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Home My WebLink AboutGerry's Catering - 12/31/2020Oto 65 ® )—gs,- \ FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued gyp,„ IVIODlie rood tstaDllsnment tivirtq rermlt Application (Application must be submitted at least 14 business days before the planned opening date 1) MFEName: C� (�ke rr 2) Applicant/Owner Name R Title: a,rqew — G G Applicant/Owner Address: r Applicant/Owner Telephone No: r-- Applicant/Owner Email address: 3) Person In Charge of Onsite Operations & Title: c w PIC Address: e - PIC Telephone No: 7-79 <I ; - Emergency/onsite Telephone No: PIC Email Address: 4) Location of Service: Date(s) if applicable: Event Name if applicable: Event/ Service Location: Event/ Service time: 5) Length of Permit: 6) Solid waste disposal plan: Annual L-3 Temporary Dates: 7) Water Source: 8) Sewage disposal plan: i 9) Food will be prepared: o Onsite for immediate consumption o Onsite and held at proper hot/ cold holding temperatures (LZt—Offsite and held at proper hot/ cold holding temperatures O Offsite, cooled and reheated on site E-1 Other: 10) Please attach a menu or a website link to the menu or give a brief description of the food to be served: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: / Food Safety Manager: /�1 ,l9/Y7 /Z".yT� Allergen Awareness: C� C'wto 1 y/ 12) Please describe on site hand washing facilities that will `be_utilized: -5MI( �/ih �T d 13) Please list all sanitizing solutions that will be on site: 5'lQiG�%l/2y"/C) r��/�/✓ G�// dLs'1/�/� 14) Do you have propane, fryolators and/or hoods on your truck? 4_ If yes, you must first be inspected and approved by the Mansfield Fire Department. Phone number: 508.261.7321 Fire Department Signature of Approval: 15) If applicable, please describe your FOG management plan or attach the written plan: 16) Location of Base of Operations or Commissary: Please attach copies of Base of Operations or Commissary Permit. 17) Please list additional communities where a food permit is held: I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. 1 have been instructed by the board of health on how to obtain colas of 10ACMR 590.000 and the)federal Food Code. 18)Signature of 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. 19) Social Security Number or Federal 20) Signature of Individual or Corporal 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 "*Social Security No. (Voluntan/) 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Information Please Print Le ibly Business/Organization City/State/Zip: Phone Are you an employer? Check the appropriate box: I.QI am a employer with (2employees (full and/ or part-time).* 2. F� I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 30 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/Bating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. F1 Entertainment 1 O.Q Manufacturing 11.R Health Care 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 #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lie. 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,#der the pains and penaltys ofperjury that the information provided above is true and correct. 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 www.mass.gowma The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations (' l 600 Washington Street Boston, MA 02111 "w- www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Information Please Print Le ibly Business/Organization City/State/Zip: Phone Are you an employer? Check the appropriate box: I.QI am a employer with (2employees (full and/ or part-time).* 2. F� I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 30 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/Bating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. F1 Entertainment 1 O.Q Manufacturing 11.R Health Care 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 #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: Policy # or Self -ins. Lie. 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,#der the pains and penaltys ofperjury that the information provided above is true and correct. 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 www.mass.gowma <, .O E \` r V W a U .2 V S 0 NU 3 Mw 0 0 The Commonwealth of Massachusetts Department of Public Health, Bureau of Environmental Health b Food Protection Program, 3 5 South Street, Jamaica Plain, MA 02130 I i t3 y issued CHARLES MANERO CATERING C0.1Nri ♦ fOUNTAIN STREET W*LTHAM, License issued purjsuant to: MGL c 94 s 3050 Regulated acglvity: processor Distribute Food for Sale at Wholesale Applicable rdguWtion: 105 CMR 500,000 Licensel nurilber: MA -0532 Date of i6suance: 01/03/2019 Date of expiration: 01/02/2020 .5`1 Stator foar D`epa men o isu Ic ea th Mail to: CHARLES MANERO CATERING QO.INC 16 FOUNTAIN STREET WALTHAM, MA 02154