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HomeMy WebLinkAboutBig T's Jerky House Xfinity - 12/31/2021IEE tx - (3 10c; OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued I Mobile Food Establishment {MFE) Permit Application (Application must be submitted at least 14 business days before the planned opening date) 1) MFE Name: \ Z) ApphcanVOwnrer Nain43 Tdla: Applicant/Owner Address: � Applicant/Owner Telephone No: Applicant/Owner Email address: 7) Person In Charge of Onsite Operations & Tine: 4 �r -. PIC Address: r._ r� \q PIC Telephone No: Emergency/onsife Telephone No: PIC Email Address: 4) Location of Service: Date(s) if applicable: \ q\ a3 Event Name h applicable: Event Service Location: Event/ Service time: S) Length of Permit• 6) Solid waste disposal plan: Annuai rory Dales: � 1 ssoc- �J\ 7). Water Source: e) Sevatge disposal plan: o v.� Q S g) Food will bs prepared: t= Onsde for immediate consumption ED gMita and held at proper hol/ cold holding temperatures MOffsae and held at proper hot/ cold holding temperatures o OQsde, cooled and reheated on site EZI Other. 10) Please attach a menu or a webslh link to the menu or give a brief description of the food to be served �e C.�4t3ch� 11) It PHF is being served, please list the person who has completed the following bainings and attach appropriate ca"ificates: Food Safety Manager. Allergen Awareness: r Y c�'�'cT 11✓-%R' 12) Please describe on site hand washing facilities that will be utilized: (�A 13) Please list all sanitizing solutions that will be on site: 14) Do you have propane, fryolators andfor hoods on your truck? If yes, you must first be inspected and approved by the Mansfield Fire Department Phone number, 506-261-7321 Fire Department Signature of Approval: -15) N applicable, please describe your FOG management plan or attach the written plan: 16) Location of Bass of Operations or Commissary. Please attach copies of Base of Operations or Commissary Permit 17) Please list additio at communities where a food rt it is held: /\ 1, 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 0glpipVg0ies of 105 CMR0a)and the federal Food Code. 16)Signature Pursuant to MGL Ch. 624L' c. 49A,1 certify under the penalties of peijurytlmt 1, to my best knowledge and belief, have filed all slate tax returns and paid state taxes quiied underlaw. 19) Social Security Number or Federal ID. L. '` " ti 1 20) Signature of Individual or Coiparate Name:_ S 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 checkout bags to customers. 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. 75") 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. Ihave 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 Applicant Name (please print clearly) TAX CERTIFICATION FORM I certify under, the penalties of perjury that I, to mybest knowledge and belief, have filed all state tax returns and paid all state taxes required under, law. Signature Individual or CciForate Name By-. Corporate Officer (Mandatory, if Applicabie) (-�'A - LAl 4k4 a?)C)c� "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-.W=w 6WWa&"o Swa'r Doom ftWbod M bbl(duoxls-T"WAX MRTWr-AnON FOW&c The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations It Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization City/StateMp: Phone Are you an employer? Check the appropriate box: 1 ❑ I am a employer with employees (full and/ 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.] Print Form Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc_) & ❑ Non-profit 9. ❑ Entertainment lo.❑ Manufacturing t Ln Health Care ME] Other -Ay appli,*0 that checks box t1 must also fill nut the sectim below showing their worker' conilensmion policy information. **If the wont, officers have exempted thensetvss. but the corpontion has otter employees, a workers' cooyxosatim Policy is required and such no wganundon should check box el. L am art employer that is providing workers' compensation inmrrmct for my employees. Below is the policy information. Insurance Company Insurer's City/StatelZip: policy # or Self -ins. Lic. # 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 miler Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 that the information provided a{tove is trine and correct. o wial use m4. Do not write in this area, to be completed by city or town offxiaL City or Town: Permif/Liceuse Issuing Authority (circle one): 1. Board of Health 2. Budding Department 3 City/Town Clerk 4 Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone w O W V z Mai z va W z W P4 z W W �I LL N N .24 z b U q Q 0 N Owu I 0 R�4 tl V v � w w y j N N N 0 y 0 m O ".y hc1 � z 0 oo o0 ti N N N LV o N V O lE OM— C J 2> 2 0) 2 \ / 2 lu ° \ (D 4 / = M . m� \ \ 7 ■2 \ w § ( § OQ �2 / (D , tom+ § ± I , g m rn a)\ � z / // ƒ q ( / f - © N / z } CD \ k � t m S < ■ m § m ( ■ � 0 ® 2 70 4 \ \ k /) * - q 0 rA n F m = y \ \ 0. � ) i j ` ol \ Pla` - CL cr ® W \) ® m « \ k� 3 \� \ /k ; § c > e q \ \ \ k > ] c > � M. » > r @ % c m p z § / 2 L _ / j I (D § q > J , » ? z \ 0 \\ ^ ° � ~ = 7 \ Ln } > . ` 2 \ ! 3 ) 8 Big T's MENU Specialty Items Drums wrapped in Bacon 6 BBQ Sandwiches All sandwiches served on Brioche roll with kettle chips or Fries • BBQ felt Winning Pulled Pork topped w/ Coleslaw 10 • BBQ Carolina Chicken topped w/ Cheddar Cheese 10 • Texas Brisket topped with demi-glace and crispy onions 13 • Smoked Sausage topped with peppers and Onions 8 • BBQ Spare Ribs 10 BBQ Sundae Base Irish Stout Cheddar Mac n Cheese, Baked Beans and Cornbread or Country Rice Pick BBQ Meat • Pulled Pork and coleslaw 10 • Carolina Chicken and Cheddar 10 • Smoked Sausage 10 • BBQ Spare Ribs (2) 10 • Texas Brisket with Demi Glace and Crispy onions 13 • 3 way Combo 15 4 way Combo 18 Bourbon Beef Jerky 5 French Fries 3 and 5 Sides Kettle Chips, Cole Slaw, BBQ Beans, Country Rice, Cornbread, Mac n Cheese 3 Equipment List 2 Advantco Food Warmers Model W50-CKR Food Warming Cabinet R20- FD-WRM Artic Air Counter Top Locking Glass Beverage Cooler Model-BWC120SSLT All Food comes from Performance Food Group and is Prepared at Food Truck Commissary 5 Harrison St Worcester. MA. 12 Door Beverage Air Reach In Refrigerator stores Raw Proteins 12 door Beverage Air Reach In Refrigerator stores Ready to eat prepared food All Food is cooked in our Royalton and Alto Sham Ovens at commissary to 165 degrees then transported in warmers to Food truck... Vollrath 12065-3 Vending Cart Drop -in 3 Compartment Sink Central Model#: 913-BH1 Brand: Vollrath Mfg Part#: 12065-3 Model 913-BH1 Mfg Part #: 12066-3 12065-3 is available through Central Restaurant For additional product information, please talk with one of our helpful product consultants at 800.215.9293. Detailed information may also be available via the Adobe Acrobat Specs button above. Features: • Vending Cart Drop -In Sink • triple bowl • 12-1/8"W x 6-1/8"D x 5" deep • rectangular • self -rimming • no drainboard • heavy weight 22 gauge stainless steel • NSF • USA made Product ranks 16 out of 98 in Three Compartment Sinks. Vollrath 101-1-2 Drop -In Sink, one compartment, 10"W x 14" front -to -back x 10" deep compartment Product Description Drop -In Sink, one compartment, 10"W x 14" front -to -back x 10" deep compartment, self -rimming, 2" drain, (4) stud mounts with mounting brackets included, 20/304 stainless steel one-piece, drawn construction, 13"W x 17"D O.A., Made in USA NSF Dimensions are provided by manufacturer and are not guaranteed to be precise product dimensions Height -10.00 inches Width -13.00 inches Depth -17.00 inches Sub -category - Sink, Drop -In Compartment(S) - (1) Compartment Drainboards - Without Drainboards Bowl Width (Side - Side) - 10" Width Bowl Deep (Rim - Drain) - 10" Deep Bowl Depth (Front - Back) - 14" Depth HeatMax Commercial Food Pastry Warming Case Aluminum 16x16x24 Hot Box Cabinet Item Description Professionally hold your delicious food and keep it at the perfect temperature for people on the go. Strong, lightweight aluminum frame for mobility, or to have set up on a counter top for easy access. Each of these models are hand built in the USA! Features include: • UL Listed (E487458). • All Aluminum construction. • 13in of clearance through the front door • Temperature controlled single heating element • Single hinged aluminum door • Analog temperature thermometer • Light strong aluminum frame • 360 Watt Heating element • Only uses 3 amps of power • Only 20 pounds • Fully Insulated Front Door • 4 Shelves for plenty of storage • Spacing between shelves 3.75" • Also able to keep other foods such as pastries, sandwiches, or any other food items that requires 100-160 degrees. • 120 Volts AC • NSF Dimensions are as follows: • Clearance thru front doors: 13" • Interior Dimensions: 13" x 15.5" • External Dimensions: 16" x 16" x 24" • Number of Shelves: 4 Y U b0 Q J C N C � v E o a N O O m K 0 U L O O 0 G! L N N C a -p o L u N O C m r 3 a •3 s 0 o Y O C p _ � U O Lr) U U � L -p V O G1 W u 3 N Z v v 2 0 U Y C Q paq U a LL Q V N m p L O a+ N Name `Addy i§ Telephon Owner Person In vloiauons. marKea may pose an imminent health hazard and action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE: HEALTH - �❑ 2. Reporting of Diseases by Food Employee and.PlC , Q 3. Personnel with Infections Restricted / ERcltldacl - FOOD FROM. APPROVED SOURCE ~ ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags t Records /'Accuracy. of IngredientStatements ❑ 7. Conformance with Approved Procedures ./ HACCP Plans. - PROTECTION FROM CONTAMINATION ❑ 8, Separation / Segregation / Protection ❑ 9. FoodContactSurfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices y f items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non -critical (N) violations must be corrected Of Health,: ' c -f - 23. Management and Personnel (FC-2)(590.003) 24. Food and Food Protection (eC-3)(590.004) 25, Equipment and Utensils (FC-4)(590.005) 26. Water, Plumbing and Waste (�55cC 5)(590.006) 27, Physical Facility ir kC_W�(590.007) 28. Poisonous or Toxic Mate al' (Tc 7)(sso.00e) 29. Special Requirements (590.009) 30i Other ` - TJHE C_QMMONVV LTH OF MASSACHUSETTS _ OF ' - Board ot-Health 1 :STABLISHMENT INSPECTION REPORT Tel. t` f airr r"'� 1 Date j i -/`�`c1' ;1Vna of ooeralion(s1 Noe of Inspection ❑Routine ❑ Re -Inspection Previous Inspection: �I'"Food Service ❑ Retail ❑ Residential Kitchen LevAK- rary r 913rea,k-f-ast Date: re-operatlon Ea Suspect. Illness ❑ General Complaint. I Permit In on the narrative page(s) and a isk Factors (Red Iti?MS) Non•complfance wrfh: Ami�Choking Tobacco ulre immediate corrective 590,009 (E) ❑ 590.009 (F) 0 Local Law Allergen Awareness 590.009 (G); Q ❑ 12. Prevention of Contamination from HandsEl . 13,.. Handwash Facilities ........ PROTECTION FROM CHEMICALS ❑ 14, Approved Food or Color Additives, - El 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous.Foods) ❑ 16. Cooking Temperatures ❑ 17.. Reheating 18. Cooling ❑ 19. Hot and Cold Holding . - ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) .. - ❑ 21. Food and Food Preparation. for HSP CONSUMERADVISORY 22. Posting of Consumer Advisories Number ofViolated Provisions Related To Foadborne Illnesses Interventions and Risk Factors (Red items 1-22): EJ I inspection of 105 CMR` 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 aggrieved by this order, you have a right to a hearing,. Your request must be In writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE-iNSPECTIOM Inspector's Signaller ' e:/ - / „.'_, , . Prinh-- ._-.- -P.IC'sSignal ra. � Print - -'% , .�"v�;.�~_^ �'/ lG"r.' !';,'-. Page)of�Pages FORM 7e4A IREV 9120101 HOee5 8 Wq RREN - BOSTON Tnie Form Approved by the M=iachu.wtls Departmere of Public Heukh FOOD LIABILITY aOGRAME Gatta� c�yar ImuO CE tnoup 1svlAn .fli,mmmm.com 844.520-6992 Great American Alliance Insurance company Powered by Veracity Insurance 301 E. Fourth Street, 25 S S.h4bns, LLC Cinci amb, OR 452024201 COMMERCIAL GENERAL LIABILITY COVERAGE PART - OCCURRENCE FORM CERTIFICATE PAGE IT IS AGREED THAT THIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BELOW TO CERTIFY COVERAGE UNDER THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY LISTED BELOW. INSURANCE COMPANY: GREAT AMERICAN ALLIANCE INSURANCE COMPANY POLICY NUMBER: NAMED INSURED: BEAUTY HEALTH 8 TRADE ALLIANCE PL2664771 CERTIFICATE HOLDER: Scott Te(N, DBA Big T's Jerky House ADDRESS: 29 Albright Rd, Spring. Massachusetts 01664 CERTICERTI CERTIFICATE NUMBER: F090627 POLICY PERIOD: 05114/2020 to 05/1412021 last AM.Su„ae,dnmemmendd,e.setmecemswi. adder LIMITS OF INSURANCE General Aggregate Limit (Other than Products -Completed Operations) $ 2,000,000 Products -Completed Operations Aggregate Limit $ 2,000,000 Personal and Advertising Injury Limit $ 1,000,000 General Each Occurrence Limit $ 1,000,000 Damage to Premises Rented to You Limit $ 300,000 Any Ono Premises Medical Expense Limit $ 5,000 Any One Person Professional Coverage Extension $ Not Purchased Each Claim $ Not Purcommal Aggregate Professional Coverage Deductible $ Not Purchased Each Claim Liability Deductible None FORM OF BUSINESS: Sole Proprietor/Individual BHTA Fee: $ 76 TOTAL ANNUAL COST: $ 245 (The cost is 100 % earned/non refundable) CODE NUMBER: 11168 PREMIUM BASIS: Gross Sales EXPOSURE: Up to $50,000 BUSINESS DESCRIPTION: THIS INSURANCE IS SUBJECT TO ALL THE TERMS AND CONDITIONS, INCLUDING APPLICABLE ENDORSEMENTS, OF THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY. A COPY OF THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY ACCOMPANIES THIS CERTIFICATE. ADDITIONAL COPIES WILL BE PROVIDED TO THE CERTIFICATE HOLDER. PLEASE READ THE POLICY AND ALL ENDORSEMENTS. NO ADMISSION OF LIABILITY MAY BE MADE EITHER VERBALLY OR IN WRITING FULL DETAIL OF ANY INCIDENT SHOULD BE SENT IMMEDIATELY BY EMAIL TO CLAIM8 VOPINS COM OR BY LETTER TO VERACITY INSURANCE SOLUTIONS, LLC 260 SOUTH 2500 WEST SUITE 303 PLEASANT GROVE UT 84062 FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on the attached Forms and Endorsements Schedule IL 88 01 (11/85). ADMINISTRATED BY 1 Veracity Insurance Solutions, LLC 260 Seem 25M West Suite 303 Pleasant Grove Utah U062 888568-0548 info®0iormmm wm ADMINISTRATOR'S SIGNATURE:4 f