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Home My WebLink AboutCibo Matto - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD SERVICE 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:. PETER KUPLAST Whose place of business is: CIBO MATTO 254 CHAUNCY STREET PERSON(S) IN CHARGE. PETER KUPLAST Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-8 BOARD OF HEALTH "IdichaeCHeaCey, Chairman Milk & Cream 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: CATERING 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:. PETER KUPLAST, OWNER Whose place of business is: CIBO MATTO CAFE 254 CHAUNCY STREET PERSON(S) IN CHARGE: PHYLLIS KUPLAST, GENERAL MANAGER Permit Expires: December 31, 2019 Food Fee: $35.00 License Number: C-1 BOARD OF HEALTH MichaeCHealey, Chairman shy 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: C i bu tM a M> Cu Establishment Address: C tnaw)cF Mansf kO , 1"A C) `-I g Establishment Mailing Address(if different): Establishment Telephone No.: Sub 33 q 0 6 Applicant Name & Title: KCTC-7v Ft'S C�r �W uL� Applicant Address: (_)I CA-Mv,QC-cL s'r 4AN�4rELo 1"vA 02ON( Applicant Telephone No.: '1-1 y 0-i 11 UOU 0 24 Hour Emergency No.: Applicant E-mail: Pe -Tr- P- K " rtl, d -T @ 6/vl h 1 L� . L'o 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 El An Association partner. 9"A-Corporation Name Title Address El An Individual yei'✓ V,y, t" CFI,Cahv�hzl) S�" A Partnership 171 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: VV1 ,jO'S I r��nQal 5_�-r Address: -d-V 9}e��v� St. YvAw,4; a-r d, /M/t d L °"i 113 Telephone No: 1 `� a- 0 u �4 2 o g 24 Hour Emergency No: FAX: 5u (6 `V, h ci 1 0 Lo E-mail: Vk p10s4-p5 w<t t I - 60 AltE-Mail: Clhum,"-9 e Gb)vn��tocAf�e (bv District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: ToW', SEWAGE DISPOSAL: l oc jj 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. Jo51 Ua Clo,L Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: Permanent Location Establishment Type aterer $35.00 Moblie Mobile Start Date: E] Retail ( Sq. Ft) [+Milk & Cream $10.00 Mobile End Date: Wood Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 Food Service up to 101 -200 $250.00 NO PHF PREPARED ON SITE $100.00 0 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length Of Permit: ❑1 Annual Food Service up to 201 + $300.00 Supermarkets $400 P 0 Pushcart $50.00 # of Pushcarts: i] Residential Kitchen $100,00 0 Retail Food $125.00 0 Retail Snack Food $50.00 EJ Seasonal Seasonal Dates: iJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions:PHF - Potentially hazardous food(timeltemperature controls required) Non-PHPs - non-potentialy hazardous food(no limeltemperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑] Sale of Commercially Pre -Packaged Non-PHFs ❑] PHFCooked To Order n�, Hot PHF Cooked and Cooled or Hot Held i3 Sale of Commercially Pre -Packaged PHFs n, Preparation of PHFs For Hot And for More Than a Single Meal Service [T] Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly i� Sale of Raw Animal Foods Intended Susceptible Population Facility 0 Reheating of Commercially to be Prepared by Consumer E] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations Customer Self -Service Retail Sale Q Juice Manufactured and Packaged Retail Sale Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health El Offers Raw Or Undercooked Food Of Animal Origin Offers RTE PHF in Bulk Quantities Prepares FoodtSingle Meals for Catered Events or Institutional Food Service 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 1, 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 690.000 and the -federal Food Code. Signature of Applicant: 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. Signature of Individual or Corporate Name: 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. / ignature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number By: or tea 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\Scotts Docwnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UlfBoston, MA 02111 wwlw.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C - Imo 2S 1 CkRVOG--i, St- " � +Iv ('"-�-N City/State/Zip: m u^ s t l" clMA- ow K D Phone #: Sol?, 3 3 `i `l b a t> Are an employer? Check the appropriate box: Business Type (required): ✓you [�-I 1. I am a employer with r '1 employees (full and/ 5. ❑ Retail or part-time).* 6. H-MestaurantBar/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, §I(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We by 1 L❑Health Care are a non-profit organization, staffed volunteers, with no employees. [No workers' comp. insurance re 12.0 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. Iran an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: T e Insurer's Address: ;5 01 W o d J,S 1po (lG D e iv ( City/State/Zip: 13 Policy # or Self -ins. Lie. # d rC W i= Cf . 1� 3 t o 93"t-- Expiration Date: S I °i 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 ofpeijury that the information provided above is true and correct. Phone #: '? —l't A L Ct (D o G 0 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 Phone #: www.mass.gov/dia a� z' � m O.. N e- N Q.o_` d r W 8 p Q x r- N o t 13 Po 0 W U .�2 I r