNALAaov IN,RmY S 2,000,000 _ GENt AGGREGATE LINITAPBJES PEA: POUCY n jE& ❑ LOG OTHER: GENERAL AGGREGATE _ $ 4,000,000 PRODUCTS-COMPNP PGG ___ S 4,000,000 S B AUTOMO86E V f� UUMHUrY ANY Auro OWNED SCHEOULFD AUTOS ONLY AUTOS AUTOa I NON-0WNEO AUfOONLY /� AUTOa ONLY 5023302 05/31/20 05131121 COMBNED SINGW UMIT _IEd $ 1,000,000 SOUILYWURY(Perppfzm,) S eW LYINJURY PeracWeel ( 1 $T PROPERTYDAMA GE S .,_aarlmtj_ $ UMenP.LLA LIAB ex-saa AB OCCUR CLAIMSNADE EACH OCCURRENCE $ AGGREGATE _._... $ OEO DETENTIONS S WORKERS COMPENSATION ANOEMPLOYERS'tiABRJtt YIN PNYPROPNETOWPARRlEPlEXECUTNE ❑ CERRAEM OFFISER EXCLUDED'! 004-d yMNNt n yyssss�� dedO{eoM Uer OESCRIPIIONOFOPEFAnONSh NIA STA OEDTN- - ELEACHACCIO — $ EL. DISEASE -EA EMPLO -.—_. $ ELOISEASE-POUCYLAUT — It A Business Personal Property Unit OHN-H182764-00 04/10/20 04/10/22 LIMIT S52,000 OEBCNPTIONOf OPERA➢DNS/LOCATIONSIYEMCLE$(ACORD tat AddlBo" Remelts Schedule, may W tewMd H mao%p Mm kedl Ice Cmam(Lemonade Sales: ADDITIONAL INSURED as required by contract: FOR THE ADDITIONAL INSUREDS -THIS INSURANCE IS PRIMARY & NON CONTRIBUTORY BASIS - ADDITIONA INSURED: Hingham Farmers Market SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEIIEn BEFORE THE E%PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hingham Farmers Market Inc. ACCORDANCE WITH THE POLICY PROVISIONS. Station Street AUTHOR®REPRESENTATNE Dermoll Larkin Hingham Ma 02043 AWIiZLT 7_YiCi7,`1tiTt1 ACORD 25 (2010103) The ACORD name and logo are registered marks of ACORD 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. t/ I 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. Compostabie materials must meet ASTM (American Society of the International Association for Testing, and Materials) Standards for compostability. 7y 11 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. 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 SVnature �^y Date: IF Applicant v2 Applicant Name (please print clearly) UI t a,Z Del's Lemonade Menu: Soft Frozen Lemonade Flavors: Lemon Watermelon