HomeMy WebLinkAboutBlondie's Cakes - 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)
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Establishment Name O DY\tk rrlAlu-l.-o n �/� �� p '� n, p
EstablishmentAddress IJ A 1j6�-� 0(° 'tl RsS e(d' tYV1 t/ v"f0
Establishment Mailing Address (if�erent)
Establishment Telephone No 9% - q q a. - b 0 t 1
Applicant Name & Title:
Applicant Address -7 . (p-vnno-e_r
Applicant Telephone No.: 24 Hour Emergency No.:
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Applicant Email ` o @ (j(j 00W—, llQ
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
11 An Association partner.
O A Corporation Name Title Address
f An Individual
A Partnership
IJ Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
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Name & Title: J2Se' Uu-T' -Q--
Address: Alec ✓ V V �t Y 1 Gt i�J f l d 6% 0 l g�l u
Telephone No: 9M- l 0 - (�� 1 � 24 Hour Emergency No:
FAX:
E-mail: i(Vt� (jt3rn�G1/j�, I
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: P tk I'(SEWAGE
DISPOSAL:
DEP Public Water Supply No (If applicable)
No of Food Employees: (()
DAYS/HOURS: Co
Name of Person(s) In Charge Certified in Food Protection Management:
0 cvu l lb f-O�L-
Nam/e^of Person(s) In Charge Certified in Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests r�
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. ❑ Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
'Annual
❑ 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 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00 IJ Pushcart $50.00 # of Pushcarts:
TemporaryTime:
F] Supermarkets $400 Residential Kitchen $100.00
Rain Date:
El Milk &Cream $10.00 ❑Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(ume/temperature controls required)
Non-PHFs - non -potentially hazardous food(no fim0amperalure controls required)
(Check all that pP y): RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing)
apply):
Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ 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
Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
,J Sale of Raw Animal Foods Intended
I] 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
Customer Self -Service
Customer Self -Service of Non PHF and Non - contact alternative, time as a public health
control)
Perishable Foods Only ❑ Ice Manufactured and Packaged for
r] Preparation of Non-PHFs Retail Sale EJ Offers Raw Or Undercooked Food Of
L] Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale ❑ Vacuum Packaging / Cook Chill
E] Offers RTE PHF in Bulk Quantities El 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 of(105 Cfy1R 590.000 and the federal Food Code.
Signature of Applicant:
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 state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
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.
Si ature of Individual or Corporate Name
"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.
CAUscm\sleite\Desktop\Scotrs Docttments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
J� �n 'nn y/per p
City/State/Zip: i 1 V \ , 1 � j gV t/` U//U "1 p Phone #: JD p - J ia3' %j q
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2.;P] I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required];
4. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. Retail
6. Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. ❑ Entertainment
10.F1 Manufacturing
I LEJ Health Care 12.0 Other k1DYY0_ bd)V t
*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 #1.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy information.
Insurance Company
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 certify, under thepains and penalties ofperjuiy that the information provided above is true and correct.
Phone #: U 61_ 9 "l 9- - 6 o I Of
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