HomeMy WebLinkAboutLaced Edges Pizza - 12/31/2021FOOD ESTABLISHMENT PLAN REVIEW APPLICA
(Application must be submitted at least 30 days before the planned opening date with $
�7
og
Review Fee)
Establishment Name: 6G;rn4- e4"i ®i 2z
Establishment Address: A72 A /I lediflnnSAC/16�
Establishment Mailing Address (if different):
Establishment Telephone No:
Applicant Name & Title: ,r f f S�� Si e/'"
ry�h I
Applicant Address:t'l �✓53'-�°fatns��l� o�G�%�y
Applicant Telephone No.: " 7Gj-066`7) 24 Hour Emergency No.: -5—or> 4
Applicant Email: 4"A
Owner Name & Title (If differe4t 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
ACorporation
partner. Z
NamertJ) uvhyTitle A +np� Address 4/7 &.�1-6,1fye
An Individual
..?p
/
A Partnership
TT
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: / f' V' , rvl ��nt/q_
Address:
v,e)4- 5"Iygeld'
tG.I
Telephone No: 5-6-b y6 ? 24 Hour Emergency No: Gg `fFs ?
J
FAX:
E-mail: C%try�y �7�fI7 �v 4,/31n, ( G0-n
Alt E-Mail: ✓
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply wN 105 CMR 590.000 and all other applicable law. I have been instructed by
the Board of Health on how to obtairyEdpies of 105 VMR?590.000 and the federal Food Code.
Signature of Applicant:
151
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.
n 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.
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.
u 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.
u 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.
Fj Ventilation.
I agree 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 106 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.
Canoe Rover
Snack
Prices include Mass
meals tax
Ice Cream:
small cone 2.25
sundae sm. 2.75
lg. 3.50
large cone 2.75
slush sm. 1.00
lg. 1.50
Kiddie cone 1.25
shake 3.50
Frozen Yogurt:
small cone 2.50
large cone 3.25
Sandwiches:
Hamburger 3.25
Sausage wlpeppers & onions
5.75
Cheeseburger 3.50
Hot Dog
2.50
Double Cheeseburger 5.75
Hot Dog w/chili
2.75
Steak & Cheese 5.75
Grilled Ham & Cheese
2.75
Grilled Chicken 5.50
Grilled Cheese
1.75
Snacks: Drinks:
Fries 2.50
Coffee & Tea sm.
1.00
Cheese Fries 3.25
lg.
1.50
Onion Rings 3.50
Iced Coffee 16 oz.
1.75
Nachos & Cheese 2.25
Milk
.85
Mozzarella Sticks 5.50
Juice
.95
y`
Chicken Nuggets 3.50
Hot Chocolate
1.25
Mae & Cheese 1.50
Ice Water
.75
Chicken Wings 5.75
Breakfast:
English Muffin with egg, cheese, & ham
3.50 Ham / Sausage
1.50
2 Eggs, toast, ham or sausage, coffee
5.25 Muffin
1.50
English Muffin with egg & cheese
2.75 English Muffin
1.25
1 Egg and toast
2.50 Bagel
1.50
2 Eggs and toast
3.50 w/er.cheese
1.75
Waffle Sticks w/syrup
2.75 Toast (2 slices)
A
Hash Browns
1.50 Fruit Cup
Pizza and Pried Dough served on Friday & Saturday starting at 7 PM during Summer Season
Please inform your server ifyou or anyone in your party has afood allergy.
0
wl�do�
Im
UPDATED FOOD ESTABLISHMENT PERMIT CONTACT IN
(Health Department should be notified within 10 business days of change in management (llacttworr ation)
ilk(
Establishment Name: 6LC pct r—d cie
Establishment Address
Establishment Mailing Address (if different): eye(
Establishment Telephone No: 5-6<--s1'5--*
Applicant Name & Title: Aj x_k f r,egrCJYit e,
Applicant Address: 0% "- 5fza te r445A'AW
Applicant Telephone No.: '� o'er�'?j '�) 24 Hour Emergency No.: 5��)
Applicant Email: A`an e
y
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.
O A Corporation
Name Title Address
4&'V'�'___
O An Individual
_ to ram'-7er
J5"A' Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: Aec."' y�zn/' �I C�.JW.4e
�/�
Address: ! Iti�7� s'//!L9 A-5 ev /"?,q
Telephone No: t'ryc� �Gi� , 7 I 24 Hour Emergency No:
/
FAX: G
E-mail: cv�/cn ��o� 5 m� • C�r�
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
yco'
V"\CvWA-`j
FOR BOARD OF HEALTH USE ONLY
Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name /j vi J I
Establishment Address 13 -7 ` 44-e, - /14A oaf oCi�
Establishment Mailing Address (if different) Clod Va5'� �r,-ee
/�j
Establishment Telephone No �-05 - -
Applicant Name & Title: v c ""I 1 ' �^ er 0 6�4''
4101 L�✓r?�' S fi c< 1044 -,-7/AC4 ads y�f
Applicant Address
Applicant Telephone No.: 5-6$ -41G 7 -0672 24 Hour Emergency No.:
Applicant Email
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
O An Association
partner.
El A Corporation
Na ee^ .��G� T'Ge Address /� /'
n@� �j 7` ly�ie�t/'�'
11 An Individual
C*rA Partnership
3
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 4 ell, M f / icr �7 V 44o ev--� "
-7 2ee4 I AA 4'e—q A� d�
Address: qel Ive,�,/J-
Telephone No: ���T-� 7) 24 Hour Emergency No:
FAX:
E-mail: !� �G�¢r®�G% �i�M"i �•Go�
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title: 662.1 7 qj u 5
/� 1
Address: e /7-, � 1 L,,, Vle ! c�'Th
Telephone No: � � �� - SC75-24 Hour Emergency No:
FAX:
E-mail:
IV6
Food Establishment Information
WATER SOURCE:
E DISPOSAL:
PNo.
ood Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training
Air- AtAleP
.01
—"
r_l
Name of pest control company routinely inspecting the premises for evidence of pests �
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. El Yes
Does this establishment require a FOG permit? y<� If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
❑ Retail Food $125.00
❑ Mobile Food Concession
Temporary
Rfood Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
i❑ Food Service up to 201 + $300.00
❑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 (fimeAemperature controls required)
apply): Non-PHFs -non-potentially hazardous food(no time/tempereture controls required)
(Check all that pp y): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no /udherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs [4115rHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs [g-Preparation of PHFs For Hot And
for More Than a Single Meal Service
�/ Cold Holding For Single Meal Service
Delivery of Packaged PHFs
❑ PHF and RTE Foods Prepared For Highly
Facility
Sale of Raw Animal Foods Intended
Susceptible Population
Reheating of Commercially to be Prepared by Consumer
❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
and/or HACCP Plan (including bare hand
(] Customer Self -Service of Non PHF and Non -
contact alternative, time as a public health
Perishable Foods Only E] Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
Offers Raw Or Undercooked Food Of
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 co*s of 105 CNJR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all stale tax returns
and paid state taxes required under law. �.
Social Security Number or Federal ID: 0 34- Q—/ 5 3L/
Signature of Individual or Corporate Name: (,� VV
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.
of Individual or Corporate Name orporate Officer (Mandatonj, if Applicable)
0-3/- 6�, qs
**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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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.
�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.
hj�_l 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.
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)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
y' Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
1.❑ I am a employer with employees (full and/ 5. ❑ Retail
-part-time).* 6. EKestaurant/Bar/Eating Establishment
2.1 V1 I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.E] Manufacturing
no employees. [No workers' comp. insurance required]*
4.R We are a non-profit organization, staffed by volunteers, I LE] Health Care
with no employees. [No workers' comp. insurance req.] 12.E] Other
*Any applicant that checks box #1 must also fill out the sectiou 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 41.
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. 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 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, Wer the pains and penalties ofperjury that the information provided above is true and correct
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 Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
f j 2z-1-
Address: 132 1h l sl/Bet Ak d 2,0 qV.
Mailing
ro
e�-
Phone/Fax Number: SU?— lz5S"
Email: e,_
/. c e";-1
Contact Person/Title for Grease Traps: !&1' �1/ i
Name of Company scheduled to pump internal grease trap(s) monthly:11iCL�jnL
Name of Company scheduled to pump external grease trap quarterly:
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 acknowledges that the information submitted in these documents is true, accurate and complete.
le
Signed Date
Print Name t^00/ 'c`ne,i
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
Thursday a �i
Sunday /
u
Tuesday r
Friday �� % /
Wednesday
Saturday
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
t
3 compartment sink
14)d
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
/�M
/U
Ice Making Machines
D
Fryolators
0
Grills or Ovens
Exhaust Hoods
/
t V V
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed?
If yes, at what station/sink?
Yes
No
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to each grease trap
Grease Trap 1
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)?
Yes No Size gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owners Name: _
Property Owners Address:
Property Owners Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?.
How often is this grease storage unit emptied?
Please list the vendor who removes the waste:
3
FOOD ESTABLISHMENT PLAN REVIEW APPLICA
(Application must be submitted at least 30 days before the planned opening date with $
�7
og
Review Fee)
Establishment Name: 6G;rn4- e4"i ®i 2z
Establishment Address: A72 A /I lediflnnSAC/16�
Establishment Mailing Address (if different):
Establishment Telephone No:
Applicant Name & Title: ,r f f S�� Si e/'"
ry�h I
Applicant Address:t'l �✓53'-�°fatns��l� o�G�%�y
Applicant Telephone No.: " 7Gj-066`7) 24 Hour Emergency No.: -5—or> 4
Applicant Email: 4"A
Owner Name & Title (If differe4t 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
ACorporation
partner. Z
NamertJ) uvhyTitle A +np� Address 4/7 &.�1-6,1fye
An Individual
..?p
/
A Partnership
TT
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: / f' V' , rvl ��nt/q_
Address:
v,e)4- 5"Iygeld'
tG.I
Telephone No: 5-6-b y6 ? 24 Hour Emergency No: Gg `fFs ?
J
FAX:
E-mail: C%try�y �7�fI7 �v 4,/31n, ( G0-n
Alt E-Mail: ✓
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply wN 105 CMR 590.000 and all other applicable law. I have been instructed by
the Board of Health on how to obtairyEdpies of 105 VMR?590.000 and the federal Food Code.
Signature of Applicant:
151
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.
n 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.
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.
u 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.
u 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.
Fj Ventilation.
I agree 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 106 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.
Canoe Rover
Snack
Prices include Mass
meals tax
Ice Cream:
small cone 2.25
sundae sm. 2.75
lg. 3.50
large cone 2.75
slush sm. 1.00
lg. 1.50
Kiddie cone 1.25
shake 3.50
Frozen Yogurt:
small cone 2.50
large cone 3.25
Sandwiches:
Hamburger 3.25
Sausage wlpeppers & onions
5.75
Cheeseburger 3.50
Hot Dog
2.50
Double Cheeseburger 5.75
Hot Dog w/chili
2.75
Steak & Cheese 5.75
Grilled Ham & Cheese
2.75
Grilled Chicken 5.50
Grilled Cheese
1.75
Snacks: Drinks:
Fries 2.50
Coffee & Tea sm.
1.00
Cheese Fries 3.25
lg.
1.50
Onion Rings 3.50
Iced Coffee 16 oz.
1.75
Nachos & Cheese 2.25
Milk
.85
Mozzarella Sticks 5.50
Juice
.95
y`
Chicken Nuggets 3.50
Hot Chocolate
1.25
Mae & Cheese 1.50
Ice Water
.75
Chicken Wings 5.75
Breakfast:
English Muffin with egg, cheese, & ham
3.50 Ham / Sausage
1.50
2 Eggs, toast, ham or sausage, coffee
5.25 Muffin
1.50
English Muffin with egg & cheese
2.75 English Muffin
1.25
1 Egg and toast
2.50 Bagel
1.50
2 Eggs and toast
3.50 w/er.cheese
1.75
Waffle Sticks w/syrup
2.75 Toast (2 slices)
A
Hash Browns
1.50 Fruit Cup
Pizza and Pried Dough served on Friday & Saturday starting at 7 PM during Summer Season
Please inform your server ifyou or anyone in your party has afood allergy.
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