HomeMy WebLinkAboutAntonia's International Foods (Taste of Tri-town) - 10/1/2019t r ?g FOR BOARD OF HEALTH USE ONLY
Y
2gce Permit Fee Approved By Permit # Issued
wu�
-----------Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: AW1177,"'j //l f
2) Establishment Address;
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
5) Applicant[Owner Name & Title:
rl
6) ApplicanttOwnerAddress: -3hl�
e
7) ApplicantlOwner Telephone No;
✓
8)AppiicantlOwnerEmail address:
�// CQ
9) Person Directly Responsible For Onsite Operations:
Name & Title: `WT
Ae
01P�Iall,?l
/
Telephone No: d _
Fax:
Emergency Telephone No:
10) Event Attending
%
Date(s): G
Event Name: 7d 61Ile
Event Locafion:&&/7,L-b,to?/rj
/ ej-J
Event time:
11) Check one
Food Truck
Caterer'
Other:
12) Solid waste disposal plan: vrsi
/t v/� Cl?�_��j�l/J�
/ I-elP70"I y��
�OCCl�/0�
13) Water Source: N A
14) Sewage disposal plan:
15 ) Please give a brief description of the food to be served:
4anfi&ll
16 ) Food will be prepared: /
Onsite for immediate consumption v
Onsite and held at proper hot/ cold holding temperatures
Offsite and held at proper hoU cold holding temperatures
Offsite, cooled and reheated on site
Other;
17) If PHF Is being served, please list the person who has completed the following tratnings and attach appropriate
certificates: ` /� _ _ _ ��J ��
Food Safety Manager:_-C%%/•��—/-�//={%"� /-
Allergen Awareness: 6 Q
18) If applicable, please describe your FOG management plan or attach the written plan:
V
19) For caterers: Cityrrown where food establishment permit is held. Please attach a copy of the caterer's permifi
For food trucks, please list aI communities where a food permit is held and attach copies of the permits:
I, the undersigned, attest to the accuracy of the information provided in this application and I 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.
19) 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,
20) Social Security Number or Federal ID: 7 7 / 5-3
21) Signature of Individual or Corporate
Food Protection Questionnaire for Catered Events
Date of Event: /d
Location of Event:
Event Time:
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cookin� Reh nti n4V
Food Manager Certification Person Trained On Site? des o No
Allergen Awareness Menu Label Present? o Yes o No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required. -
List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41 °F?
How will the PHF be kept at or above 1413 /�
Time of PHF? Setup.. Served Removed
List all equipment that will be supplied for an event, including but not limited to food
thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc,
TAX CERTIFICATION FORM
1 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.
k)xlzas ,T &1,1111 //
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.
Q\UscrsisleitelDeskiop&oU!s DocumentslFood Establishments- TempITAX CERTIFICATION FORM.doe
The Cotnnton wealth of Massachusetts
Department of Industrial Accidents
Office of litvestigations
600 Washington Street
Boston, MA 02111
tvrvw.niass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Are y u nit employer? Check the appropriate box;
Business Type (required):
1. 1 am a employer with employees (full and/
5. ,tail
or part-time).*
6. Fy it/eestaurant/Bar/Eat ng Establishment
2.0 I am a sole proprietor or partnership and have no
T El 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
10.❑ Manufacturing
no employees. [No workers' conip. insurance required]**
4.❑ We area non-profit by
I1.❑ Health Care
organization, staffed volunteers,
with no employees. [No workers' comp. insurance req.]
I2.❑ Other
'Any eftplicant Oral checks box 01 must alsorill out flee section belowshovviug dicir workers conipemation policy information.
*'lf the corporate oRiects have exempted Wenuelees, but the corporation has odter employees, nworkers' compensation policy is requiredand such an
0 ganization should check box ltl.
I ran air ernp/oyer that is providlrrg rvorke�' cnlufrensntior! insarmlce fur my ellrptwees. Beloly 1s /!!e poticy rrefonnation.
insurance Company Name:
Insurer's Address: /
Policy # or Self-itts. Lie.
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 ora
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a tine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of die DIA for insurance coverage verificatiqn� -, _
I do hereby certifv,
-1,'79 9
Official use only. Do not write in this area, to be completed by ciot or town official
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6.Other
ve is trite and correct.
0/N
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Contact Person: Phone
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date 9 d
r
We, _,T/%& restaurant/ organization )
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. *
P ease list the organization:
-I We are not charging a fee for food/drink being served.
❑l We are a religious organization
y' Other: TASTE OF THE T^' T^'"'"'
Thank you,
/ffA
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature:
Date:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigeetions
600 Washington 24reet
Boston, AIA 02111
www.ntass.go v1dia
Workers' Compensation insurance Affidavit: General Businesses
Applicant information Please Print Lcgibly
i
Business/Organization
Are yo an employer? Check the appropriate box:
1. [11 am a employer with_J_employees (full and(
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
1 ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]**
4.E] We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. MW 't
6. Restaurant/Bar/EatingEstablishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
S. ❑ Non-profit
9. ❑ Entertainment
to.[:] Manufacturing
I L.0 Health Care
t2.[:) Other
*Any applicant that checks box #1 must also rill out the section below shoving their workers' compensation policy infnnnation.
**If the corporate oaicers have exempted themselves, but the corporation has other employees, a workcri compensation policy is required andsuch an
oreoaniratiun should check box # I.
l am an eafplgper that is providhig workers' compensation insttra�eJ'ar my e' nployees. Below iv the poll information.
Insurance Company Name:
Insurer's
City/State/Zip:
Policy 9 or Self -ins. Lic.
V a
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. a 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 firm 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 die DIA for insurance coverage veriiicagok. ___7
I do hereby
provided above is true and correct.
ite: 01dOl/i
Official use only. Do not write in this area, to be cotnpleteel Gr 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
b. Other
Contact Person: Phone #:
267/0ng._-.A.f�.-.-.-----..268/097 26S/oJG
` NOTICE
TO
EMPLOYEES
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 Hartford Fire Insurance Compan
NAME OF INSURANCE COMPANY
One Park Place,300 South State St, 7th Floor Syracuse NY 13202
ADDRESS OF INSURANCE COMPANY
76 WEG AD0173 05/01/19
POLICY NUMBER EFFECTIVE DATES
150 SAWGRASS DRIVE
PAYCHEX INSURANCE AGENCY INC ROCHESTER NY 14620 (877)-266-6850
NAME OF INSURANCE AGENT ADDRESS PHONE
ANTONIA'S INTERNATIONAL FOODS INC 369 CENTRAL ST FOXBORO MA 01035
EMPLOYER ADDRESS
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
Workers 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 ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 D Printed in U.S.A.
'I, W4&eFk
I EV I
z
0
z
04
C*4
0
C�
04
"I
C\l
LO
QN
ORA
� \/��:
� � \
\� � � �
\� � / �\: \
A
ff
on
Fo101O°I
V
0
z
z d
V
IL
c �
A
O 00 M M
CM
rM'^J i C4 N
M
W4 O ,
t3
z m O
C
U'
0
O O
•CL Q v ti
E X
� L)
O O O Zg
E �+ •�'o
0
Qh
� l
42 U a
v -
ts
x m
q
o
�a n w
tT�
1 QQ
3
A
s