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HomeMy WebLinkAboutEllen's Ultimate Cookie - 12/31/2019F� 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 Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. ELLEN BORDEN Whose place of business is: ELLEN'S ULTIMATE COOKIE 23 CAVAN CROSSING PERSON(S) IN CHARGE ELLEN F. BORDEN, OWNER Permit Expires: December 31, 2019 Food Fee: $100.00 License Number: RK-01 BOARD OF HEALTH Michaet-HeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permit# FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned gw S Q, 330 Establishment Name: ,fit _ I p Establishment Address: oZ� C�YCL<1 CC-C»j ((�\ 1" `Gt_il"�� A i M AI © �S r Establishment Mailing Address (if different): Establishment Telephone No: Applicant Name & Title: ��LCl ejC>i cn�57 �> usle f Applicant Address: -6cLc )e Applicant Telephone No.: e 24 Hour Emergency No.: Applicant Email: n��se����r� eCc.�(x-N 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 '❑O An Association partner. Ed A Corporation Name Title Address $4LAn Individual E3 A Partnership _ O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: F_1k e_n'F. bG c—Ae— -,') cx_< ne c Address: .46c"'"e Telephone No: 24 Hour Emergency No: FAX: E-mail: tJQCne- 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: SEWAGE DISPOSAL:l�G DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management: Z_eo F. aC-A-e rl If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ _ Location: >ZPermanent Location Establishment Type: 0 Caterer $35 00 ❑I Mobile Mobile Start Date: E] Retail ( Sq. Ft) $125 ❑ Milk & Cream $10,00 Mobile End Date: Mobile Comments: Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 0 Food Service up to 101 -200 $250.00 0 Mobile Food Concession NO PHF PREPARED ON SITE $100.OD Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length Of Permit: 52 Annual Food Service up to 201 + $300.00 Supermarkets $400 ❑ Pushcart $50.00 # of Pushcarts: Residential Kitchen $10D.00 Tobacco Products $150.00 Q Seasonal Seasonal Dates 0 Temporary Temporary Start Date: E] Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions:PHF- Potentially hazardous food ftimeRemperature controls required) Non-PHFs- non -potentially hazardous food(no tima/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) iEJ Sale of Commercially Pre -Packaged Non-PHFs F-I PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs E Preparation of PHFs For Hot And Cold Holding For Single Meal Service E]PHF and RTE Foods Prepared For Highly Susceptible Population Facility 0 Delivery of Packaged PH Fs E]Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Reheating of Commercially Processed Foods for Service Within 4 HoursEl ❑ Vacuum Packaging / Cook Chill ___........._. ___ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ------ 1 Customer Self -Service of Non PHF and Non- Perishable Foods Only Customer Self -Service Q Ice Manufactured and Packaged for Retail Sale __ -Preparation of Non-PHFs Other Food Operations 0 Juice Manufactured and Packaged for Retail Sale E Offers Raw Or Undercooked Food Of Animal Origin _ ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service E] Offers RTE PHF in Bulk Quantities E Retail Sale of Salvage, Out -Of -Date or Reconditioned Food be completed by the Board of Health �To Total Permit Fee: Payment is due with application E]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 1055CCMR 5990.000 andthefederal Food Code. Signature of Applicant: � ,Q r ,,.k,�d Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid stale taxes required under law. Social Security Number or Federal ID: 6 t 5 5QP AR of U 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 co\ -'�) >la L1q-�,6 "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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts 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: fj cP t � l•-6 MLAC CC�C_-,1_, e g Address: C tst,fro City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. R 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. [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, §I(4), and we have 10.❑ 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.D,Other fDCKkp c� *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 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 and penalties ofperjury that the information provided above is true and correct. Signature: � C) o x� - IVR7' �.`�rs Date: I �;k I � 1 � `� Phone #• % ` 1 i ri 1 > lo le_ —1'( 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 Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone www.mms.gov/dia