HomeMy WebLinkAboutLinda's Cookies - 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; RESIDENTIAL KITCHEN
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:.
LINDA FERNANDO
Whose place of business is:
LINDA'S COOKIES
6 CEDAR RIDGE LANE
PERSON(S) IN CHARGE:
LINDA FERNANDO
Permit Expires: December 31, 2019
Food Fee: $100.00
License Number: RK -04
BOARD OF HEALTH
NichaeCHeaCey, Chairman
-
6'r
FOR BOARD OF HEALTH USE ONLY Permit# Issued
r
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name:
Establishment Address: eU�( Uklam/
Establishment Mailing Address(if different):
Establishment Telephone No.:°`�'
Applicant Name & Title. ' J\,
Applicant Address: S4Ar4�Q
Applicant Telephone No.:S�- q� 24 Hour Emergency No.:
Applicant E-mail: LA kt_ 0
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
0 An Association
partner.
El A Corporation
Name Title Address
QZ An Individual
El A Partnership
El Other legal Entity
Person DirectlResponsible.([F�)or Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: v ' Yom` 'U �^�Q/�(J OkL
Address: 4 L"d t» �)' H W) e T4P ( d Y Y
,)
Telephone No: �1- 1 / ,-Z 24 Hour Emergency No:
FAX: —
E-mail: �Akd� kA-
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:
DEP Public Water Supply No: (If applicable)
SEWAGE DISPOSAL:
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: 0 Permanent Location
❑Moblie Mobile Start Date:
Mobile End Date:
Mobile Comments:
Establishment Type
❑ Retail ( Sq. Ft)
El Food Service up to 100 INCLUDING
FOOD TRUCKS $175.00
Food Service up to 101 -200 $250.00
❑Food Service up to 201 + $300.00
Supermarkets $400
Q Caterer $35.00
❑ Milk & Cream $10.00
0 Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
ii Manufacture Frozen Desserts/lee Cream
$25.00/freezer
Q Pushcart $50.00 # of Pushcarts:
'Residential Kitchen $100.00
0 Retail Food $125.00
Q Retail Snack Food $50.00
Length Of Permit:
Annual
---
Seasonal
Seasonal Dates:
171 Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
—
-
Food Operations
(Check all that apply):
Dentitions: PHF-Potentially hazardous food(dmeRempmatum controls requlrod)
Non-PHF's - non -potentially hazardous food(no t/me/tempersturo controls required)
RTE -reedy-to-eat foods fEx. sandwiches, salads, muffins which need no furtherprocessing)
W Sale of Commercially Pre -Packaged Non -PRFs
Q PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
E] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
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
❑ Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Customer Self -Service of Non PHF and Non-
Perishable Foods Only -
❑ Customer Self -Service
Q Ice Manufactured and Packaged for
Retail Sale
E] Preparation of Non-PHFs
Other Food Operations
Q Juice Manufactured and Packaged for
Retail Sale
Q Offers Raw Or Undercooked Food Of
Animal Origin
O Prepares Food/Single Meals for
Catered Events or Institutional Food Service
0 Offers RTE PHF in Bulk Quantities
Q Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
Tc 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 oL()Lain copies of 10 CMR 590.000 and the federal Food Code.
Signature of Applicant: \ A�_�` �� -a k \
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. j, r\ - C\
Signature of Individual or Corporate N
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.
V\Afi_t, (� LL .c
S
Signature of Individual or Corporate Name
"Social Security No. (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 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:\Usem\sleite\Desktop\Scoa's Docutnents\Food Establislunents- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth tfMassachuseds
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Uf www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Ll' lam_ f. S
U
Phone #: Z 1 ' 1'(
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 I am a sole proprietor or partnership and have no
7, E] Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ Non-profit
[No workers' comp, insurance required]
I ❑ 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]*
I1.❑ 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
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 maybe forwarded to the Office of
I do hereby certify, under the 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 Clerk 4. Licensing Board 5. Selectmen's Office
G. Other
Contact
www.mass.gov/dia
Phone