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HomeMy WebLinkAboutBar Pizza & Salad - 12/31/2021FOOD ESTABLISHMENT PLAN REVIEW APPLICATIO (Application must be submitted at least 30 days before the planned opening date with $100 Establishment Name: bj\ Il Qti2YN + 51\1tn 1/0EstablishmentAddress:'190 SU*01- SI ) I35 02/ Establishment Mailing Address (if different): `2 �kvfq"tJLD ,y)0,L6L qt Mkl OJ qg E Establishment Telephone No: y (1• °1�1' Iq b Applicant Name & Title: jkssOn) co t?*) Applicant Address: Q'L (t/ a RZ j wj Ud l r (Y) A I ow� A Applicant Telephone No.:Oil- 4N1-gg41- 24 Hour Emergency No.: Applicant Email: 3C &xLfToe . vxy-\ 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 An Association partner. ACorporation An Individual Name Title BwtC LL(- iz Address (VAf'AV&" A Partnership W1 L L0_Sbe'/) / M 6) Va q w1 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: A SSO d %b t-kC Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 1, the undersigned, attest to the establishment operation will coi the Board of Health on how to c the infor tion provided in this application and affirm that the food i CM 0.000 and all other applicable law. I have been instructed by CMR 590.000 and the federal Food Code. i Signature of Applicant: New Remodel Conversion CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS Proper plan review submittal with EQUIPMENT listed and located on floor plans as well as specifications for finish and plumbing schedules will highlight potential problems on paper while allowing for modifications to be made before costly purchases, installations, and construction are performed. All facilities, systems, processes, and menus, when applicable, will be evaluated to determine minimum operational requirements. The following should be included in the plan submittal: ❑ Legible plans at minimum of 11 x 14 inches in size drawn to scale (scale - % inch = 1 foot) ❑ Proposed menu, seating capacity, and projected daily meal volume for the FOOD ESTABLISHMENT. ❑ Provisions for adequate rapid cooling, including ice baths and refrigeration, and for hot and cold -holding of TIME/TEMPERATURE CONTROL for SAFETY JCS) FOOD. ❑ Location of all FOOD EQUIPMENT. Each piece of EQUIPMENT must be clearly labeled, marked, or identified. Provide EQUIPMENT schedule that identifies the make and model numbers and listing of EQUIPMENT that is certified or classified for sanitation by an ANSI accredited certification program (when applicable). Elevation drawings may be requested by the REGULATORY AUTHORITY. 11 Location of all required sinks: HANDWASHING SINKS, WAREWASHING sinks, Utility Sink and FOOD preparation sinks (if required).* ❑ Auxiliary areas such as storage rooms, garbage rooms, toilets, cleaning area with mop sink, basements and/or cellars used for storage or FOOD preparation. ❑ Entrances, exits, loading/unloading areas and delivery docks. ❑ Complete finish schedules for each room including floors, walls, ceilings and coved juncture bases. ❑ Plumbing schedule including location of floor drains, floor sinks, water supply lines, overhead waste -water lines, hot water generating EQUIPMENT with capacity and recovery rate, backflow prevention, and wastewater line connections. ❑ Location and strength of lighting fixtures.** ❑ Source of water and method of SEWAGE disposal. ❑ A color coded flow chart demonstrating flow patterns for: o FOOD (receiving, storage, preparation, service); o UTENSILS (clean, soiled, cleaning, storage); and o REFUSE (service area, holding, storage, and disposal). ❑ Storage of Employee Personal Items. ❑ Ventilation. XIee to work with licensed contractors and file appropriate building permits with the Town of Mansfield. NO RENOVATION OR CONSTRUCTION WORK TO BE DONE IN FOOD ESTABLISHMENT BEFORE WRITTEN APPROVAL FROM HEALTH DEPARTMENT * Minimum sink requirements Any food establishment preparing any food: 1 bathroom (toilet and sink) 1 hand sink in food prep area 1 mop sink (floor washing water disposal and mop rinsing) • 1 3-bay sink for dishwashing with grease trap 1 prep sink (filling pots, washing food, etc.) Any food establishment selling retail only: • 1 bathroom (toilet and sink) 1 mop sink **Lighting schedule with protectors According to 105 CMR 590, 6-303 Lighting, 6-303.11 Intensity - The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach -in and under -counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. FOOD PREPARATION PROCEDURES FOOD DELIVERY Are all food supplies from inspected and approved sources? a'Yes ❑ No How often will frozen foods be delivered? ❑ Daily ❑ Weekly ❑ Other: _ I `— How often will refrigerated foods be delivered? ❑ Daily ❑ Weekly ❑ Other: F71 LH How often will dry foods or supplies be delivered? ❑ Daily ❑ Weekly ❑ Other: 6 i ,Vk FOOD STORAGE* - Identify amount of space (in cubic feet) allocated for: Dry Storage Refrigerated Storage Frozen Storage (41°F) Utensil Storage * Identify on plans where storage will be located. INSTRUCTIONS: Describe the following with as much detail as possible. Indicate Not Applicable (NA) as appropriate. PROCESS IDENTIFY FOOD ITEMS INDICATE LOCATION AND EQUIPMENT ��I11 I L Washing FDA Food Code §3-302.15 Thawing FDA Food Code §3-501.13 Cooking FDA Food Code §3-401 Hot Holding Hot food maintained at 135OF Cooling Time/Temperature Control for I b�'11 wjs�FI�w Safety food will be cooled to 41OF within 6 hours; 1350F to 700 in 2 hours Reheating Ck L�1 % SA1JSNh-e slits p/ Food must be reheated to a I temperature of 1650 for 15 seconds within 2 hours PHYSICAL FACILITIES Handwashing facilities Identify number of the handwashing sinks in food preparation and warewashing areas: Food Preparation: Warewashing Area: Please indicate type of hand drying device to be used Disposable towels WYes ❑ No Hand -drying device ❑ Yes ❑ No Warewashing Facilities Manual Dishwashing Identify the length, width, and depth of the compartments of the 3-compartment sink: Will the largest pot/ pan fit into each compartment of the 3-compartment sink? ZYes ❑ No If No, what will be the procedure for manual cleaning and sanitizing of items that will not fit into sink compartments? Describe size, location and type (drainboards, wall -mounted or overhead shelves, stationary or portable racks) of air drying space: Indicate the type of sanitizer to be used for manual dishwashing Chemical ❑ Yes ❑ No If yes, please list type of chemical: Hot Water ❑ Yes ❑ No Mechanical Dishwashing Identify the make and model of the mechanical dishwasher: Sec��5 Indicate the type of sanitizer to be used for mechanical dishwashing Chemical ❑ Yes ❑ No If yes, please list type of chemical: Hot Water ❑ Yes ❑ No Will ventilation be provided? 0 Yes 0 No Water Supply Is the water supply public or non-public/private? ® public ❑ Non-public/private If private, has source been approved? ❑ Yes ❑ No Is ice made on premises or purchased commercially? El"Made on -site ❑ Purchased Will there be an ice bagging operation? ❑ Yes C/ No Sewage Disposal Is the sewage system public or non-public/private? Public ❑ Non-public/private If private, has the sewage system been approved? ❑ Yes ❑ No Are grease traps/interceptors required? .Yes ❑ No *If yes, identify location on plan. Backflow Prevention Will all potable water sources be protected for backflow? [a/Yes ❑ No Are all floor drains identified on the submitted floor plan? ErYes ❑ No Toilet Facilities Identify locations and number of toilet facilities: Are hot and cold water provided? I0Yes ❑ No Dressing Rooms Will dressing rooms be provided? ❑ Yes �No Describe storage facilities for employee personal belongings: Agk 54 Off CdL4' Linens Will linens be laundered on site? ❑ Yes H No If yes, what will be laundered and where? If no, how and where will linens be cleaned? If no, how often will linens be delivered and picked up? Identify location of clean and dirty linen storage: J?'t l,\ r(tR� Poisonous/Cleaning Storage Identify the location and storage of poisonous or toxic materials: t1`t \AAA A V)6A Where will cleaning and sanitizing solutions be stored at workstations?_ BiLi eys ISPXN 061-rLt5, How will these items be separated from food and food -contact surfaces? t)P% Dti"f( Kft Pest Control Will all outside doors be self -closing and rodent proof? i4es ❑ No ❑ NA Will screens be provided on all entrances left open to the outside? ❑ Yes ❑ No t/NA Will all openable windows have a minimum #16 mesh screening? ❑ Yes ❑ No t7NA Will insect control devices be used? ❑ Yes ❑ No PfNA Will air curtains be used? ❑ Yes ❑ No I;7 NA If yes, where? Note: All pipes and electrical conduit chases must be sealed to prevent rodent access. Refuse, Recyclables, and Returnables Will refuse/garbage be stored inside? ❑ Yes dNo If yes, where? Identify how and where garbage cans and floor mats will be cleaned? DTI Ll fV Will a dumpster or a compacter be used? C3 Dumpster ❑ Compactor Identify locations of grease storage Will there be an area to store recyclables? ❑ Yes ❑ No If yes, where? Will there be an area to store returnable damaged goods? If yes, where ? ❑ Yes ❑ No Approval of these plans and specifications by this Health Department does not indicate compliance with any other code, law, or regulations that may be required (federal, state, or local). It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A pre -opening inspection of the establishment with equipment will be necessary to determine if it complies with the local and state laws governing food service establishment. 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I �I 0 1 � E E l i I, I �g 3 N $ I Ha omQ, -1 k HRR _ mG� ��o �w�m� a 4 w�.�oaa3 o3�`obGOo -3388�i�i8° p S60ZO VW'OlAlASNM � z p{ey 5EW 3110S'133N1S 100HOS 00Z _ zg H£W pt 6Zs ONISSSNO 0131iSNVW pp wad a' a1313SMdW - 31d dVG s i o3� 4 Q .'s E a SI, ry� u € ` i o LJ r---- ezm� 8p°C gad — e8pLL�� Goo 9 WPM, 0 W� o���o�zw5a. i s� n I o�.ad:S��6m u Er�m35a�g = Q._g8 8 N-UH� 0 3 g " m2q�M go��Gm¢m w�b�����=w� Cw'm�U"Saa 9- s e�ap �fw�po� e4 zs �g 'g3 z �e aC xo3p d.. aa� g e F � is $v »r .i at�d EI SALADS House: romaine, cucumber, tomato, red onion, carrot, crouton, banana pepper, red wine vinaigrette Caesar: romaine, shaved parmesan, crouton, pepper, Caesar dressing Caprese: spinach, mozzarella, tomato, basil, balsamic glaze Arugula: toasted almond, red onion, apple, shaved parmesan, lemon vinaigrette Greek: romaine, tomato, cucumber, feta, kalamata olive, red onion, red bell pepper, Greek dressing Spinach: strawberry, beet, candied walnut, goat cheese, balsamic vinaigrette Celery: shaved parmesan, breadcrumbs, Caeser dressing Cabbage: mandarin orange, roasted sesame, carrot, scallion, red bell pepper, crispy wonton, sesame vinaigrette Mixed Green: tomato, avocado, hardboiled egg, carrot, breadcrumb, honey mustard dressing SIGNATURE PIES Baconburger: bacon, hamburger, pickles, thousand island drizzle Caprese: tomato, basil, fresh mozzarella, balsamic glaze Buffalo Chicken: garlic cream sauce, crumbled blue cheese, ranch drizzle Spicy Hawaiian: pepperoni, pineapple, banana pepper Veggie: mushroom, pepper, onion, broccoli, black olive Tarte Flambee: bacon, caramelized onion, creme fraiche, ricotta Chicken Caesar: garlic cream sauce, romaine, shaved parmesan, Caesar dressing Meat Sweats: pepperoni, hamburger, linguica, prosciutto, bacon Potato Skin: potato, creme fraiche, cheddar, bacon, scallion, sour cream Prosciutto & Pear: EVOO, caramelized onion, goat cheese, mozzarella, arugula, balsamic drizzle PIZZA TOPPINGS $1 pepperoni, mushroom, onion, green pepper, black olive, broccoli, anchovy, banana pepper, pineapple, garlic, tomato $2 chicken, hamburger, sausage, linguica, bacon, ham, goat cheese, ricotta, fresh mozzarella ❑ [��jwu n. � Q4 m. ae� 4n4v - - -- ONISSONOOISIiSNtlW i I�eN $USA kd :..d edd add dd.d $d::d dd $dxs.A dd<:d *esryli pJlpp sx8 p�. �@IN B� 1 dd<$a $ .A ddsA Ad d add edA add ddd eA eA aA eH Via E p�` d Big p�, c� g, � n, � u���� e����e ¢„.- a�A E��„ 8868 id'"d kdn..A ddsn".d �d:A �dsA kdsA dSgfkq &dt%�pd8899ed� $ggddgggq488 ndAgqS5edgqApg ndgdgted �ggdGGG �dgg�gqA sd<g.gd $dpp;:GAq �d.rd#pp77dd..gdqq$ds$gqd 55qqqq qq a p5 pp n i �S Y ¢5N 9 �C3 i3 a �� ADM hN; 83�9a 2mg 410 �tl9693�af�� 3O dds.d &d:s edA sd a" dsi:d dkd $ds`sd d;.A gdarA Edss"% A d Ad: M 48x.A A. Adsd $d:.a Ab'9 adsA 88tld 86n..A �daA Adad x � / � x d� V I z / u g I '1 I, I (0) Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS All items in this section must be completed. Business Name: �� � `PIZ� Lt) C' Address: Z i✓ ST 3 Mailing v �- L(V I Phone/Fax Contact Person/Title: M W 0 6jb z 9 j Person to contact concerning information provided herein: Name: b w 06piv� Title: Business Phone Number: W )1- Sq G - 13 JU Does the business own or rent the facility? C If rented, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: WS D u& KOu r Property Owners Address: 33 60�b.�W C // W �)6-V'1, 1—A)V(`l)�1 L(,/Mks %1' b7 Property Owner's Telephone Number: 8 11' Z57- 1 6q LTD 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. I THE UNDERSIGNED CERTIFY UNDER THE PENALITIES OF PERJURYTHAT THE APPLICANT HAS FILED ALL STATE AND LOCAL TAX RETURNS AND PAID ALL STATE AND LOCAL TAXES AS REQUIRED BY LAW (MGL CH. 62c Sec. 49A) NAME/TITLE OF APPLICANT DATE 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): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday —/o Tuesday -�/ 0 Thursday ®) 0 Friday ®) Sunday () Wednesday 9'/ 0 Saturday y/) 0 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 3 Handwashing sink Commercial Dishwasher 1 Domestic Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods with Automatic Cleaning System Exhaust Hoods without Automatic Cleaning System Floor drains Other: If exhaust hoods are without an automatic cleaning system, how are hoods cleaned? (i.e., in three (3) bay sink, off site): 6 Are there any storm drains near the unit? How often is this grease storage unit emptied? ®UIKRY-L V Please list the vendor who removes the waste: S'Ot/OL, Describe the location(s) in your facility where samples may be obtained after any grease removal processes but prior to any mixing with domestic sewerage: Outside Manhole o eIJ l AN GQ-7tVtA 7V Outlet Tee Inside Floor Drains Under sink Grease Traps 91 Other Describe liquid wastes, other than what is removed from any GRUB that are hauled away for disposal (such as recyclable oil, etc.): Type of Waste Waste Hauler Disposal Site u D(L wmr 6/tt)Os W -r Please attach the following documents to this application: • Menu of the foods prepared and served at the facility • 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) Any establishment that generates FOG and does not have FOG $50 containment In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowle hat t rmation submitted in these documents is true, accurateandcomplete. Signed Date Print Name M &Vu- d 6 ell e;YJ Is dinnerware pre -rinsed before being washed? N 1 tv Yes No If yes, at what station/sink? Any additional water using devices? If yes, how many: If yes, what type: Sanitary Fixtures (Total): Number of Lavatory Sinks Is Number of Toilets 3 Yes No Number of Urinals Does this, establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? v/ Yes No Size �5�� gallons Where is the existing outdoor GRU located? gEmo 8o , l wr Does this establishment have any indoor Grease Removal Units (GRU/trap)? J Yes No If yes, where are the existing indoor GRUB located? Location Size (gallons) Automatic/ Passive If a grease removal unit is utilized, how often is the grease removal unit cleaned? rat Outdoor: peryear Name of Hauler j Indoor: per year Name of Hauler Do you have external storage of grease waste? Yes Where is the grease storage unit located? Is the grease storage unit locked? How is the grease storage unit cleaned? How is the area around the unit cleaned? 3 4r