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Commonwealth 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:.
RAYMOND DEAGRELA
Whose place of business is:
TASTY RAY'S LLC
20 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
RAYMOND DEAGRELA, OWNER MANAGER
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS-74
BOARD OF HEALTH
NichaeCHeatey, Chairman
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Milk & Cream
Commonwealth 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: CATERER
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:.
RAYMOND DEAGRELA
Whose place of business is:
TASTY RAYS LLC
20 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
RAYMOND DEAGRELA
Permit Expires: December 31, 2019
Food Fee: $35.00
License Number: C-3
BOARD OF HEALTH
9blichaeC.Heatey, Chairman
FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned
Establishment Name: C c, k' S L..L C
Establishment Address: ) ? � +k 1)1 v A S e 2 e jyj ,y _, rip: -L1)
Establishment Mailing Address (if different):
Establishment Telephone No: i?20 �� — 0 `13
Applicant Name & Title. ] r4 y v,o n j 11 c i �1: -d
Applicant Address: L),n_4 17
Applicant Telephone No.: ()"-I } 5 -"-; 5`2 24 Hour Emergency No.:
Applicant Email: % 4 e r)
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
EJ An Association
partner.
El A Corporation
Name Title Address
El An Individual
EJ A Partnership
Other legal Entity L (_ C
Person Directly Responsible For Daily (owner, person in charge, supervisor, manager etc.)
/Operations
Name & Title:
Address: u _; L=J e;} u I iAc S l r.._-f lJ r
Telephone No: j 7 - cl 6 - 7 5' 24 Hour Emergency No:
FAX:
E-mail: to erg c(L;(4�o�.Gr
Alt E-Mail: ! ws� 1 y5 1 v L7,o .Coma
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: C)
DAYS/HOURS: ).f rAt < l ��tr, D,iI'l
—
Name of Person In Charge Certified in Food Protection Management:
If more; 3 individuals are certified, complete
list is on file.
than
RI � yr" a n <i z f 30c.� 9
Person Trained in Anti -Choking Procedures (If 25 Seats or more): it
Location: `, Permanent Location
Establishment Type:
-.+. Caterer $35.00
0 Mobile Mobile Start Date:
EVR,t,il ( Sq. Ft) $125
NdMilk & Cream $10.00
Mobile End Date:
Food Service up to 100 INCLUDING
0 Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
i Manufacture Frozen Desserts/Ice Cream
Le gth of Permit:
Food Service up to 101 -200 $250.00
$25.00/freezer
Annual
----------- ------
0 Food Service up to 201 + $300.00
❑ Pushcart $50.00 # of Pushcarts:
i -, Seasonal
Residential Kitchen $100.00
Seasonal Dates:
0 Supermarkets $400
Q Tobacco Products $150.00
%1 Temporary
Q Retail Snack Food $50.00
Temporary Start Date:
Temporary End Dale:
Temporary Time:
Rain Date:
Food Operations:
Definitions:PHF- Potentially hazardous food (fimellemperature controls required)
Non-PHFs - non -potentially hazardous food(no fima/temperature controls required)
(Check all that apply):
RTE -ready-to-eat
foods (Ex. sandwiches, salads, muffins which need no further processing)
E d Sale of Commercially Pre -Packaged Non-PHFs
[y4HFCooked To Order
Q Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑7 Sale of Commercially Pre -Packaged PHFs
�' reparation of PHFs For Hot And
PHF and RTE Foods Prepared For Highly
Cold Holding For Single Meal Service
❑ Delivery of Packaged PHFs
Susceptible Population Facility
i] Sale of Raw Animal Foods Intended
to be Prepared by Consumer
I'i Reheating of Commercially
0 Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
0 Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
control)
Ice Manufactured and Packaged for "
Retail Sale
lJ Preparation of Non-PHFs
Other Food Operations
iJ Juice Manufactured and Packaged for
Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
E] Offers RTE PHF in Bulk Quantities
LJ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
E] Retail Sale of Salvage, Out -Of -Date
To be completed by fhe "-of Health
or Reconditioned Food
Board
Total Permit Fee:
Payment is due with application Q 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 nd all other applicable law. I have been instructed by the
board of health on how to obtain copipp of 105 CMR 590.Q6� and the federal Food Code.
Signature of Applicant:
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: 61 —f�
Signature of Individual or Corporate Name:
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 (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.
Q\UsersWeite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massach usetts
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: � cls�-�i t��t �t �
f i._ C:
City/State/Zip: Phone #:
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. j�
,d
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 1
10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
12.90ther C' "
with no employees. [No workers' comp. insurance req.]
e"y-'r Y
*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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
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 certify] under the pains alaipenalties ofperjury that lire information provided above is true and correct.
-)/14f )0)
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,mms.gov/dia
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