HomeMy WebLinkAboutHometown Bakery - 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 -tr-%- drzu-A y'1�& L e,rf / ® p
Establishment Address 60 5- eg ✓li.5 i� S•7 ;I Ccf
Establishment Mailing Address (if different)
Establishment Telephone No S-P >`r - ,1 Y-V - 9 % 3 3
Applicant Name &Title: prl e4a c, l p Le-iw
Applicant Address 0 S*4 01 S A-'✓e
Applicant Telephone No.: 3TC-- >S_V47 33 r24 Hour Emergency No.:
Applicant Email �grn v ,�r.bakryyNtfnSTi�-lle H✓ �rnt "'
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
11 An Association
11 A Corporation
e-An Individual
El A Partnership
Other legal Entity
If a corporation or partnership, give name, title, and home address of officers or
partner.
Name Title Address
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: fi-r/e-At 60C w e-r�
Address:
Telephone No: 24 Hour Emergency 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:
Food Establishment Information
WATER SOURCE: j SEWAGE DISPOSAL: t O �y M
O n
DEP Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Arl.dte 6, c,- : 04—
Name of Person(s) In Charge Certified in Allergen Awareness Training
&I64t e lc
Name of pest control company routinely inspecting the premises for evidence of pests
If there is seating for 25 peopl or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. ' Zs
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit: Establishment Type:
(eAnnual ❑ Retail Food $125.00
❑ Mobile Food Consession
Temporary ❑ Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
Temporary Start Date:
n Manufacture Frozen Desserts/Ice Cream
0 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
[residential Kitchen $100.00
Rain Date:
0 Milk &Cream $10.00
❑Caterer $35.00
Food Operations: Definitions:PHF-Potentially hazardous food (limellemperature controls required)
(Check all that apply): Non-PHFs -non-poten6'ally hazardous food(no fime/temperature controls required)
PP Y)' RTE - ready-to-eal foods (Ex. sandwiches, salads, muffins which need no fu therprocessing)
Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
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
0 Reheating of Commercially to be Prepared by Consumer
[] Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only ❑ Ice Manufactured and Packaged for
control)
El Preparation of Non-PHFs Retail Sale
E] Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Ej Vacuum Packaging /Cook Chili
Offers RTE PHF in Bulk Quantities
❑ 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 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 A 105 CMR 590.000 and
/the federal Food Code.
Signature of Applicant e00
Itte f ,GLeT-
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 stale tax returns
and paid state taxes required under law.
Social Security Number or Federal ID: —'tSl 3301
Signature of Individual or Corporate Name:
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.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Nmnber
*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\s1eile\Desktop\Scot1's Documents\Food Estublishmen(s-Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Address: 60 Shot nS ke
City/State/Zip: Phone #: 57> r - d fY — % 7 33
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. Q'ffetail
r part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. 1 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 100 Manufacturing
no employees. [No workers' comp. insurance required]** I I ❑ 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 requited 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
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. # Expiration Date
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 certify, under the pains andpenalties of perjury that the information provided above is true and correct.
Signature: (24e% t"j• LOLL Date: /�//.3-b/ %
Phone #: or — 77 3 ,?
Official use only. Do not write in this area, to be completed by city or tows: 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:
www.mass.gov/dia
Phone