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HomeMy WebLinkAboutMansfield Station Convenience, Inc. - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATIO (Application must be submitted at least 30 days before the planned �eP 2 date) Establishment Name Mar4eA3 12Na-oy\ C6(\&y-,ke_Y\ce ZT\L Establishment Address e214 RtkMS ciRc� \j erUe_ tWr�vr C' �c5 MA O DU (.y% Establishment Mailing Address (if different) Establishment Telephone No 6t] R1q_3%G Applicant Name & Title: �(nrY1E M. ' TL C 0 tU�� Applicant Address l-j \,�'J' Qc{� JJA ©o2 �iry Applicant Telephone No.: CIj qi>$- 3_QAG 24 Hour Emergency No.: Applicant Email Iioro 0gz(,e e�Ac7li- Co41 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 RM An Association partner. ® A Corporation ®An Individual Name Title �Adndre'sts �YY�i�I 4��'li�F cm)VHCR_ _! HLWe. Qj ooaak) Rm A Partnership ❑O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: �M'kA \ t• ra i , raaOu)�P � Address: �—j Zp,\e, R3 Oc(2_T7Yy q- 0&ja Telephone No: 22A,�1 24 Hour Emergency No: FAX: E-mail: I ion oal3/ a�� Cor" Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Maoe'M- lUn (' SEWAGE DISPOSAL: JC) w P No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: AMii,'IG I,�f1T i Name of Person(s) In Charge Certified in Allergen Awareness Training �MIAIC �R41ARt /� rft� 0 5 ✓ t lw�_ 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. ® Yes Does this establishment require a FOG permit?0U If yes, please attach the FOG permit application. Length of Permit: Establishment Type: I'M Annual 9 Retail Food $125.00 ItU Mobile Food Consession ❑M Temporary Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00. FOOD TRUCKS $175.00 4&0dafiufacture Frozen Desserts/Ice Cream Temporary Start Date: --�6 fRI Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ❑Q Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: ® Supermarkets $400 IN Residential Kitchen $100.00 Rain Date: W Milk &Cream $10.00 ] Caterer $35.00 Food Operations: Definifions:PHF- Potentially hazardous food(Nme4emperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous(ood(no fime/lempemture controls required) RTE - ready-m-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs R PHFCooked To Order ® Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot And for More Than a Single Meal Service Gg Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑51 PHF and RTE Foods Prepared For Highly Frol Sale of Raw Animal Foods Intended Susceptible Population Facility ❑tD Reheating of Commercially to be Prepared by Consumer Q Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours FNJ Customer Self -Service and/or HACCP Plan (including bare hand Q Customer Sell -Service of Non PHF and Non- contact alternative, time as a public health P Perishable Foods Only BE Ice Manufactured and Packaged for control) tD Preparation of Non-PHFs Retail Sale Juice Manufactured and Packaged for ®Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations Retail Sale Q Vacuum Packaging /Cook Chill Q Offers RTE PHF in Bulk Quantities ® Prepares Food/Single Meals for [j] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the establishment operation will cc� ealth board of hon how to otl(�i! Signature of Applicant: (- Pursuant to MGL Ch.62C, ,1 ce and paid state taxes required under law. of the information provided in this application and affirm that the food 105 CMR 590.000 and all other applicable law. I have been instructed by the ,f 105 CMR 590.000 and the federal Food Code. under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: O /" a53oib 7q _ Signature of Individual or Corporate Name: 1 ILiYL ��Ca 5�m'V CC7Y�J[%(1.\Q nce -i Y1 C 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. Han6F AJ ella, wexiiewine Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number Am,ne k�-1aelCak By: Corporate Officer (Mandatonj, 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\Users\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u,p www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: L" r3Y1�r�icl �la'61� lgYtA(e�liettie r3ne_ Address: City/State/Zip: t'64Vi�A-A HA agoO Phone#: 6'j Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ® Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7.❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 I .❑ Health Care 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other, *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 #I. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie, Expiration 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 e. 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 ceffy> n - pains and penalties of perjury that the information provided above is true and correct. Phone #: co,g q 74 — 3au, 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 Person: Phone #: www.mass.gov/dia 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. 4--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. ii�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. —0--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 II °r�- ii Date: q-'Q;� - Applicant Name (please print clearly) Am i oy M . Lao_\c� o5 • FOR SERVICE CALL: LOCATION#: SG MS NA 888-BLUE-BUG BIG BLUE BUG OFFICE OFFICE USE ONLY PEST CONTROL SERVICE AGREEMENT This agreement authorizes Big Blue Bug Solutions to provide Regular Pest Control Service at this premise: . SERVICE TO BE PERFORMED NAME: STREET: CITY: V)qnS , .A STA-T 7 N' zlPy� 1 0 SERVICE CONTACT: PHONE: PROPOSAL DATE:BIG BLUE BUG REP: Present pest problem(s) to be INFORMATION NAME: STREET: CITY: STATE: ZIP: BILLING CONTACT: PHONE: iL— THIS AGREEMENT by and between the two parties indicated above and hereinafter referred to as "CUSTOMER" (the buyer) and "CONTRACTOR" (the seller). The CONTRACTOR agrees to furnish Pest Control Service for a period of ) a-- months from the date of this agreement under the following terms and conditions: / THE PESTS SPECIFICALLY COVERED BY THIS PLAN ARE (check box): Cockroaches, Silverfish, Carpet Beetles, Food Infesting Insects, Mice, Rats, Bees' Nests, ❑ Only: Spiders, Earwigs, Millipedes, Centipedes, Ground Beetles, and Ants (Except Carpenter Ants). ❑ Also covered for: SERVICE SCHEDULED FOR: DATE: 1I/30 TIME: -3P,- TE( EXTRA FOLLOW-UP NEEDED: Y -�N;nn WHEN: DUF SUPERVISORY INSPECTIONS NEEDED: Y FREQUENCY: TYPE OF STRUCTURE L er-t e AREA(S) OF SERVICE: a /I SPECIAL INSTRUCTIONS: Sr M # OF CUSTOMER AGREES to pay $ � a— )' for the initial clean out service plus $!' for the equipment. Regular service will be performed after the initial clean out service with a frequency of: service(s) every y'no>, %' � at a cost of $ per service. (State Tax included where applicable.) , .T REGULAR SERVICE INFO: SERVICE CODE: CALL RECEIPT: Y N PEST LOG: Y N _ COD:,-N AMT.J EST. SER. TIME: I FREQ.: �1'1cr�y 11y BEST DAYTIME FC/R SERVICE: EQUIPMENT PRODUCTS REQUIRED: ;1Y) N TAX EQUIPMENT TOTAL SERVICE GUARANTEE - The Contractor agrees to keep the treated buliding(s) or location specified herein, free SERVICE RENEWAL -At the end of the herein specked service of insect and/or rodent pests listed above for the term of this agreement. No extra charge will be made for re- guarantee period, this agreement automatically renews itself for a like servicing during guarantee period, during normal business hours, unless Customer is deemed to be at fault by period under the same terms and conditions. Either party may cancel this Contractor. Customer agrees to make premises available to Contractor so that service can be performed, agreement by giving written notice 30 days before any expiration date. Big Blue Bug Solutions cannot assume liability for any damage caused by insects and/or rodents. 8.0110 The client agrees to pay all Invoices as Results of service are relative to and dependent upon cooperation given by the Customer as to housekeeping, sanitation conditions, stipulated in this agreement, and to maintenance, and accessibility of areas to be serviced and extent of preparation. The Customer agrees to cooperate with Big Blue assume reasonable attorney fees and Bug Solutions In whatever reasonable manner necessary to facilitate treatment and control. Big Blue Bug Solutions reserves the right court costs which may be necessary to to re-enter Customer's property and remove from same all of Big Blue Bug Solutions' equipment including bail stations, traps, and collect fees due the Company. etc., upon termination of this agreement. MEMBER Big Blue Bug Solutions reserves the right to after or amend this agreement if it is not accepted within 30 days. >'� < NATIONAL Any pests not covered by this plan can be treated for an additional fee. PEST i MANAGEMENT TERMS: NET CASH UPON COMPLETION OF WORK UNLESS CREDIT ARRANGEMENTS HAVE BEEN AGREED UPON. I ASSOCIATION me A finance charge of 1.5 % per month (an annual percentage rate of 18%) will be computed an the entire past -due balance after 3) days. Should an account become 90 days delinquent, service will be stopped or be rendered on a cash basis only until the past -due balance is naught current. ACCEPTED BY (print): SIGNATURE: DATE: WHITE -(OFFICE) YELLOW (SIGN AND RETURN TO BIG BLUE BUG SOLUTIONS) PINK - (CUSTOMER) BBB-5 MANSFIELD STATION CONVENIENCE,Inc age -restricted products policy and procedures:tobacco location Every employee at this location has the legal and mormal responsibility to control the sale and distribution of age restricted items to ensure there items do not get sold to a minor. tobacco product sales policy.. Objective: that all store employee follow all laws and procedures of this policy related to the sale of tobacco products including cigarettes,smokless tobacco,loose tobacco, pipe tobacco,rolling papes, cigars,e-cirarettes,vape and lighters. The minimum age to purchase tobacco products is twenty one (21) Procedures: 1:this policy will reviewed with all employees before they can operate a cash register and sell tobacco products. 2:all store employees to take a computer bases traing and seccessfully pass with 100% prior to starting on the register.This certification to be updated on a annual basis prior to previous year expiration. 3:a valid form of indentification will be required for all tobacco purchases regardless of age of frequency of customer visits. Acceptable forms of ID are as follows : Valid Massachusetts license valid massachusetts id valid US passport valid outof state license No expired identification will be accepted. photos must be visually matched to the customer purchasing and licenses scanned into the register. Driver's license is to be scanned into the registersystem.All other identification from the acceptable list will require manual entry of the date of birth listed on the document. 4: If it is suspected that someone is purchaising tabacco from