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HomeMy WebLinkAboutHarry's Place - 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 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:. HARRY KELLOWAY, OWNER Whose place of business is: HARRY'S PLACE 1 CROCKER STREET PERSON(S) IN CHARGE: HARRY KELLOWAY Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS -34 BOARD OF HEALTH MichaeCHeaCey, Chairman Milk & Cream )' . 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) Establishment Name: ll arrl\ S P la ue Establishment Address: CfOCk-er S f " ���' � '° f -" Establishment Mailing Address(if different): NOV 2 9 2018 Establishment Telephone No.: p 3(�9S�yi .> W Applicant Name & Title: 11Afr✓– — ApplicantAddress: i cruL(ter St I Applicant Telephone No.: 'w m �) q / 24 Hour Emergency No.: / f/ J � 9 30 9 D 7 I Applicant E-mail: I16l1- �9 � yG�uu . Cu Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: J Ct w'( Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or El An Association partner. A Corporation Name Title Address aAn Individual El A Partnership _ El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: C'wl l<iIln Qwoor Address: No: 'l 24 Hour Emergency No: n S O G W Telephone OQ 3w 9 5,? o J I J d FAX: E-mail: yq Aab- C o v , 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:-/y��^�� % SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) �/V" V� No. of Food Employees: DAYS/HOURS: _ 5 / 1/ Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. f6WA Person Trained In Anti -Choking Pro dures (If 25 Seats or more):=1� Location: E] Permanent Location Establishment Type Ed terer $35.00 OMoblie Mobile Start Date: Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Food Service u to 100 INCLUDING p Q Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 EJ Food Service up to 101 -200 $250.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer L Length Of Permit: Annual ----------------- - — — Q Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Q Seasonal Seasonal Dates i1 Temporary Temporary Start Date: Supermarkets $400 0 Residential Kitchen $100.00 [] Retail Food $125.00 ❑% Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions:PHF - Potentially hazardous food(timellemperature controls required) Non-PHFs - non -potentially hazardous /ood(no time/temperatum controls required) RTE -ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service EJ Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And E] PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours 0 Vacuum Packaging / Cook Chill 0 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Q Customer Self -Service of Non PHF and Non- Perishable Foods Only Q Customer Self -Service Ice Manufactured and Packaged for Retail Sale El Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale Offers Raw Or Undercooked Food Of Animal Origin EJ Prepares Food/Single Meals for Catered Events or Institutional Food Service Q Offers RTE PHF in Bulk Quantities _ EJ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application i waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain gopies of 10$ CMR 590.000 gnd-the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I dertiq under thehenalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. ` Signature of Individual or Corporate Name: J t J /� o (Q ,x' Social Security Number or Federal to: 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 Intlividual or Co sate Name n- �-s3oo61 Social Security Number (Voluntary) 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 famished 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. The Commonwealth of Massachusetts UflDepartment of Industrial Accidents 1 Congress Street, Suite 100 Boston, DIA 02114-2017 www.mass.gov/dia Yorkers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: c Kr 5 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ el an 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ 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. F1 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] Phone Business Type (required): 5. [:]Retail 6.Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.0 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 #1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under theNains andpenalties ofperjury that the information provided iibove is true and con•ect Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other 11 Contact Person: Phone#• 11 www.mass.gov/dia Notification of Test Results IDI$: XXX -XX - Scaled Test Score: 86 Candidate Status: Pass fest Date: February 5, 2019 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES HARRY J KELLOWAY HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT' LAWRENCE J. LYNCH, CAE ISSUE DATE: FEBRUARY 5, 2019 EXPIRATION DATE: FEBRUARY .$, 2024 CERTIFICATE NO: 21544878 TEST FORM: EZS43 This certificate is not valid for more than five years from date of issue _ National Registry of Food Safety Profession CERTIFIED FOOD SAFETY MANAGE LARRY J KELLOWAY Certificate No 21544878 Issue Date: February 5; 2019' Expiration Date: February 5, 2024 congratulations! Attached is your certificate and wallet card. Please notify HARRY J KELLOWAY he National Registry of name or address changes at the address below. 19 GARFIELD ST FOXBORO, MA 02035 r Vol 1, _rr1d, areventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Competent) Crocke� fictively Managing Controls in a Food Establishment (Competent) -` , Monitoring the Flow of Foods (Needs review) Ensuring Product Time and Temperature (Competent) MR wSrt -e Jonducting Cleaning and Sanitizing (Mastered) Managing: Physical Facility Design & MaintenanceRreventing & Controlling Pests (Mastered) Al..e:....nln=.........-ro7--1C-I....--1.....:--- -- I "II --.....'l — o - "I I nI 11e11 1 nL —'I cel Io n I n_... API 'III I—I c5 'd I� �Fn^rrFiFn Notification of Test Results IDI$: XXX -XX - Scaled Test Score: 86 Candidate Status: Pass fest Date: February 5, 2019 NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES HARRY J KELLOWAY HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT' LAWRENCE J. LYNCH, CAE ISSUE DATE: FEBRUARY 5, 2019 EXPIRATION DATE: FEBRUARY .$, 2024 CERTIFICATE NO: 21544878 TEST FORM: EZS43 This certificate is not valid for more than five years from date of issue _ National Registry of Food Safety Profession CERTIFIED FOOD SAFETY MANAGE LARRY J KELLOWAY Certificate No 21544878 Issue Date: February 5; 2019' Expiration Date: February 5, 2024 congratulations! Attached is your certificate and wallet card. Please notify HARRY J KELLOWAY he National Registry of name or address changes at the address below. 19 GARFIELD ST FOXBORO, MA 02035 r Vol 1, _rr1d, areventing Contamination and Cross Contamination (Mastered) Ensuring Personal Hygiene and Employee Health (Competent) Crocke� fictively Managing Controls in a Food Establishment (Competent) -` , Monitoring the Flow of Foods (Needs review) Ensuring Product Time and Temperature (Competent) MR wSrt -e Jonducting Cleaning and Sanitizing (Mastered) Managing: Physical Facility Design & MaintenanceRreventing & Controlling Pests (Mastered) Al..e:....nln=.........-ro7--1C-I....--1.....:--- -- I "II --.....'l — o - "I I nI 11e11 1 nL —'I cel Io n I n_... 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