Loading...
HomeMy WebLinkAboutHilliards House of Candy, Inc. - 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) 09 Establishment Name ,e Llf- baf) Y Establishment Address "'Al AC Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: C Applicant Address Ni 114 Applicant Telephone No.: 24 Hour Emergency No.: Applicant Email j 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. [V�A Corporation Name Title Address H An Individual it inc El A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: r Address: P Telephone Na 24 Hour Emergency No: CI FAX: E-mail: i t 0i /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: _ SEWAGE DISPOSAL: DEP Public Water Supply No (if applicable) No. of Food Employees DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: h i 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, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. O Yes ('tr4 Does this establishment require a FOG permit? N'' C If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Retail Food Annual $125.00 Mobile Food Consession a Temporary 0 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 Q Pushcart $50.00 If of Pushcarts: Temporary Time: � Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk $Cream $10.00 E] Caterer $35.00 Food Operations: Detinitions:PHF - Potentially hazardous food (time4emperatum controls required) (Check all that apply): Non-PHFs- non -potentially hazardous(ood(no tiinadamperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muf los which need no fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs CJ PHFCooked To Order Q Hol 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 Q Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly 0 Sale of Raw Animal Foods Intended Susceptible Population Facility 0 Reheating of Commercially to be Prepared by Consumer ❑Q Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours,�` u 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) Q Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Ej Vacuum Packaging /Cook Chill E] Offers RTE PHF in Bulk Quantities ❑i Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Dale 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 1,05 CMR 590.000 and the federal Food Code. Signature of Applicant: /X..- /- rte' ;/ri 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- f hf" 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. z Signature of Individual or Corporate Name r t. L.f -f, ✓1k4 - i ,,' -7/ jy"_ *"Social Security No. (Voluntary) or Federal Identification Number i. By: Corporate Officer (Mandatory, if Applicable) J *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:\Useis\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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 ci C fbo i Address: 1 fy ( City/State/Zip: k! r. r h"Phone #: t Are you an employer? Check the appropriate box: Bu sin ss Type (required): 1. [1 I am a employer with � employees (full and/ 5. Retail 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. [No workers' comp. insurance required] S• ❑ 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.❑ 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 *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 insurance for my employees. Below is the policy information. Insurance Company Name: � � '[ ? C" F i) `j 'C i (U l ' r (_E 0 4' f e r ,. ! t' 7 Insurer's Address: `4 `1 % L (. n \ ii City/State/Zip: t_d , i? E, ` c" MIJA Policy # or Self -ins. Lic. # t ' l' " `9fir3 �� r F`"" ) Expiration Dater 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 and penalties of perjury that the information provided above is true and correct. Phone #: X, r ase; 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 NOTICE TO EMPLOYEES WBN9160789 3202338 NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: CITIZENS INSURANCE COMPANY OF AMERICA NAME OF INSURANCE COMPANY 440 Lincoln Street, Worcester MA, 01653 r„trwm ►RT_7F ADDRESS OF INSURANCE COMPANY ESS HILLIARDS HOUSE OF CANDY INC 316 MAIN STREET EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 100028 / no , \ w\ \ƒ .% ) § y CD ( \\k\ \ 7 ? 9°:e©CD § \\F\ \§§f 2 \ ®42$ \7\( \ � � � � MI z Ml CA CA �Mnq � � z � z 0 � .� no \ w\ \ƒ .% ) § y CD \ 7 ? 9°:e©CD — � � � � MI z Ml CA CA �Mnq � � z � z 0 � .� a m »,& e � � � � .� tTi z � � � � 4 t" � cn � z 0-4 z C � � � I G ` \« e � � � � .� tTi z � � � � 4 t" � cn � z 0-4 z C � � � I G Mar es y,& 2160 P.1 _ =ft 00 z■ ƒƒ � ¢{ Z � (\ & ®( / \ § E (/ $ & C < R & §( @ \ ( ƒƒ [{ £( {f \i + 2160 P.1 _ =ft 00 z■