HomeMy WebLinkAboutUncle Joey's Cannoli (NEFFA) - 4/14/2019Commonwealth 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: TEMPORARY FOOD PERMIT - NEFFA
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:.
Whose place of business is:
UNCLE JOEY'S CANNOLI
MANSFIELD SCHOOL COMPLEX - EAST STREET
PERSON(S) IN CHARGE:
JOE SIDELINGER
Permit Expires: April 14, 2019
Food Fee: $0.00
License Number: NEFFA-7
BOARD OF HEALTH
NichaeCHealey, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Permit Fee Approved By Permit # Issued
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: 7," k- A
2) Establishment Address: 4
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
5) Applicant/Owner Name &Title:
6) Applicant/Owner Address: &/4
7) ApplicantlOwner Telephone No:
8) Applicant/Owner Email address:
9) Person Directly Responsible For Onsite Operations:
Name & Title:
Address:
Telephone No: Fax:
Emergency Telephone No:
10) Event Attending
Date(s):
Event Name:
f
Event Location: 0 )/f
Event time:
el)
11) Check one
12) Solid waste disposal plan:
Food Truck
Caterer
Other:'I? (
13) Water Source:
14) Sewage disposal plan:
15 Please give a brief description of the food to be served:
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Food Protection Questionnaire for Catered Events
Date of Event: `li " " ;I / `,t Event Time:
Location of Even'e i J r 4I �%
�-
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
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Food Manager Certification Person Trained On Site? Yes o No
Allergen Awareness Menu Label Present? oafYes o No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
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List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41 °F?
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How will the PHF be kept at or above 140°F?
Time of PHF? Setup % U U, Served ; arr -, 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.
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16 ) Food will be prepared:
Onsite for immediate consum tp IOn
_ Onsile and he[Ka olding ten� proper hoU cold herature�.r
0 site 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 trainings and attach appropriate
certificates:
Food Safety Manager:
Allergen Awareness:w't'
18) If applicable, please describe your FOG management plan or attach the written plan:
19) For caterers: City/Town 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:
1, 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 oboi rcopies gf 105 CMR 590.000 and the federal Food Code.
19) Signature of
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, 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: 0 )2, Y k/ , f _'
21) Signature of Individual or Corporate Name: s ---
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.
SS 6r o dividual or Corporate Name
"Social Security No. (Voluntary) or Federal
Idenhflcation Number
By: Corporate Officer (Mandatory, ifApplicable)
*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:\Usem\sleile\Desklop\Scott's Documents\Food Eslablishmenls- Temp\TAX CERTIFICATION FORM.doc
the t,oninionweaun ojmassaenusens
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name: l,, r✓(' f
) r ? � 5 Phone #:
City/State/Zip:lr�t ` �--�-�-� �
Are you an employer? Check the appropriate box: Business Type (required):
1. Q I am a employer with t employees (full and/ 5. ❑ Retail
,emor part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. [1 s 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, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]**
4. ❑ We are a non-profit organization, staffed by volunteers, l l.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*My 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 #I.
I arty an employer that is providing workers' compensation insurance for ray employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. # Expiration Date:
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 ceftify, unde11
r the pAi(rs and penalties ofperjnry that the information provided above is true and correct.
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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 Person: Phone
INUIV n $50.00
2018- V36
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF BRIDGEWATER
BOARD OF HEALTH
PERMIT TO OPERATE A MOBILE FOOD ESTABLISHMENT
Permit No. 36
December 2, 2018
accordance with Regulations promulgated under authority of Chapter 94, Section 305 A and
iaoter 111, Section 5 of the General Laws a Permit is hereby granted to:
Uncle Joey's Cannoli
place of business is: Joseph Sidelinger, 414 River Street, Apt 4, Waltham, MA 02453
operate a mobile food server in: Bridgewater. (Christmas on the Common 2018)
mit Expires: December 2, 2018 at 6:00 PM
Eric 1. Badger, Health Agent
CITY OF NEWTON
Health and Human Services Department Permit
1000 Commonwealth Avenel] Newton Centre, Massachusetts 02459
Phone: 617-796-1420 Fax: 617-552-7063
SEASONAL FOOD PERMIT
In accordance with the rules and regulations established by the City of Newton Health and Human Services Department under the
authority of Massachusetts General Laws Chapter I11, Sectional and Chapter 140 Sections 51 & 53
Permit Type: ' Peimit No.
UNCLE JOEYS CANNOLI
SEASONAL SOl-19
The City of Newton Health and Human Services Department does hereby grant this permit to:
Name: Uncle Joeys Cannoli
Address: 414 River Street, Waltham, MA 02453
Limited to: Cannoli
Issue Date:
06/01/2019
NON -TRANSFERABLE
Expiration Date:
12/31/2019
Health and Human Services Department Agent
POST CONSPICUOUSLY
Q�pte0 A TOWN
oT
24
�WALTHAAM
o m
re. A �t
JOHN P.ZUPPE
DIRECTOR OF PUBLIC HEALTH
MASSACHUSETTS
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:
•
THIS PERMIT MUST BE POSTED IN A CONSPICUOUS PUBLIC PLACE
MOBILE 1 1. MAY BE REFERRED TO THE
DEPARTMENT
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CITY OF WORCESTER, MA
Department of Inspectional Services
25 Meade Street, Worcester, MA 01610
Phone:(508)-799-8539
FOOD ESTABLISHMENT PERMIT
PIN: FM-19-269
EFFECTIVE DATE: Tuesday, January 01, 2019
2019
PERMIT EXPIRES:
PERMIT FEE:
Tuesday,
December 31,
2019
250.00
In accordance with Regularions promulgated under authority of M.G.L. c. 94, ss 305A; c. 111, ss. 5 123A,
105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to:
Name of Permit Holder UNCLE JOEY'S CANNOLI
Address of Permit Holder 414 RIVER STREET APT. 4
Name of Food Establishment UNCLE JOEY'S CANNOLI
Address of Food Establishment 25 FRANCIS ST
OPERATIONS PERMITTED
Food and Drink Establishment 1 - 100 Occupancy
Comments: Restrictions:
Common Notes:
Renewal of Permit:
DURATION OF PERMIT
Annual
An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the
expiration of the permit.
Notification of Changes:
This permit is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If
this business is to close or there is a change in ownership, The DIS must be notified at least two weeks prior
to closing and this permit must be returned to the DIS.
Director of Housing and Health Inspections
Post Conspicuously
The Commonwealth of Massachusetts
City of Chelsea
Board of Health
Inspectional Services Department
PERMIT(S) NUMBER
047
A 1 t
ISSUE DATE
6/1/2018
In accordance with Regulations promulgated under authority of Chapter 111, Section
127A of the General Laws a Permit is hereby granted to:
CORPORATE NAME COMPANY NAME
Golden Cannoli, Inc. dba Golden Cannoli
Street Number Street Name
Whose place of business is 99 Crescent Ave.
Bar/Club Frozen Desert Milk Food Service
Type of business / restrictions
Wholesale Food Wholesale / Retail Food Retail Food
Yes
Comments / Restrictions
EX IreS 5/31/2019
Permit p
Richard Zullo - City of Chelsea
Code Enforcement Supervisor
FEE
150
Regular Cannoli shell with filling
Small: $3.00 or 2 for $5.00
Large: $5.00
Cannoli Chips and Dip
Container of chips with a choice of today's flavors
Fillings: $5.00
To go boxes available
Half dozen: Small/Large Dozen: Small/Large
Regular: $15.00/$25.00 Regular: $30.00/$50.00
YOU KNOW YOU WANT SOME CANNOLI