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Home My WebLink AboutPushcart Cafe - 12/21/2021FOR BOARD OF HEALTH USE ONLY Permit # issued FOOD ESTABLISHMENT PERMIT (Application must be submitted at least 30 days before the planned opening OCT 2 6 7021'j'111) Establishment Name Establishment Address '2_11 d fta4yA 3 Establishment Mailing Address (it different) Establishment Telephone No L, Applicant Name &Title: W6L 6WVLe_P-s Applicant Address 4 Applicant Telephone No.: 24 Hour Emergency No,: I Applicant Email Owner Name & Title (if different from applicant) f Owner Address Owner telephone number Owner email: Establishment Owned By: If azorporation or partnership, give, name, title, and home address of officers or 11 An Association partner. 0 A Corporation Name 'title Address EJ An Individual IYA Partnership O Other legal Entity A4 A Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc;) Name &Title: geLCc� otsCAMU Address: I 2I) OulmCc 0 TelephoneNo,. G'& 7 24 Hour Emergency No, FAX: E-mail: pp LAI 'P Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title., tq 4'Z rS)l 14 40 Address,- t3a,l, �,' C P-1 eL'W Telephone No: '7Y 24 Hour Emergency Nx FAX- E-mail: oc4wt Food Eistablishment Information WATER SOURCE, SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) No. of Food Employees; DAYWHOURS: Name of Person(s) In Charge Certified in Food Protection Management: S Name of Person(s) In Charge Certified in Allergen:Awareness Training 5 (>,-% 14 '5 e yvi, I �( V + Name of pest control company routinely inspecting the premises for evidence of pas If there is seating for-25 pe pleor more; a person trained in manual choka savings procedures will be onsite,at ail times Est food is, being prepared. Does this establishrinent require a FOG permit! __ If yes, please attach the FOG permit application, Length of Permit: Establishment Type; 0 Annual 9 Retail Food $126.00 Mobile Food Consesslon 0 Temporary (Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $1 00= Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Dessertatico Cream Food Service up to 101 -200 $250;00 $25.00/fteezer Temporary End Dais: Service, up to got + $s0o.00 E3 Pushcart $50.00 # of Pushcartc Temporary'ritnet iFood Supermarkets $400 E] Residential KJtchen,$l 00,00 Rain Detaii Ej Milk & Cream $10-00 Ej Caterer $36,00 Food Operaffons: 6afinitions, PH'F - Po"ally hazardous, Idad (Cherk'afl that apply): !'ion-PNF's, non-polonbsffyhszirdous fwd(vo limaAwnpetalum CbnWe required) PTE. ready-M-eat totx&- (Ex. sandoiclw, tasds;.mugns whkh need nP,1v1nhsrprocessing) Sale of Commercially Pre -Packaged Non-PHFs Ej PHFCooxedrq Order D Hot PHF Cooked and c4oledor Hot Held El Sale of Commercially Pre -Packaged PHFs El Preparation of PHFs For Hot And for More Than..a single Meal Service Ej Delivery. of Packaged PHFs Cold Holding For Single Meal Service it PHF and RTE Foods Prepared,Fot Highly C31 Reheating of Commercially El'Sale of Raw Aninta(Foods Intended Susceptible Population Facility to 64 Prepared by'Gonsumer E3 Use of Process Reticiring A Variance Processed Foods for Service Within 4 Hours: and/or HACCIP Plan (including bare hand El Customer Salt -Service of Non PHF and Non- Customer Self -Service contact afternative, time as a public h"Ith Perishable Foods Only El lc6 Manufactured and Packaged for control) [I Preparation of Non-PHFs Retail Sale [3 Offers Raw Or UnlorcookLd Foodof Juice Manufactured and Packaged for Animal origin Other Food Operations Retail Sale [I VacuumPackaging /Cook Chill Offers RTE PHF In Bulk Quantities ED Prepar4a roodtSingleVeals for Retail Safe of Salvage, Out-ot-Date Catered Events or Institutional Food Service' or Reconditioned FC70d ------- --- 1, the undersigned, attest to the accuracy of the information provided In this application and affirm that the food, establishmentoperation will comply with 106 CMR 500.000 and all other applicable law. I have been Instructed by the board of health on how to obtain copleapt 105 CMR 590,000 and the federal Fnad (WA- SignatumotApplIcantz Pursuant to IVIGL Ch.62C, see. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. SoclalSecurfty Number or Federal IM Signature of Individual or Corporate Name: 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 ail 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 finesassociated 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 JI 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 containersmade.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 Assoclatioi for Testing and Materials) Standards for compostability. _JI have received copyofthe 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. _�)_I fiave received a copy 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 _A Zi 2TA =;j ' Date; Applicant Name (please print clearly) 6741,17 `}"�'A );3u - TAX CERTIFICATION FORM I certify under the penalties of perjury that L to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law, --FSAP�' 1AC — Signature Of IndiVidual or Corporate Name By: Corporate Officer (Mandatory, if Applieable) XfA 37ZqYfo,R�o "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is, signed by the applicant. x-* Your social security number will be ftu-nished 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. I I DoCuMeWAF(Jod EstablishnldUs- Temp\TAX CERTiFicxrioN FORM.doc The Commonwealthof Massachusetts Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 www.mass.govvdia Workers' Compensation Insurance Affidavit: General Businesses; Applicant information Please PrintLesibIX Business/Organization Name: r" A r' fAIC- L ® I am a employer with employees (tidl and/ 5- or pert -time);* 6. I ❑ I am a sole proprietor or partnership and haveno employees Working forme in any capacity: [No workers' comp, insurance required] $' In We are a corporation and its officers have, exercised 4. 4.0 We Office andtorSales 6nci: real estate; auto, etc:) Beldw, ig ;the policy i"Pr/nation. Insurer's Address t-r rd tr Y1 ! b � i l a✓cK °c+ }�{ City/State/Zip: 8�0 y (A)490,-J M in C-) 2 Policy # or SelPrins, Lic. # ri t772 Ply Cam` apiration bate: Attach a copy of the workers' compensation policy declaration page (showing the poliev number, and exniratinn date OVIcial use fmy. Do not. n rite in this area, to City or Town: 3?exmitlLieense:# Issuing Authority, (circle one): 1. Board of Health 2. Building Department 'I City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other FSAHt-1 OP 113. CERTIFICATE OF LIABILITY INSURANCE °";;, 9W A THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the If SUBROGATION IS WAIVED, subject to the terms and conditions of i I must have ADDITIONAL INSURED provisions or be endorsed. certain. policies may require an Endorsement, A statement on Merrill Insurance Agency PHONE 781-702.73Q0A 17 Central Street ,7.8.._1...-762-7419 CMgii Norwood MA 02062 Nevin Gilligan INwnEalsLAtFFFoaml+rLcovERaoe _ xA1cA _ jigvNERA, Hartford Insurance Groug 30104 11"MI t°A sa nn dba Pushkart Cate p,Utica First Insurance Company17 d2171 qu181yin�A mm avR NSURERF: nnsrconr_sc ncaTTCTraTF u)iMRFR• 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. NMt TYPE OF SISURANCE D4 UER MO NUMBER POLICY EFF PDLIGY EYJr LIMIT g X COMMERCIAL GENERAL LIABILITY 1,000,000 nAAwGE TG flENTEo 1OO10O0 CLAiMS•MADE { h i OCCUR 1000001194 1012112021 1012112022 EXp fAnvJiM.vsceNni....... Sr000 PEBOCNAL$hDvw 1,000,000 __ 'L AGGR LIMIT AP 1 8PER: POLICY P&O nLOC R 2,000,000 2,000,000 AUTOMOBILE LIABILITY COMS)NEO SINGLE LIMIT $ ANY BOOILYINJURY PAr rmon EOOaYi, U Yfar Acclaom e..,�.._ µAUTO (WMEWONLY 18YO ULED ��REp ONUTOB tlNLY AUTOS LY A ONLY Pp��p�H AMAGE Per l UMBRELLA LIAO OCCUR AP,7,GATE_��,. EXCESS LIAR CLAIMS -MADE no RETENTION E A WOR"R$ COMPENSATION AND EMPLOYERS` LIABILITY ANY PROPRIEPORIPAMENEXECUTIVE ( i N/A QQppFI E EXCLUDED? L___7 IwrnCde n } iI Sd. 1I864'1`.htl Vfl(18OPERATIONS below ( 8 WEC AN$GM8.001 10/2112021 4012112022 X FER OTH• ,p ACCYDEN�_ {Sg,A,,$,E,•EA EMPLO"" EL DISEAS ..> r.....�,.._._, 500,000 _ fJO0,000 MVgIQQQ DESCRIPTION OF OPERATONI I LOCATIONS I VEHICLES (ADDED 10i, AddlRemi Rmmrkr SCNduls, may Sr Mtsohod R t ima" Is reguind) Coverage for Pushkart Restaurant located at 219 N. Main St Mansfield Town of Mansfield 8 Park Row Mansfield, MA 02048 SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE Kevin Gilligan AnnOn 14 /1MI4181\ (0)19119.2015 ACORO CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Town of Mansfield HealthDepartment APPLICATION FOR FATS OILS, and GREASE DISCHARGE PERM RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Mailing Address: � 2 QNeA P ` Phone/Fax Contact Name of Company scheduled to, pump Internal grease trap(s) monthly:, 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 collectlon container $50 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.. Print Name n,zj2 1� Date S Grease Traps 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 �hckrNsw _ JkIn ai 1 Grease Trap 2> Grease Trap 3 Grease Trap 4 GreaseTrap 5 External Grease Traps Does this establishment have an outdoor Greas 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 Property PropertyOwner's Telephone Number:, YellowGrease Waste Do you store yellow grease waste from fryolators? N `P' Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste'. 3 Please answer all questions in this section. if an item is not applicable, indicate "N/A". Uniess'otherwise specified, please print or type. Seating Capacity (per Fire Department l Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service:' Monday Thursday %fir" Sunday �y Tuesday c— 1 Friday Wednesday G Saturday Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units(GRU/trap); Numberin establishment Attachedto GRU 3 compartment sink i Handwashing sink Commercial Dishwasher Bar sink Mop Sink �y Garbage Disposal (� Ice Making Machines ¢( Fryolators Grills or Ovens Exhaust Hoods 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? No 2. rn m S, i' Sr / G b\«! \\\( \ {!, \ \ I t-I . � . � � � � 0 7 ƒ% n m $ 2 i K (D 7 \ 0 0 0 \ cr 0 0 ... (D cr . .E.... .� 7 7 § 0 U o � z 0=10 z C) I I I �i I