HomeMy WebLinkAboutOur Daily Bread - 12/31/2020FOR 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 Q)wr Jr� ��t S-C'..0�. CYC +�S L C>
Establishment Address L-5- �/1��l �/ } rye .
Establishment Mailing Address (if different) [ �� W f ,z cj } r
m'a o _:>'0?4 &
Establishment Telephone No
Applicant Name & Title. -I �L._�� �1((��cL��•�`jv�� P n�
Applicant Address'
`
Applicant Telephone No.: `I 'ti. -I --1 1 i `��.i(e 24 Hour Emergency No.: C�� -�3r7 - �� 7
Applicant Email l
Owner Name & Title (If different from applicant)
Owner Address 1
Owner telephone number C)0 �3 . aa> 14 719 3
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
Ed An Association
partner.
11 A Corporation
Name Title Address
11 An Individual
El A Partnership
Other
legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title:��tCy
Address:
Telephone No: _D'8 —a3 3 tl 24 Hour Emergency No: !'Cj'�j' ^ j �(_ �ks a
FAX:
E-mail: < Q�00 ie_
Alt E -Mail:
District Or Regional Supervisor(diff alipplicable)
Name&Title: bi<-� ��n��
Address: �-A\
Telephone No: "j�l�°' 24 Hour Emergency No:
l[ 7
FAX:
E-mail:
(
Food Establishment Information
WATER SOURCE: TG 7 t\
SEWAGE DISPOSAL
DEP Public Water Supply No: (If applicable)
No. Food Employee� , I ' (' cp_,r S
iof
DAYS/HOURS: t� II!0 w tl ESCJt
Name of Person(s) In Charge Certified ih Food Protection Management:
Name of Person(s) In Charge Certified in A lergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests I i� f � ��G t ('01,
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? If yes, please attach the FOG permit application.
th of Permit:
Establishment Type:
7Len
Annual
[I Retail Food $125.00 [] Mobile Food Consession -
E] Temporary
[] Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
El Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
[ Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 0 Residential Kitchen $100.00
Rain Date:
Ej Milk &Cream $10.00 E] Caterer $35.00 � 0
Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required)
(Check all that ap ly. Non-PHFs- non -potentially hazardous food(no time/temperature controls required)
RTE -ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing)
Sale of Commerciialllly Pre -Packaged Non-PHFs El PHFCooked To Order [I 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
Cold Holding For Single Meal Service � PHF and RTE Foods Pron eparedFor Highly
El Delivery of Packaged PHFs Susceptible acility
Q Sale of Raw Animal Foods Intended
E] Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Q Customer Self -Service contact alternative, time as a public health
0 Customer Self -Service of Non PHF and Non -
Perishable Foods Only ❑ Ice Manufactured and Packaged for control)
Preparation of Non-PHFs ,Retail Sale [TOffers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
0 Vacuum Packaging /Cook Chill
E] Offers RTE PHF in Bulk Quantities 0 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 c mply with 105 CMR, 590.000 and all other applicable law. I h e been instructed by the
board of health on how to obta opies of 105 M 590.0 0 and the f deral:�ed-Gede
Signature of Applicant:
-
Pursuant to MGL Ch.62C, sec. 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. 11 G
Social'Secuiity Number or Federal ID: ✓q - I ` a 10'4 1
Signature of Individual or Corporate Name:
to
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date NII=Y.`4
We,
organization )
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. *
Please list the organization:
We are not charging a fee for food/drink being served.
❑ We are a religious organization.
X
I;A-Other:
Thank you,
t � c
!J
K
J
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
u,p
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address:
1-yu e,1,NVloq. eeS
City/State/Zip: [%rs l—j,�A , 0141 n 3VQPhone #: �5D% -J� 1 _ /3.,/3
Are you an employer? Check the appropriate box: Business Type (required):
1.❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ 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] g• Non-profit
3.❑ We are a corporation and its officers have exercised 9. Lj Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required] * 11.❑ Health Care
4. We are a non-profit organization, staffed by volunteers,
with no employees. rNo workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box #I 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 #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic.
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 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 cert/fy,,untler the pains-axd penalties atfperjury that the information provided above is true and correct.
Phone#: —1 -A --I iq- a�)-)� / A� � ) ��)-%d-boJ_�A%
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
► I- U- At
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
www.mass.gov/dia
Phone
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of Individual or Corporate Name By: Corporate Officer (Ma atop,/, if AP licab le)
' TTL
AAL
"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