HomeMy WebLinkAboutThe Live Right Way (N. Antonucci) - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
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(Application must be submitted at least 30 days before the planned opening dam) ,
Establishment Name W
Establishment Address i 19(7��
Establishment Mailing Address (if di/fferent)cr
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Establishment Telephone No 7b 1 — p 5 6 _5&q
Applicant Name & Title: F(C�
Applicant Address (v t(t n AV& i E'�� LiiS-Ci
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Applicant Telephone No.: 24 Hour Emergency No.: � I"
jAppiicantEmail O V�i(
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Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
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Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
An Association
partner.
0 A Corporation
Name Title Address
XAn Individual
L7 A Partnership
Other legal Entity
--.__-.....---------.._.._--
Person Directly Re onsiblefo�r D/aiily, O erations (owner, person in charge, supervisor, manager etc.)
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Name & Title: 7 /�Ty cd(UU to w}i-
Address: U
i Telephone No: ('� q ,� �� (j 2,4/ Hour Emergency No:
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FAX:LV V t 1 �.. V'
E-mail:
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: SEWAGE DISPOSAL:]
DEP Public Water Supply No: (If applicable) y t No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in F/opojd� Protection Management:
Name of Person(s) In Chparge Certified in Allergen Awareness Training
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hGL1f N f0011- (
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. [7 Yes
Does this establishment require a FOG permit? �/ �� If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
[] Annual
R Retail Food $125.00 i j Mobile Food Consession
trs Temporary
[I Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 Q Manufacture Frozen Dessertslice Cream
Temporary Start Date:
Q Food Service up to 101 -200 $260.00 $25.00/freezer
Temporary End Date:
C Food Service up to 201 + $300.00 ( Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 Residential Kitchen $100.00
Rain Date:
Q Milk & Cream $10.00 r' Caterer $35.00
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Food Operations: Definlitons:PHF-Potentially hazardous food (Ilmeltemperature controls required)
Check all that I Non-PHFs- non -potentially hazardous!ood(no limeRempemfore controls required)
( PP YX RTE -ready-fo eat foods (Er. sandwiches, salads, muftlns which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs €di PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs l Preparation of PHFs For Hot And for More Than a Single Meal Service
Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs Susceptible Population Facility
�r Sale of Raw Animal Foods Intended
Eg 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
EJ 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
E,] Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale E� Vacuum Packaging / Cook Chill
Offers RTE PHF In Bulk Quantities Prepares FoodlSingle 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 obta o�pies /ofg10�5/CM/R5y0000 0 ederal Food Code.
Signature of Applicant ✓� /%,✓�f t r.G
Pursuant to MGL Ch.62C, sec. 49A, I cert� rrjnd'penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state takes required under law. �/. '1t7 tr311
Social Security Number or Federal 10.
Signature of Individual or Corporate Name:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: The Live Right Way
186 Stearns Ave
City/State/Zip: Mansfield, MA 02048 Phone
781-858-5691
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. Q✓ 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.❑ We are a corporation and its officers have exercised 9. Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4. 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 Name:
Insurer's
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 certi , under the paitoq/ and penalties of perjury that the information provided above is true and correct.
Signature: (/U//Lfti' �ii Date. 11-25-19
FZc�1
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
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
oJo -zl "-W37
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, 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\Scours Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
1RS
DEPARTMENT ETREASURY
INTERNAL REVENUESERVIC
CINCINNATI OH 45999-0023
NANCY E ANTONUCCI
NANCY ANTONUCCI
166 STEARNS AVE
MANSFIELD, MA 02048
Date of this notice: 09-21-2016
Employer Identification Number:
81-3915194
Form: SS-4
Number of this notice: CP 575 G
For assistance you may call us at:
1-800-829-4933
IF YOU WRITE, ATTACH THE
STUB AT THE END OF THIS NOTICE.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER
Thank you for applying for an Employer Identification Number (EIN). We assigned you
EIN 81-3915194. This EIN will identify you, your business accounts, tax returns, and
documents, even if you have no employees. Please keep this notice in your permanent
records.
When filing tax documents, payments, and related correspondence, it is very important
that you use your EIN and complete name and address exactly as shown above. Any variation
may cause a delay in processing, result in incorrect information in your account, or even
cause you to be assigned more than one EIN. If the information is not correct as shown
above, please make the correction using the attached tear off stub and return it to us.
A limited liability company (LLC) may file Form 8832, Entity Classification Election,
and elect to be classified as an association taxable as a corporation. If the LLC is
eligible to be treated as a corporation that meets certain tests and it will be electing S
corporation status, it must timely file Form 2553, Election by a Small Business
Corporation. The LLC will be treated as a corporation as of the effective date of the S
corporation election and does not need to file Form 8832.
To obtain tax forms and publications, including those referenced in this notice,
visit our Web site at www.irs.gov. If you do not have access to the Internet, call
1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office.
IMPORTANT REMINDERS:
* Keep a copy of this notice in your permanent records. This notice is issued only
one time and the IRS will not be able to generate a duplicate copy for you. You
may give a copy of this document to anyone asking for proof of your EIN.
* Use this EIN and your name exactly as they appear at the top of this notice on all
your federal tax forms.
* Refer to this EIN on your tax -related correspondence and documents.
If you have questions about your EIN, you can call us at the phone number or write to
us at the address shown at the top of this notice. If you write, please tear off the stub
at the bottom of this notice and send it along with your letter. If you do not need to
write us, do not complete and return the stub.
Your name control associated with this EIN is ANTO. You will need to provide this
information, along with your EIN, if you file your returns electronically.
Thank you for your cooperation.
(IRS USE ONLY) 575G 09-21-2016 ANTO O 9999999999 SS-4
Keep this part for your records. CP 575 G (Rev. 7-2007)
Return this part with any correspondence
so we may identify your account. Please CP 575 G
correct any errors in your name or address.
9999999999
Your Telephone Number Best Time to Call DATE OF THIS NOTICE: 09-21-2016
( ) - EMPLOYER IDENTIFICATION NUMBER: 81-3915194
FORM: SS-4 NOBOD
INTERNAL REVENUE SERVICE NANCY E ANTONUCCI
CINCINNATI OH 45999-0023 NANCY ANTONUCCI
L IuLLI�I�Iu ICI uI�IuII�uIL�mLL�ILLL�) 186 STEARNS AVE
MANSFIELD, MA 02048