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HomeMy WebLinkAboutReservoir Hotel Fairield Inn -12/31/2021#-/000 35.-� IF FOR BOARD OF HEALTH USE ONLY Permit# FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name Reservoir Hotel Partners, LLC D/B/A Fairfield Inn & Suites Establishment Address 50 Reservoir Street, Mansfield, MA 02048 Establishment Mailing Address (if different) P O Box 248, Westport, MA 02790 Establishment Telephone No 508-452-0700 Applicant Name & Title: Sean Lafrance Applicant Address 36 Aimes Way, Westport, MA 02790 Applicant Telephone No.: 508-676-7888 24 Hour Emergency No.: 508-294-7097 Applicant Email sean@lafrancehospitality.com Owner Name & Title (If different from applicant) Richard Lafrance Owner Address 1436 Drift Road, Westport, MA 02790 Owner telephone number 508-676-7888 Owner email: richard@lafrancehospitality.com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. Ed A Corporation Name Title Address O An Individual Richard Lafrance LLC Manager/Owner 1436 Drift Road, Westport, MA 02790 Marco Crugnale Owner 10 Kals Way, Mansfield, MA 02048 IN A Partnership 0 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Sean Lafrance Address: 36 Aimes Way, Westport, MA 02790 Telephone No: 508-676-7888 24 Hour Emergency No: 508-294-7097 FAX:508-250-0647 E-mail: sean@lafrancehospitality.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Michael Dougherty Address: Telephone No: 508-676-7888 24 Hour Emergency No: 973-600-5423 FAX: E-mail: mdougherty@lafrancehospitality.com Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (If applicable) No. of Food Employees: 5 DAYS/HOURS: Breakfast 6am-10am Bar 5pm-12am 7 days per week Name of Person(s) In Charge Certified in Food Protection Management: Michael Dougherty Angela Melanson Name of Person(s) In Charge Certified in Allergen Awareness Training Michael Dougherty Angela Melanson Name of pest control company routinely inspecting the premises for evidence of pests Ecolab 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. ?7 Yes Does this establishment require a FOG permit? Yes If yes, please attach the FOG permit application. Length of Permit: Establishment Type: K Annual ❑I Retail Food $126.00 ❑ Mobile Food Concession J Temporary(] Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 � Manufacture Frozen Desserts/Ice Cream Temporary Start Date: 0 Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 E] Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions. PHF - Potentially hazardous food(fime/temperature controls required) (Check all that apply): Non-PHFs- non-potenfially hazardous/oodfno time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Xi 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 I[ Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer [] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours EX] Customer Self and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- -Service public health contact alternative, time as a P Perishable Foods Only [ Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale ❑j Offers Raw Or Undercooked Food Of X❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale [] Vacuum Packaging / Cook Chill Offers RTE PHF in Bulk Quantities 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 applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 5QO,009 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns 9q -a`/U0o7 t; 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. ture of Individual or Corporate Name 84-3716007 *"Social Security No. (Voluntanj) or Federal Identification Number Jeffrey P. Pineault By: Corporate Officer (Mandatory, 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. C:\Osers\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORNI.doc 17 The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Reservoir Hotel Partners, LLC 50 Reservoir Street City/State/Zip: Mansfield, MA 02048 Phone #: Are you an employer? Check the appropriate box: 1. Q I am a employer with 30 employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.Q Health Care 12.❑✓ Other Ho IC *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 91. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lie. # 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 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 unde t pains and er:a 'es ofperjuiy tlzat the information provided above is rue and correct. Signature: l // i� � �e q a G'� bate. A / �� `,.f3 � / ... 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Reservoir Hotel Partners, LLC D/B/A Fairfield Inn & Suites Address: SO Reservoir Street, Mansfield, MA 02048 Mailing Address: PO Box 248, Westport, MA 02790 Phone/Fax Number: phone 508-676-7888/fax 508-250-0647 , iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillillillillilillillillillillillillillilliillillilillillillilI Contact Person/Title for Grease Traps: Sean Lafrance Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: I 'M� 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 acknowledggs that the information submitted in these documents is true, accurate and complete. Date 3/29/2021 Print 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): 98 Seating Capacity (Actual Count): 70 Normal Hours of Food Preparation/Service: Monday 5am-10am/5pm-12am Thursday 5am-10am/5pm-12am Sunday 5am-10am/5pm-12am Tuesday 5am-10am/5pm-12am Wednesday 5am-10am/5pm-12am Friday 5am-10am/5pm-12am Saturday 5am-10am/5pm-12am 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 Yes 3 compartment sink 1 Yes Handwashing sink 1 Yes Commercial Dishwasher 1 Yes Bar sink 1 Yes Mop Sink 1 Yes Garbage Disposal 1 Yes Ice Making Machines 0 No Fryolators 1 Yes, oven Grills or Ovens 0 No Exhaust Hoods g Yes Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): n/a Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? at the dishwasher x Yes No i] Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 1 Please list fixtures attached to each grease trap Grease Trap 1 1 food prep sink, 1 (3-bay) warewashing sink, 1 hardwashing sink, 1 dishwash Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? x Yes No Size 4,000 gallons Where is the existing outdoor GRU located? under front parking lot If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: Marco Crugnale Property Owner's Address: 163 Rumford Ave, Mansfield, MA 02048 Property Owner's Telephone Number: 508-958-0139 Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit How often is this grease storage unit em Please list the vendor who removes the 3 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. SL. L 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. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. _5,VL I 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. >k L 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 Signature Applicant Name (please print clearly) 3/29/2021 s � b § 1za I I I RESEHOT-01 LMENC CERTIFICATE OF LIABILITY INSURANCE DgTE(MMIDD YYYI 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(ies) 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 riahts to the certificate holder in lieu of such endorseRlenf/Rl_ PRODUCER n vovova HUB International New England 222 Milliken Boulevard Fall River, MA 02721 INSURED Reservoir Hotel Partners LLC c/o Lafrance Bros. P.O. Box 248 Westport, MA 02790 COVERAGES CFRTIFICATF KI IMRFR- DCV10in Nl rdl IssDDD. 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 CONTRACTOR 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 CED BY PAID CLAIMS. INSR - ___ ___ TYPE OF INSU �ADOL SUER - LTR INSURANCE ,INSD Me POLICY NUMBER MMIDDlYYYY MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY — EACH OCCURRENCE S 2,000,000 1 CLAIMS -MADE X OCCUR X CP00926814 6123/2021 12/3112021' DAMAGETORENTED 4 PREMISES LEa omunencel ! $ 1,000,000 ` MEDEXP�A_nyone person) S 10,000 - JII INJURY _ S ,000,000 NLAGGREGATE LIMIT APPLIES PER POLICY PRO LOC GENERAL AGGREGATE 4 y5 ,000,000 4,000,000 JECT _I OTHER; PRODUCTS COMP/OP AGO Liquor Liab. $ s 1,000,000 AUTOMOBILE --1 LIABILITY ! COMBINED SINGLE LIMIT '!(Ea eccdentl $ ANY AUTO BODILY INJURY (Perpersonj ($ _I OWNED SCHEDULED _ iII AIUIRRTEEO��S ONLY AUTOS BOODILY INJURY (Per amdenn`LI$ I _AUTOS pp ONLY A�OS Of�LY (�e1aacantj AMAGE -- 15 I$ UMBRELLA LIAB OCCUR ��EACH OCCURRENCE 1EXC5 ESS LI I.CLAIMS MADE (_AGGREGATE S DEDRETENTIONS _ - _'', 5 A WORKERS COMPENSATION PER OTH AND EMPLOYERS' LIABILITY YINC0770372 ANY PROPRIETOR/PARTNER/EXECUTIVE - 6/23/2021 12/37/2021 STATUTE ER E L EACH ACCIDENT F $ 1,000,000 OFFFICER/ryEMBE1 EXCLUDED? o in NH NIA I _ (Nand. IIfgs, describe under �E L DISEASE _EA EMPLOYEE( $ 1,000,000 —, _ _.. -- 1,000,000 T. ESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT I B Cyber/Privacy/Networ V2F518210101 6/23/2021 112/31/2021 Cyber 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, me be attached if more space Is required) RE: Reservoir Hotel Partners LLC (Fairfield Inn & Suites) Mansfield 50 Reservoir St. �ansfield MA 02048 Marriott International, Inc. & its affiliates and subsidiaries are an additional insuredlGrantor on a Primary Non-contributory basis, on the general liability policy as respects to operations of the named insured when required by executed contract prior to the loss/claim. A 30-day notice of cancellation applies. Marriott International Inc. 10400 Ferwood Rd. Attn: Law Dept. 521923.27 Bethesda, MD 20817 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUUKU m tzul b/Us) ©1988-2015 ACORD CORPORATION. All rights reserved. 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