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HomeMy WebLinkAboutMansfield Farms Fresh Market - 12/31/2021Ili ✓ FOR BOARD OF HEALTH USE ONLY Permit # Issued I I FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name /y%l�il/S`/LZ/% rii eiirf �l2�ii //IfI12�CG� Establishment Address Fj�L�� NCJ_ ��/✓LS Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title44LA' 7j ` v! WLL5'Applicant Address /S"V(A/r-A-&-L - r,, M `J4/kk�_ Applicant Telephone No.: 7B/- %67.- W K 6 24 Hour Emergency No,: Applicant Email &3 C/?U O ,t- e 67W47C eCAA- Owner Name & Title (If different from applicant) M /{'its 2A-t�� - vc C v19uw If Owner Address Lzm S T. Ij2rfMSF7 C� rJ� �� Owner telephone number Tel- 706 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 Name !Title Address V/w7 lh WoL 11 An Individual w u halt,,Ylr77 ipt+�t !S M AKk 1?A2% Y1L� ISzt3�Df+f 1 5-r. MA-JSHt;-t# APartnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �016enT-o CRU yn(A t'0_— Address: Telephone No: /� {1t Lf� 24 Hour Emergency No: %6r-76% • b066 U FAX: ✓ tr'✓ E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name&Title: ,N)iLV 1�1r- Address: Telephone No: 24 Hour Emergency No: 7 6 i . 74 , F-6 0 FAX: E-mail: Q,j(ee rA Food Establishment Information WATER SOURCE: SEWAGEDISPOSAL: DEP Public Water Supply No: (If applicable) �— No. of Food Employees: y S DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: 0 " Aw Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests��V4.V If there is seating for 25 people or more, a pe son trained in manual choke saving procedures will be onsl a at all times food is being prepared. I] Yes AIM Does this establishment require a FOG permit? At If yes, please attach the FOG permit application. Length of Permit: Estabishment Type: ( Annual .: Retail Food $125.00 El Mobile Food Consession El Temporary L] Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream Temporary Start Date: [f 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: 0 Supermarkets $400 [] Residential Kitchen $100.00 Rain Date: pe Milk 6 Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(fimeAempemfure controls required) (Check all that apply): Non-PHFs- non-pofentiallyhazardous food(no thaultemperature controls required) RTE - ready-toeat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) �// L�j 5 e of Commercially Pre -Packaged Non-PHFs ❑ 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 Deliveryof Packaged PHFs Cold Holding For Single Meal Service 9 " ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ale of Raw Animal Foods Intended [] Reheating of Commercially to be Prepared by Consumer L] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self and/or HACCP Plan (including bare hand -Service E] Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ❑Ice Manufactured and Packaged for control) Retail Sale Preparation of Non-PHFs L 3 Offers Raw Or Undercooked Food Of E] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Q Vacuum Packaging !Cook Chill Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for EJ 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 690.000 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 state tax returns and paid slate taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name:LC-- 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. Signatu e of Individual or Corporate Name -e,6 -22-75-1`/ 3 *"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\Deskiop\Scott's Docments\rood 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 Wast eduction No retail a ablishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to stomers. 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 alternate es. Compost able materials must meet ASTM (American Society of the International Association for Te ing and Materials) Standards for compostability. 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 conjun ion 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. V _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 irnflnes. Applicant Applicant Name (please print clearly) The (tintrnotnvenith of Maesltettn5etln' Deporltrte,M of lndnstrud Aecittents Office i4'Investigotiotn.s _ 600 Wnshinbhlott ,Street Boston, MA 02/II ngvrv.nntss.gavkjja Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Andress_ 6 5 l (x)oYb- -Phone Are you an employer? Check the appropriate box: I,n 1 am a employer with employees (full any or part-time).* 219 1 an a sole proprietor Or partnership and have no employees working for me in any capacity. No workers' comp, insurance required( 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), mid we have no employees. INo workers' comp. insurance required(' d.Q We are a no"nifit organization, staitcd by volunteers; with no employees. INo workers' comp, insurance real Buxinesx Type (required): 5. 0 Retail 6. QRcslanranUBar/EafingEstablishment 7. ❑ Office a iVor Sales (incl, real estate, auto, etc.) 8. nNomprofif % ❑Eutcnainmout ioQManufacturing I I E] Health Care 120 Outer *:1ny appticmt atat dweks box AI mart alsoas out tiro saxiun below showing tharwurk+as' eompemalinn polity inftmmtfon. "IMC co" ' unieem have exempted flx Ives, but the eorporotim has othe,employees, a.., e,' c.pa. poney is raquimd attd wch mr orgoniration Aould click box kl. I am an employer that iv providrrr narkerr' Taypmsar un iresamnce jor my empitTeer. Ba"v is the policy injornuilion. Insurance Company �h-e'..r♦' Insurer's Address: IS J �+� In ... S a A 1. w. City/Slale/Zip: Policy # or Self -ins. Lic. #_ -7-, t a l 0 (e d a u V Expiration Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Paflure to secure coverage as required under Section 25A of MGL c. 152 can lend to die imposition of criminal penalties of a fine up to $1.500.00 and/or one-year imprisonment, is well as civil penalties in the foam 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 die DIA for insurance coverage vocation. I do hereby certify, render the pains af(d,Bptaltr'�F ofperjnty that Phone #• M . Offjciot use only. Do our twite in this area, to he completed by city or loon ojfarial and correct City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk A. Licensing Board S. Selectmen's Office 6. Other Contact taww.maccgovrwa Phone LEDGE-2 OP ID: DE T ,4coi2o CERTIFICATE OF LIABILITY INSURANCE `..�� DATE(MMIDD/YYYY) 10/1212021 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 INSURERS), 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 rights to the certificate holder in lieu of such endorsements . PRODUCER 506.673.5808 Rua-Dumont-Audet Ins. Agcy. In 155 North Main Street CONEACT Jason Rua, LIA, CIC, AAI PHONE 508.673.5808 FAX 508-677.4828 (Me, No, Ext): (A/C, No): E b'DR"ESS, Fail River, MA 02722 Jason M. Rua, LIA ,CIC, AAI INSURERS AFFORDING COVERAGE NAIC q INSURER A : Vermont Mutual Ins. Co. 26018 INS BRED DBAMANgFIELD FARMS FRESH db Mansfield Farms Frsh Marko Walpole, lMF r 081 ne INSURER 8: The Travelers -Commercial Line 19038 INSURER C: INSURER D: NSURER E: INSURER F : nnVFRAGFR CERTIFICATE NUMBER' REVISION NUMBER: 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 CONTRACT OR 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 BY PAID CLAIMS. INSR 11 PE OF INSURANCE OOL NSD UBR MDPOLICY NUMBER POLICY EFF POLICYEXP LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Business Owners BP21060244 05114/2021 05/14I2022 EACH OCCURRENCE $ 1,000,000 PREMISES his DAMAGE TO RENTED oxu ce 8 50,000 X MED EXP (Anyoneperson) 5,000 PERSONAL &ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO LOG OTHER: GENERALAGGREGATE 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 AUTOMOBILE LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY ALTOSWN AUTOS ONLY AUTOS ONLY C21%eI1ePtSINGLE LIMIT $ BODILY INJURY Per cement $ BODILY INJURY Per accident $ Pfte', ,, AMAGE PP $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACHOCCURRENCE $ AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILiry ANY PROPRIETOR/PARTNERIEXECUTIVE YINUB1S85378A tpFICEr MEMBER EXCLUDED? ❑ (Mantle cry io NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 05/14/2021 05/14/2022 X I PER OTH- A UT E.L. EACH ACCIDENT 8 500,00 E.L. DISEASE - EA EMPLOYE SOO,000 $ E.L. DISEASE - POLICY LIMIT 500,000 A PROPERTY BPZJUUU244 05114/2021 05114/2022 PROPERTY 123,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Sub Bet to actual policies' terms, conditions, definitions, coverages & exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVVEE IZIZ ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD