HomeMy WebLinkAboutNancy Antonucci - 12/31/2019Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishment
Type: RESIDENTIAL KITCHEN
In accordance with Regulations promulgated under authority of Chapter 94, Section
305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
NANCY ANTONUCCI, OWNER
Whose place of business is:
NANCY ANTONUCCI
186 STEARNS AVENUE
PERSON(S) IN CHARGE:
NANCY ANTONUCCI, OWNER
Permit Expires: December 31, 2019
Food Fee: $100.00
License Number: RK -05
BOARD OF HEALTH
MichaeCHeatey, Chairman
V<
jY FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening
Establishment Name: Nancy's Kitchenu
Establishment Address: 186 Stearns Avenue O C 0 5 20ja
Establishment Mailing Address(if different):
Establishment Telephone No.: A I 7811-858-5691
Applicant Name & Title: NahCy' Avi.+-ov aeb , o war
Applicant Address: 186 Stearns Avenue
Applicant Telephone No.: 781-858-5691 24 Hour Emergency No.: 781-858-5691
Applicant E-mail: nancy@theliverightway.com
Owner Name & Title (If different from applicant):
Owner Address:
Owner Telephone No.:
Owner E-mail:
Establishment Owned By: If a corporation or partnership, give name title, and home address of officers or
Ej An Association partner.
orpora ion Name/J I Title Addres
0 An Individual IJ0,1QA r1 r 60um'I ounler- AQe
%A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: N ahoy 4Rn Vvlaw;t r Owner
Address: 186 Stearns Avenue
Telephone No: 781-858-5691 24 Hour Emergency No: 781-858-5691
FAX:
E-mail: nancy@theliverightway.com
Alt E -Mail: nancy.antonucci@comcast.net
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE: Town SEWAGE DISPOSAL: Septic
DEP Public Water Supply No: (If applicable) No. of Food Employees: 0
DAYS/HOURS: Varies daily
Name of Person In Charge Certified in Food Protection Management Nancy Antonucci
If more than 3 individuals are certified, complete list is on file.
Person Trained in Anti -Choking Procedures (If 25 Seats or more): n/a
Location: Q Permanent Location
Establishment Type
Caterer $35.00
0 Moblie Mobile Start Date:
Retail ( Sq. Ft)
Q Milk & Cream $10.00
Mobile End Date:
Food Service up to 100 INCLUDING
Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
Q Manufacture Frozen Desserts/Ice Cream
Length of Permit:
E] Food Service up to 101 -200 $250.00
$25.00/freezer
Annual
EJ Food Service up to 201 + $300.00
0 Pushcart $50.00 # of Pushcarts:
----- ---------
E Seasonal
Residential Kitchen $100.00
Seasonal Dates:
Supermarkets $400
ERetail Food $125.00
EJ Temporary
Retail Snack Food $50.00
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
-__--
Food Operations Dentitions: PHF- Potentially hazardous food (time/temperature controls roqulred)
Non-PHFs - non -potentially hazardous food(no time/temperaturs controls required)
:heck all that apply): RTE -ready -to -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
-- - --Pack- for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And
--------- Cold Holding For Single Meal Service iE PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs Susceptible Population Facility
-PPPPPP— --- Sale of Raw Animal Foods Intended
Reheating of Commercially
Processed Foods for Service Within 4 Hours to be Prepared by Consumer E Vacuum Packaging / Cook Chill
-- --- -- - ---- ---- Lj Use of Process Requiring A Variance
r❑ Customer Self -Service of Non PHF and Non- E Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only g contact alternative, time as a public health
..a Ice Manufactured and Packa ed for
DN Preparation of Non-PHFs Retail Sale control)
Other Food Operations i,a Juice Manufactured and Packaged for E Offers Raw Or Undercooked Food Of "
Retail Sale Animal Origin
Q Offers RTE PHF in Bulk Quantities E Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date - --- ---
or Reconditioned Food To be completed by the Board of Health
--- Total Permit Fee:
Payment is due with application waived
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 nd all other applicable law. I have been Instructed by the
board of health on how to obtain cppi Ss of 105 CMR 590. 0 and in federal Food Code.
Signature of Applicank ���(/�(�t,/[x p� ,8TU&,�
Pursuant to MGL Ch.62C, sec. 49A, I certify una he enalties of perjury t I, to my best knowledge and belief, have fled all state tax returns
and paid state taxes required under law.
Signature of Individual or Corporate Name:7/ /Civ✓�'�r
Social Security Number or Federal ID: �. j A i : I _ 9 I 15I q
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 lwvidual or Corporate Name By: Corporate Officer (Mandatory, 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:\UsemWeite\Desktop\Scou's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial AccideYats
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Address: I SIO t�'neL1 Ir(/�S �jMVC,•
City/State/Zip: i � 'L(� H 1 OU4 Phone
79(-269 -SA
Are you an employer? Check the appropriate box:
Business Type (required):
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.
S• ❑ 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
10Manufacturing
no employees. [No workers' comp. insurance required]*
11..❑ ❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance
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 an: an employer that is providing workers' compensation insurance for nay employees. Below is the policy information.
Insurance Company Name:
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 cer/f, under the pans andpenalties ofperjury that the information provided above is true and correct.
Cionafi,re• �I D /11 41,t- (`JiI,(7"_IMA,� v —/ 3–
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