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HomeMy WebLinkAboutWhite's Pastry Shop - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE ESTABLISHMENT 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:. DAVID WHITE, PRESIDENT Whose place of business is: WHITE'S PASTRY SHOP 321 SCHOOL STREET PERSON(S) IN CHARGE: TRACY CARIFA Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-83 BOARD OF HEALTH MichaeCHeatey, Chairman I Milk & Cream �001 FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 6i—t Establishment Name: W h r z" Establishment Address:3qlSc,440o/ S�, Arf, Id AQ 0�L f v Establishment Mailing Address (if different): `UN I ne�l S4. 6aCYl'-frn, MfJ0a30 Establishment Telephone No: g�3 7J3!" Q Applicant Name & Title: J ain re c4iy l/Yt-Gi G M Applicant Address: l o � Povq S7 , A I'J0f n /06- d ?,30 1 Applicant Telephone No.: D F- jf—"%5700 24 Hour Emergency No.: 5-7 g%2(eq-57d7 Applicant Email J 6LM j e. fes bake_rya,ndca:Pe . co at Owner Name & Title (If different from applicant): D&VM W h r 4T torz S / r1 Owner Address: a o garnabctS Rd, Fx1 Pno^ 03 0 OZS-7 , Owner telephone number: 6DT - o2 & 9 — S-Rol Owner email: d,awh,-4-c aq @ ho4mail. com Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. 4 A Corporation El An Individual Name Title Address tmwid lA)hi-K PaSlAtn4 `iQ_Wn&bjas j21SAMV^M4 i A Partnership 9 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Ira, Cyr l -Fa '^� Address:3a1 S&k o1 �'� /vianSA'elclr rK. Telephone No: 99-33q-W36 24 Hour Emergency No: FAX: r E-mail: /YI cLn S F7'e(cl manra�er� -wh; d es baker "dcaj�. Corp-) 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 In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: N Permanent Location Establishment Type: ❑ Caterer $35.00 E3 Mobile Mobile Start Date: 49 Retail ( Sq. Ft) $125 d Milk & Cream $10.00 Mobile End Date: Mobile Comments: Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 EJ Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Length of Permit: Annual E] Food Service up to 101 -200 $250.00 [i Manufacture Frozen Desserts/Ice Cream $25.00/freezer ---- ---- --- - -- ❑ Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: 0 Seasonal Seasonal Dates: ❑ Supermarkets $400 ❑ Residential Kitchen $10 Tobacco Products $150. 00 00 Q Temporary Temporary Start Date: Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) E] Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs El Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Delivery of Packaged PHFs F] Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑i Reheating of Commercially Processed Foods for Service Within 4 Hours ❑i Customer Self -Service of Non PHF and Non- Perishable Foods Only I� Customer Self -Service 0 Ice Manufactured and Packaged for Retail Sale E] Preparation of Nan-PHFs Other Food Operations 0 Juice Manufactured and Packaged for Retail Sale Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service 0 Offers RTE PHF in Bulk Quantities E] 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 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 t9-el2tain copies of 105 CMR 590.000 pnd the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, #c. 49A, I certify under the p es f 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: 0 4 -3' 1�%� jt/,� t d 1 1 Signature of Individual or Corporate Name: i/V Y11'fY. �a S�)ry s hop In C - 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. _l kJf-.s PaSinl.S hon.1nC. QAAM-4-p c444 A Signature of Individual or C rporate Name By: Cot orate Officer (Mandato"r pplicable) "*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:\Users\sleite\Desktop\ScoLVs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassaehusetts 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 N Address: Sal sch.dd 1 S-4- n �] , a City/State/Zip: l�/IaASAdd MA-DZOKWPhone#:,� p `3,3q d p ,;136 Are you an employer? Check the appropriate box: Business Type (required): L N, I am a employer with 125 employees (full and/ 5. A Retail or part-time).* 6. DQRestaurant/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]* I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121-1 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 nny employees. Below is the policy information. Insurance Company Nair Insurer's City/State/Zip: S Policy # or Self -ins. Lic. # o l q ©D So3 171 6 I 19 Expiration Date: l Attach a copy of the workers' compensation policy declaration page (showing the policy number amil 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Serldfy, under fire pains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mass.gov/dia INFORMATION PAGE Insurer: MA Retail Merchants WC Group Inc. PO Box 859222-9222 Braintree, MA 02185 (Carrier Code: 34355) 1. The Insured: White's Pastry Shop Inc Mailing Address: 1041 Pearl Street Brockton, MA 02301 Other workplaces not shown above: SEE SCHEDULE OF OPERATIONS RENEWAL AGREEMENT PRODUCER: Agent$ 2036 Morse Insurance Agency, Inc. 285 Washington St. N. Easton, MA 02356 Carrier Policy #: 014005031718118 Carrier Prior Policy gyp: 014005031718117 Fein: 043056801 Type of Business: Corporation Risk ID: 2. The policy period is from 12:01 a.m. on 1/01/2018 to 12:01 a.m. on 1/Ol/2019 at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15) WC000406 WC000414(07/90) WC000422B(Ol/15) WC200102(01/14) WC200301(04/84) WC200302A(09/08) WC200303D(08/10) WC200306B(06/13) WC200405(06/01) WC200601A(07/08) 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis No.. Total Estimated Annual Remuneration SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 56,763.00 Minimum Premium $ 329.00 Expense Constant $ Rate Per Estimated $100 of Annual Remuneration Premium 00 Deposit Premium $ .00 O M Z Z O LL z Q x W MO Q X w w O w U w H W U V z MCI z -44 •! 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