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Home My WebLink AboutMansfield Service, Inc. - 12/31/20204qq FOR BOARD OF HEALTH USE ONLY Permit# Issued Fnon F:;TARI ISHMFNT PERMIT APPI Ir..ATI(1NI (Application must be submitted at least 30 days before the planned opening date) ` Establishment Name Mans )f C Isepale- ( V1 . /% q/ I� Establishment Address 107 C�C(AhC�/ �T t�0S�fW aw e / f /'Ipl. Establishment Mailing Address (if different) Establishment Telephone No �� _ Sri ,_ Applicant Name & Title: �ShYZIr/1� �2S 1>CI"CU1 f / Applicant Address 1 d 7U l dl fa riv1 O i^- 0e n iw y lq r4 647 FD — / V 6 So, _24 Hour Emergency No.: e Applicant Telephone No.: �W C/ -- S;73 w ✓ k&"3p VA a )t- cc Wj Applicant Email (� C�iNtb� Owner Name & Title (If different from applicant) Sc' V-e� Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. tkA Corporation Name A Title,,, I Address ��l f ktrzRll� An Individual Sl ht }rnwk_ 6.�o El A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, in charge, supervisor, manager etc.) Name & Title: T -L) Js K A Z Otv I i &SI6614 Address: Sa u.2 aS a 6vu-- Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E -Mail: f '->tg �1e� �j j �, CO District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: T6vh SEWAGE DISPOSAL: A b C IS QI Oed No. of Food Employees: 5 DEP Public Water Supply No: (If applicable) DAYS/HOURS: OV Name of Person(s) In Charge Certified in Food Protection Management: PaU� Aogcea Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, p person trained in manual choke saving procedures will be onsite at all times food is being prepared. ® Yes .N! 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 E] TemporaryFood 19 Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream 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 Q Residential Kitchen $100.00 Rain Date: "" Milk &Cream $10.00 6:3 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs -non-potentially hazardous foodfno time/tempereture controls required) RTE - ready4o-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order EJ Hot PHF Cooked and Cooled or Hot Held Sale of Commercial) Pre -Packaged PHFs 0 y g � Preparation of PHFs For Hot And for More Than a Single Meal Service E] Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended I�tr3 Reheating of Commercially Susceptible Population Facility to be Prepared by Consumer �-rocessed Foods for Service Within 4 Hours E] Use of Process Requiring A Variance ustomer Self -Service and/or and/or HACCP Plan (including bare hand ❑t Customer Self -Service of Non PHF and Non- tV contact alternative, time as a public health U Perishable Foods OnlyIce Manufactured and Packaged for control) etail Sale Preparation of Non-PHFs 0 P 0 Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Q Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for "a Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 1, 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 obtai>>� p' sof 1o5 CM590.000 and the federal Food Code. Signature of Applicant: 4 C Y, V--" Pursuant to MGL Ch.62C, sec. 49A, I certify under the pe and paid state taxes required under law. Social Security Number or Federal ID:I 3 Signature of Individual or Corporate Name:g N . of perjury that I, to my best knowledge and belief, have filed all state lax returns q V 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 (Matkatory, if Applicable) **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:\Uscm\sleite\Desktop\Scott's Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Address: Are you an employer? Check the appropriate box: 1 I am a employer with 9-- employees (full and/ Bus'ne s Type (required): 5. VZki etail 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. 8• ❑ Non-profit [No workers' comp. insurance required] 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.❑ Manufacturing no employees. [No workers' comp. insurance required] * 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees.. [No workers' comp. insurance req.] 12.❑ Other *My applicant that checks box # I most 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 Insurance Company Nan Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. insurance for my employees. Below is the policy information. m, 0710 3iti�S:f`a'D� � • r Attach a copy of the workers' compensation policy declaration page (showing the policy number X270 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. Ido hereby certify, under thepains andpena/ties ofperjury that the information provided above is true and correct. » Phone#: !S -bo — / r. -V 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 ANS/ ___-- -- _ -- -- ION POULA ABED fur sesems6nY smgbtirg the skerJads wi fonh fu the SorvSe(o' fmJ Raic an hkenlrcCemhwnov bmnlnawn, s bmh h..0 d'ned 61hv Amedme Netweol5iarclwds In9�nee I?, I¢Y-Canks mjoi Food PIWMme (CFP) CERTIFICATE OF ALLERGEN AWARENESS TRAINING L�IIC_CJWt.t4Eu? xx�f�. b i Date c Dam 7brarv[rramotpmm L F.anbj iunrl t5v artifran far rampirting rn allrrgrx awarmm Hain ins �°aTF4A ne�gnfrJ3y iht hfanac},mu[t DtJurnrent vjAtbl�xNmtrd ir. artasdanv mGfi IOS Chin 590.tk14(CJ(JJ ja). Tfiu MPju'u& sAl br saJL{fwJrvr (Sf Srmfiwn du¢ afmnp]rdan. � sz;�r��' d'„�fL•t ° AMM, WIT r hiuo-hu.cm Namunnt As.n6.:bo )d 01I T,cophc Hwd� 01 S,t01 SaphWro�q;4 htA b177I a v.<mvrmotmg 508301-99115 law.mamrwan+n+�c.or8