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FOR 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: 6AC4;?M?1- 91Vc otlble. yie"12A-�mr kd
Establishment Address: a l tf leco c) / 57 is d-/OG ✓'!iGr+� 1 sfi"GL l ✓�/� t%� U tY
Establishment Mailing Address(if different):
Establishment Telephone No.: y U mot 0003
Applicant Name & Title: A OrA ✓1
Applicant Address: 21 k t?weL vt /,-e .%7* Vk °4 -4 2,<5
Applicant Telephone No.: g 6 tt➢ 8 L r t p 24 Hour Emergency No.: At/
Applicant E-mail: v7toyhU
'n" C) ( @ �^" a4— cG�
Owner Name & Title (If different from applicant):
Owner Address:
Owner Telephone No.:
Owner E-mail:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
Cl An Association partner.
VA Corporation Name
" Title L Address p ,
0 An Individual v nr v kl� �7 !` tte , t��i v tn�t/_' o�t'Y /�/rw�-&d AV.G
R A Partnership s M ozwo,
L] Other legal Entity r
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No, of Food Employees:
DAYS/HOURS:
Name of Person In Charge Certified in Food Protection Management
If more than 3 individuals are certified, complete list is on file.
A
Person Trained in Anti -Choking Procedures (If 25 Seats or more):
Location: ukermanent Location 1❑ Establishment Type Caterer $35.00
❑Moblie Mobile Start Dale: �� ❑ Retail ( At k.d Sq. Ft) i [L rMilk & Cream $10.00
Moblie End Date: ❑ Food Service up to 100 INCLUDING ❑ Mobile Food Causes
sion
Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00
Length of Permit: ❑ Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00 $25.00/freezer
Annual
- -_ - - - - - - - - ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 q of Pushcarts:
Seasonal -
Seasonal Dates:
❑ Supermarkets $400 ❑ Residential Kitchen $100.00
_ _.. El Retail Food $125.00
❑ Temporary [�2etail Snack Food $50.00
Temporary Start Date:
Temporary End Date:', ❑ Tobacco Products $150.00
Temporary Time:
Rain Date:,,
Food Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
--- - -- ---
Sale of Commercially Pre Packaged PHFs
for More Than a Single Meal Service
❑ Preparation of PHFs For Hot And
Delivery of Packaged PHFs
Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly
❑Sale of Raw Animal Foods Intended Susceptible Population Facility
❑� Reheating of Commercially
to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service - - ❑Use of Process Requiring A Variance
and/or HACCP Plan (includingbare hand
Perishable Foods Only
_ - ',, contact alternative, time as apublic health
❑Ice Manufactured and Packaged for P ,
'�'�� Preparation of Non-PHFs
control
Retail Sale )
-
ElJuice Manufactured and Packaged for'! ❑ Offers Raw Or Undercooked Food Of
Other Food Operations
Retail Sale
Animal Origin -_
❑ Offers RTE PHF in Bulk Quantities
❑ Prepares Food/Single Meals for
_-
Catered Events or Institutional Food Service.
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be completed by the Board of Health
- -
Total Permit Fee: '.
'., Payment is due with application ❑ waived
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 co of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
_
Pursuant to MGL , sec. A, I certify under the per the ral7`--� perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxeses required under law.
Signature of Individual or Corporate Name:
Social Security Number or Federal ID: 2 6
a
Amy Donovan -Palmer
From: Momin Khan <mominkha0l@gmail.com>
Sent: Monday, December 30, 2019 5:39 PM
To: Amy Donovan -Palmer
Subject: Pest Control
Hey Amy!
Sony for the late response but can you please add AAA Pest Control as the company for our inspection.
Thank you so much!