HomeMy WebLinkAboutBite of Everything - 12/31/2020C'SA'1 oa. y
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION " A
(Application must be submitted at least 30 days before the planned opening date)A `
Establishment Name Bite of Everything Catering
Establishment Address 287 Chauncy Street B-303 Mansfield MA 02048
Establishment Mailing Address (if different)
857-242-956
Establishment Telephone No
Applicant Name & Title: o e
287 Chauncy street B-303 Mansfield MA 02048
Applicant Address g5�-242-956
Applicant Telephone No.: 867-242-9567 24 Hour Emergency No.:
Ashlaymhammach@gmnil.co
Applicant Email m
Owner Name & Title (If different from applicant)
Owner Address 287 Chauncy streetB-303 Mansfield MA 02048
6"I �-3-19-864
Owner telephone number
Fzacr,lcr na..,..,acr,@9ma11-co
Owner email: ^
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
O An Association
partner.
O A Corporation
tti�ee q
Name Ashley Hammach &IRachid Hammach ddress
td An Individual
J
Pl A Partnership
>-87 Chauncy st B-303 Mansfield MA 02048
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
ASY�Iey Hammach -
Name & Title:
Address: 287 Chauncy street B-303 Mansfield MA 02048
Telephone No: SS' -242-956 24 Hour Emergency No: 757-242-sss
FAX:
E-mail: Contact@biteofeverythingcatering.co
n
Alt E -Mail: %sh leym ham mach @g mail. com
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: Town of Mansfield
SEWAGE DISPOSAL:
Town of Mansfi
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
v
DAYS/HOURS: 9-s
Name of Person(s) In Charge Certified in Food Protection Management:
A-^�F-iloy
Ham mach
Name of Person(s) In Charge Certified in Allergen Awareness Training
Hemmc cl-�
Name of pest control company routinely inspecting the premises for evidence of pests Provided by landlo
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. IN Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
ii nnual
3 '. Retail Food $125.00
Mobile Food Concession
F❑_9 Temporary
L1 Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
0 Manufacture Frozen Dessertslice Cream
Temporary Start Date:
„3 Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400
Aesidential Kitchen $100,00
Rain Date:
Milk &Cream $10.00
[d Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food (h'meltemperatum controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no
furtherpmcessing)
0 Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service
0 PHF and RTE Foods Prepared For Highly
Sale of Raw Animal Foods Intended
Susceptible Population Facility
0 Reheating of Commercially to be Prepared by Consumer
I] Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
0 Customer Self
and/or HACCP Plan (including bare hand
-Service
0 Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only 0 Ice Manufactured and Packaged for
control)
.�C
U Preparation of Non-PHFs Retail Sale
Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
ry Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
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 obtahn codeslbf 105 CMR 590.000 and the federal Food Code.
Signature of Applicant: 1 147-/_I
Pursuant to MGL Ch.62C, sec. 49A, I cE
and paid state taxes required under law.
the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: oos-�s-sso
M
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.
w4jv�o��
Signature of Individual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable)
008-76-9609 g08 -960
"Social Security No. (Voluntan/) 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:\Users\sleit6,Desktop\Scott's DocumentsNood Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
19 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Bite of Everything Catering
287 Chauncy Street B-303
City/State/Zip: Mansfield 02048 Phone #: 857-242-9567
Are you an employer? Check the appropriate box:
Business Type (required):
1.❑
I am a employer with employees (full and/
5. Q Retail
or part-time).*
6. E]Restaurant/Bar/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
3.❑
[No workers' comp. insurance required]
We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have
1 10.❑ Manufacturing
4. ❑
no employees. [No workers' comp. insurance required]*
We staffed by volunteers,
11.❑ Health Care
are a non-profit organization,
with no employees. rNo workers' comp. insurance req.]
12.❑ Other
*Any applicant that checks box # I 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 #/.
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
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 qnd penalties ofperjury that the information provided above is true and correct.
- . n n I„ a 7 - ,.1/1512020
857-242-9567
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 Person: Phone #:
www.mus.gov/dia
Sheet4
TOWN OF MANSFIELD - -
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURERS
_-_ - DEPT:: WAR 'OFHEALTH
anent: CASH - ACCOUNT NOi 01512-445006
FROM WHOM
imach
TOWN OF MANSFIELD
rsn H)
JAH, 12 1 2020
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