HomeMy WebLinkAboutHilliards Chocolates - 12/31/201910
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: RETAIL FOOD
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:.
JUDITH MCCARTHY, PRESIDENT
Whose place of business is:
HILLIARDS HOUSE OF CANDY, INC. DBA HILLIARDS CHOCOLATES
333 SCHOOL STREET - B150
PERSON(S) IN CHARGE:
CHARLES C. MCCARTHY, OWNER
Permit Expires: December 31, 2019
Food Fee: $125.00
License Number: RF-6
BOARD OF HEALTH
MichaeCHeaCey, Chairman
FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATIO
(Application must be submitted at least 30 days before the planned ope *-date)-
EstabIishmentName:
Establishment Address:,,/
Establishment Mailing Address(if different): 3/G w /moo-.-t.r ors^4'r 16,7'1 O
Establishment Telephone No.:
Applicant Name & Title: CZ� (,e-, C. r��� � -7e- sstu er'
ApplicantAddress: G islo o S� /Vo %� ��5"Z"; l�tt 0 3S
Applicant Telephone No.: fig_ z_ z 3l 24 Hour Emergency No.:
Applicant E-mail G�� t, e �a� �, %J.a s Ca na✓�. Cam
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
n Association
partner.
XX'l
A Corporation
Name Title Address lv rrd
An Individual
7 tF'tlea to 1hy res ee_4- 3/ mom. .fist v_
C4�1� C }-r,��,�,.,���. -�r,�<, r r�•-�r �a07R�
El APartnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: (414r/1 c r.
Address: Sri y
Telephone No: 24 Hour Emergency No:
FAX: 5O S 3 g- .z 73 99
E-mail:
Alt E-Mail: A 4
District Or Regional Supervisor (if applicable) IYIq
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
AGE DISPOSAL:'
LNo.
of Food Employees: ! <J
DEP Public Water Supply No: (If applicable)
DAYS/HOURS: PAL',- � ��. 9�'rR
<}--
Name of Person In Charge Certified in Food Protection Management
If more than 3 individuals are certified, complete list is on file.
r' "
Person Tralnetl in Anfi-Choking Procedures (If 25 Seals or more):
Location: Q'Permanent Location
Establishment Type
f_1 Caterer $35.00
QMoblie Mobile Start Date:
3 Retail ( Sq. Ft)
(] Milk & Cream $10.00
Mobile End Dale:
Q Food Service up to 100 INCLUDING
❑I Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
0 Food Service up to 101 -200 $250.00
Manufacture Frozen Dessertslice Cream
$25.00ttreezer
Length Of Permit:Ei
_
0 Annual
Q Food Service up to 201 + $300.00
Ej Supermarkets $400
u_ p
f Pushcart $50.00 # of Pushcarts:
E3 Residential Kitchen $100.00
r�Relail Food $125.0D
n Retail Snack Food $50.00
-
Seasonal
Seasonal Dates_
E3 Temporary
Temporary Start Date:
Temporary End Dale:
Temporary Time:
Rain Date:
Food Operations
(Check all that apply):
Definitions: PHF - Potentially hazardous food(timaRamperaturs controls require
Non-PHFs - non -potentially hazardous /ood(no tfineltemperefure controls required)
RTE-ready-to-eat foods (Exsandwiches, salads, muffins which need no further processing)
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
Q Sale of Commercially Pre -Packaged PHFs
ll Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
_
ElPHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Ej Delivery of Packaged PHFs
0 Sale of Raw Animal Foods Intended
to be Prepared by Consumer
El Reheating of Commercially
Processed Foods for Service Within 4 Hours
Vacuum Packaging / Cook Chill
--
di Variance
0 Use of Process Plan (including
and/or HACCP Plan InGuding bare hand
contact alternative, time as a public health
control)
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
_
�� Customer Self -Service
� Ice Manufactured and Packaged for
Retail Sale
0 Preparation of Non-PHFs
Other Food Operations
i] Juice Manufactured and Packaged for
Retail Sale
0 Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Q Offers RTE PHF in Bulk Quantities
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 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 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.52C, sec. 49A, I certify under the penalties of penury that 1, to my best knowledge and belief, have filed all slate tax returns
and paid state taxes required under law. )
Signature of Individual or Corporate Name: t"f' (1v A -h
Social Security Number or Federal ID:
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.
rf/,%t.�� �'.���o/err ��,� � �%s�✓
Signature of Individual or Corporate Name By: Corporate Officer Wdmf5tory, if Applicable)
'� V?JG
'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.
CAUnm\sleite\Desktop\SwtYs DocumentsTood Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Nate:
Address: '); I r�'i 4 �T
City/State/Zip: J`,', ; ,- j L r' c MA A . Phone #: -C� - C
Are you an employer? Check the appropriate box:
Businesk Type (required):
LEI
I am a employer with ,`5 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.
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
W ❑ Manufacturing
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 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 Address: q`*`; t'� C u tr^, '-}. .
City/State/Zip: 'i )11,
�z
Policy # or Self -ins. Lie. # L." t(/N ` 11 Cr,C, -4 Vt Expiration Date: �, f k}/ <'
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 penahies 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 Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone
NOTICE
TO
EMPLOYEES
WHN9160789
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will
give you notice that I (we) have provided for payment to our injured employees under the
above -mentioned chapter by insuring with:
THE HANOVER INSURANCE COMMA v
NAME OF INSURANCE CO
MUM
440 Lincoln Street, Worcester MA, 01653
ADDRESS OF INSURANCE COMPANY
ST
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to
the injured employee. The employee may select his or her own physician. The reasonable cost of the
services provided by the treating physician will be paid by the Insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby
notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL A
TO BE POSTED BY EMPLOYER
3202338
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