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Home My WebLink AboutFlaky Crust Pies (Taste of Tri-town) - 10/1/2019FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Temporary Food Establishment Permit Applicc-mon (Application must be submitted at least 7 business days before the planned opera date) F. 1) Establishment Name: Fj kG ( C r I10 z: 2) Establishment Address: Atn 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 26 o O`CJ 5 0(a 6 / 5) ApplicanNOwner Name & Title: 6) Applicant/Owner Address: 7) ApplicanNOwner Telephone No: -7 7 q 8) ApplicanttOwner Email address: 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: � Telephone No: j q z5_ Fax: Emergency Telephone No: 7 1 _ _ / "T 10)Event Attending Date(s): lob Event Name: ,k ac I s Event Location: cJ,e e( 1, p 5s �kc)A -, Event time: 11) Check one Food Truck Caterer( Other: 12) Solid waste disposal plan: �) I� �IY\ 'S)oOt i C I Sr l 13) Water Source: (� 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: afpij�, i lam 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at ro er hol/ cold hold i ern eratures ([site and held at proper hot/ cold holding temperatures Offsite, coole—®d and reheafe on si e Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: p 1 f Food Safety Manager:��lJ Allergen Awareness: a�l� 18) If applicable, please describe your FOG management plan or attach the written plan: 19) For caterers: CitylTown where food establishment permit is held. Please attach a copy of the caterer's permit: For food trucks, please list additional 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.1 have been instructed by the board of health on how to 94a1A copies of 105FMR 5P.000 and the federal Food Code. 19) Signature of 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: x 6 - 21) Signature of Individual or Corporate Food Protection Questionnaire for Catered Events Date of Location of Event: Event Time: ` Oyly t List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Food Manager Certification Person Trained On Site? yes m No Allergen Awareness Menu Label Present? XYes m 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 140°F? 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 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. oak -Gosh- Pigs WU - Signature of Individual or Corporate Name By: Corporate O icer (Mandatory, if Applicable) <3-,� _ 6N cl v gGa� 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. C:\UseN\sleite\Desktop\Scott's Dmumentffood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Inlnsb'ial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IN Ivtvrv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: IFIG L1 L jry S+— f Address: City/State/Zip: a Phone #: - 20 > ' d &() 7 Are you an employer? Check the appropriate box: Business Type (required): I.JV<'I am a employer with_employees (full and/ 5. ❑ Retail or part-time).* 6.kRestaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. 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, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box NI nhusl also fill out die section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' conhpensalion policy is required Laid such an organi/mion should check box # I. I nm an employer that is Insurance Company Nair Insurer's my employees. Below is the policy information. City/State/Zip: /� f Policy # or Self -ins. Lie. # �i � ��d . H'lb,H � r Expiration Date: l Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late). Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a tine 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 tine 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 rho hereby certifh under the pahrs ano penalties of peijur , that the information provider/ Above iyr true raid correct. Ofjicial use only. Do not write in this area, to be eompleled by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: Mansfield Board of Health Request for Fee Waiver for Food Permit Date aq We, 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. W Please list the organization: We are not charging a fee for food/drink being served. ❑ We are a religious organization ✓ Other: TASTE OF THE TRI-TOWN Thank you, A, A Sig ature Title�� "Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 MB 01 003754 03005 H 16 C �II'I�I)I,I,I„�)I,III)I)I(�IIII„I'1"IIII111'I�)1')I'IIII"I'I' FLAKY CRUST PIES, LLC 164 RICHARDSON AVE ATTLEBORO MA 02703-1220 Policy Information: Policy Holder Details: Flaky Crust Pies, LLC Policy Number Policy Term 08 WEC AC4F7F 11/26/18 to 11/26/19 i Dear Policyholder, November 26, 2018 %Q Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (877) 853-2582 Fax: (888) 443-6112 Email: aaencv.servicesCathehartford.com Website: www.thehartford.com Enclosed are posting notices for your Hartford Worker's Compensation policy listed in the below snapshot. Your policy documents have been delivered in accordance with your policy delivery preferences, which can be managed on www.thehartford.com/servicecenter. As a courtesy, we have mailed your posting notices directly to you. We recommend that you post these documents in accordance with your state requirements. If you misplace them or need additional copies, please contact your agent at (508) 339-7913. On behalf of your agent, ROBERT W EAMES INSURANCE AGNCY INC and The Hartford, we appreciate your business Sincerely, Your Hartford Service Team WCPNLTRO02 n A n lzi ti� rt � A y � l+• •P ww,co n N N N p p o o ro N J V , rt �O a. ray �y r �{ %f, � �7+ p• gg�$g�� O Otn rD G n Rai yam, � 1 O n J t+ NN a i g pad u 5 � _ 1 0 m X N 3 in C) N i