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Home My WebLink AboutJessica Gaudette - 12/31/2019r:- 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: RESIDENTIAL KITCHEN In accordance with Regulations promulgated under authority of Ch 'pter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is Oereby granted to:. JESSICA GAUDETTE Whose place of business is: JESSICA GAUDETTE 7 MAYFLOWER DRIVE PERSON(S) IN CHARGE: JESSICA GAUDETTE Permit Expires: December 31, 2019 Food Fee: $100.00 License Number: RK-03 BOARD OF HEALTH MichaeCHeaCey, Chairman I \\\ FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: 6eSstcv , �e- Establishment Address: �(Att��r Oi,ns ftGlAi /ram p�v-tu Establishment Mailing Address(if different): Establishment Telephone No.:.� Applicant Name & Title: TeSco' co , GAAAtk%e_ , I r at r Applicant Address: -7{�/�pfu=?_r Or MnNs.� jl WA �g Applicant Telephone No.: 5bQ-,nrl3_/oi q �2�4wH.�our Emergency No.: oG1rl Applicant E-mail: ,t ^ 7� nr��' �_I�IOV l J l Owner Name & Title (If i erent 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 El An Association partner. A Corporation Name Title Address ,�_"An Individual A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 59SSrlC�O._ CVAA �ll••��e,��,•e -.,- n J Address: I rJl �1 � &. 1'tw 1 utj''V� VOv t d Telephone No: r7��bjt�q�a /J�lOI 24 Hour Emergency No: FAX: E-mail: (%cy�. AJJ _ec*nq C�r Alt E-Mail: (0� District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: el"Clwy\ SEWAGE DISPOSAL: � 1 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: ❑ Permanent Location Establishment Type n Caterer $35.00 ❑Moblie Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ 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 Length of Permit: Food Service up to 101 -200 $250.00 ❑ Manufacture Frozen Desserts/ice Cream $25.00/freezer 74 Annual ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: Seasonal Residential Kitchen $100.00 Seasonal Dates: Supermarkets $400 __ ❑ Retail Food $125.00 Temporary ❑ Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): turs inval Definitions: PHF -Pore-nonpotenthazardous hazardous hood(no timetempersum cot Non-PHFs -non-potentially hazardous Iood(no time/temperature controls required) RTE-ready-to-eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only (Preparation of Non-PHFs Other Food Operations n PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer U Ice Manufactured and Packaged to Retail Sale Juice Manufactured and Packaged Retail Sale Retail Sale of Sal or Reconditioned n Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health U Offers Raw Or Undercooked Food OfAnima Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service rTo becompleted by the Board of Health Total Permit Fee: Payment is due with application n 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 copies of,105 CMR690.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, se 9A, I certify under the penalties of perjury that 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: Social Security Number or Federal ID: TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. atuBy: Corporate Officer (Mandatory, if Applicable) re of Individual or Corporate Name *"Social Security No. (Voluntanj) 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:\Usen\sleite\Desktop\Scoa's Docaments\Food Establishments- Temp\TAX CERTIFICATION FORM,doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization 0 Jam" City/State/ZiI d M4 r%gU"IlS 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 2PI 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. [No workers' comp. insurance required] 8. ❑ Non-profit 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company 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 certify, under the pains and penalties of perjury that the information provided above is true and correct Phone #: U V 9- q 7 .)- 6 o m 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 #: