HomeMy WebLinkAboutDel's Lemonade - 9/30/2019Commonwealth 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: XFINITY RETAIL FOOD PERMIT
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..
RYAN SUKASKAS
Whose place of business is:
RM SUKASKAS INC. DBA DEL'S LEMONADE @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE
RYAN SUKASKAS, OWNER
Permit Expires: September 30, 2019
Food Fee: $100.00
License Number: XP-2
BOARD OF HEALTH
.'lichae(HeaCey, Chairman
t
3"1 FOR BOARD OF HEALTH USE ONLY Permit # Issued XP- 4
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name RM SUKASKAS INC. DBA DEL'S LEMONADE @ THE XFINITY CENTER
2) Establishment Address 885 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 446 CENTRAL AVNEUE
PAWTUCKET, RI
4) Establishment Telephone No (401) 413-5494
5) Applicant Name & Title: RYAN SUKASKAS, OWNER
6) Applicant Address 28 WOODSONG DRIVE, N. SCITUATE, RI 02867
7) Applicant Telephone No.: (401)413.9494 24 Hour Emergency No.: (401)413-6404
8) Owners Name & Title RYAN SUKASKAS
9) Owner Address (If different from applicant)
Owner's telephone number 4014136494
10) Establishment Owned By:
Ll An Association
ICJ A Corporation
❑ An Individual
❑ A Partnership
❑ e e a
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
ame & Title:
RYAN SUKASKAS, OWNER
ddress:
28 WOODSONG DRIVE, N. SCITUATE, RI 02867
elephone No:
AX:
(401) 413-5494 24 Hour Emergency No: (401) 413.5494
E-mail:
RYANSUKASKASOGMAIL.COM
A E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
CORY SUKASKAS, VICE PRESIDENT
Address:
431 GREENVILLE AVENUE, JOHNSTON, RI 02919
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
r14) WATER SOURCE: TOWN
15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable)
16) No. of Food Employees: 1
17) DAYS/HOURS: EVENTS
18) Name of Person In Charge Certified in Food Protection Management:
j If more than 3 individuals are certified, complete list is on file.
IRequired as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of
I certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
20) Location: ❑ Permanent Location
22) Establishment Type
❑ Caterer $25.00
❑ Mobile Mobile Start Date:
❑ Retail ( Sq. Ft)
❑ Milk & Cream $10.00
Mobile End Date:
❑ Food Service up to 100 or
❑ Mobile Food & Consession $75.00
Mobile Comments:
up to 10' PHF display $125.00
❑ Food service up to 101 -200
or up l0 25' PHF display $150.00
❑ Food Service up to 201 +
or 254 PHF display $276.00
❑ Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
<�
n Pushcart .00 # of Pushcarts: "L-
❑ Residential Kitchen $100.00
❑ Retail Food $100.00
21) Length of Permit:
I !Annual
lyI Seasonal
1 Seasonal Dates:
[j Temporary
❑ Food Service - Institution
❑ Retail Snack Food $25.00
Temporary Start Date:
( MealsiDay)
❑ Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Dale:
r'
23)Food Operations
(Check all that apply):
Definitions: PHF - Potentially hazardous food (ilmeAemperature controls required)
Non-PHF's - non -potentially hazardous food(no t/meAemperature controls required)
RTE - ready-fo-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Delivery of Packaged PHFs
.- -
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (Including bare hand
contact alternative, time as a public health
control)
[ Customer Self -Service of Non PHF and Non-
Perishable Foods Only
! y
❑ Customer Self-service
El Ice Manufactured and Packaged for
Retail Sale
Preparation of Non-PHFs
❑ Offers Raw Or Undercooked Food Of
Animal Origin
Other Food Operations
❑ Juice Manufactured and Packaged for
Retail Sale
_
❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Offers RTE PHF in Bulk Quantltles
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
---
To be completed by the Board of Health
Total Permit Fee: $100.00
Payment is due with application ❑ waived
I, the undersigned, attest to the accuracy of the information provided In this application and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been Instructed by the
board of health on how to obtain roles of 105 CMRw90.000 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal to: 46.2640543 /7
26) Signature of Individual or Corporate Name: !4 ��
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Q M .S"ICASICAS Zile, 2_yr;J% M • St-Lkocts(o ,.S
Signature of Individual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable)
,�6 - acy0sy3
*"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Osecs\sleite\Desktop\ScotPs DoeumentsTood Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Y— Please Print Legibl
(VA
Business/Organization Name: M StlkAS14$K Tvic
Address: ag-
CA?67 phone#: �i01—Nl3-5�9�f
Are you an employer? Check the appropriate box:
Business Type (required):
I. ❑ I am a employer with employees (full and/
5. ®,Retail
or part-time).*
6. ❑ 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.
S• ❑ Non-profit
[No workers' comp, insurance required]
3. We are a corporation and its officers have exercised
9. ❑ Entertainment
thew right of exemption per c. 152, § 1(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
I I.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.❑ 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.
I am an employer tliat is providing workers' competisatiort insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
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 and penalties ofperjury that the information provided above is true and correct.
Signature: e— ^ Q� Date: 5 �f 1
Offreial 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.mass.gov/dia
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