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FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name C(Ojg atsia�oc7��iF 0(_-
Establishment Address 16 Prx_- >Oee(e_ LcVL~-) JAoQ "4Tfc(d
Establishment Mailing Address (if different)
Establishment Telephone No .7 74 -L+ S ( - 2-oc.Q 2-
Applicant Name & Title: �Zcko_,� f"tS.IO Hj S i
Applicant Address b 47pI� Ajetd (C LOAC I J�_,tCLV?S k(Cl
Applicant Telephone No.: ]t��t� 51 _ z 24 Hour Emergency No.:
Applicant Email�((L,�c,
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
H An Association
partner.
171 A Corporation
Name Title Address
Y� An Individual
0 A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title: F-ttrAL&[ �,/ tk 0-i dVa7wZ�/r
,A
Address: �5 P(tiL�_ 1JQedl e- La-Gl e I ,I�,Ll.G2J 0 �/lA
Telephone No: 24 Hour Emergency No: 7%N-L45(--?fXe2_
FAX:
E-mail: Za iµ A VLAt deA VzS 0iP�> IAAtL 0Y)/1
Alt E-Mail: Vf Atk&( Nf_Q V1.'C Lea (- I t rreovIL
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: - TOLp IZ/L'
SEWAGE DISPOSAL:
No. of Food Employees: JL
DEP Public Water Supply No: (if applicable)
DAYS/HOURS: IN
Name of Person(s) In Charge Certified in
Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests
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. H Yes
Does this establishment require a FOG
permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Vi"l Annual
�❑�' Retail Food $125.00
Mobile Food Consession
0 Temporary
`❑�- Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
Ig Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Q Food Service up to 201 + $300.00
IF] Eushcart $50.00 # of Pushcarts:
Temporary Time:
ram.; Supermarkets $400
Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
;~-1 Caterer $36.00
Food Operations: Definitions: PHF - Potentially hazardous food(fimeRemperature controls required)
Non-PHFs- non -potentially hazardous footl(no GmeNemperature controls required)
(Check all that apply): RTE - ready -to -eat foods (Ex. sanclviches, salads, muffins which need no furlher processing)
I7 Sale of Commercially Pre -Packaged Non-PHFs
(4i PHFCooked To Order
Q Hot PHF Cooked and Cooled or Hot Held
ft Sale of Commercially Pre -Packaged PHFs
0 Preparation of PHFs For Hot And
for More Than a Single Meal Service
0 Delivery of Packaged PHFs
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
0 Sale of Raw Animal Foods Intended
Susceptible Population Facility
F Reheating of Commercially
to be Prepared by Consumer
Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
0 Customer Self -Service
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Foods Only
0 Ice Manufactured and Packaged for
control)
/Perishable
N Preparation of Non-PHFs
Retail Sale
Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations
Retail Sale
-�❑,'1 Vacuum Packaging /Cook Chill
F❑�.". Offers RTE PHF in Bulk Quantities
Q Prepares Food/Single Meals for
I] 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 obtain copies of 105 CMR 590,000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. i9A, 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.
Social Security Number or Federal ID: V,] / -70 i j 4 "7,(�1-� A (�
Signature of Individual or Corporate Name: ram{'' A a ll �X �ii A ^ ,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.
Si
nadividual or Corporate Name
"*Social Security No. (Voluntanj) or Federal
Identification Number
By: Corporate Officer (Mandaton/, 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.
C:\Users\sleite\Desktop\ScotPs DocumentArood Establishments- Temp\TAX CERTIFICATION FORM.doc
I',AI
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information ��"� Please Print Legibly
Business/Organization Name: Caw e n* 4 C v S
Address: P.) P1vic- tiJ?,eXJ1P
Phone #: 771-I - li 71 — % �) L� 2—
Are you an employer? Check the appropriate box:
Business Type (required):
Ln 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
I, ❑ Office and/or Sales (inel. 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' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
I Ln Health Care
✓❑'Other
with no employees. [No workers' comp. insurance rec
12.
*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 C.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Nan
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.
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
www.mass.gov/dia
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www,mass,gov/dia
Form Revised 5-26-05
TOWN OF MANSFIELD LOCAL BYLAWS
The following bylaws apply to all food establishments permitted by the Mansfield Health Department:
Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
Please indicate by initialing the following statements that the permitted food establishment will adhere
to all applicable bylaws. The applicant and associate corporation are subject to fines associated with
violations.
Plastic Waste Reduction
No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
bags to customers.
t./I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this
bylaw will result in fines.
Polystyrene Container Reduction (effective January 1, 2021)
Food establishments are prohibited from dispensing prepared food and drink in disposable food service
containers made from expanded polystyrene. All food establishments are strongly encouraged to use
reusable food service containers and cutlery, and when possible biodegradable, compostable
alternatives. Compostable materials must meet ASTM (American Society of the International Association
for Testing and Materials) Standards for compostability.
have received a copy of the Polystyrene Container Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Plastic Straw/Stirrer Reduction (effective January 1, 2021)
Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction with the serving by business establishments or at any town -sponsored event of liquid,
slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption.
__ZI have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
violations of this bylaw will result in fines.
Applicant Signature. C�- ��--'�✓�1��C���)i�f tti� i_�j Date:
Applicant Name (please print clearly) 4.w tC \ ��C Eli
§ 180-16 § 180-17
ARTICLE III
Plastic Waste Reduction
[Added 4-10-2018 ATM by Art. 451
§ 180-16. Purpose.
The purpose of this bylaw is to protect the Town's natural beauty and
irreplaceable natural resources by reducing the number of single -use
plastic check-out bags that are distributed and used in the Town of
Mansfield and to promote the use of reusable bags.
§ 180-17. Definitions.
The following words shall, unless the context clearly requires
otherwise, have the following meanings:
CHECK-OUT BAG — A bag provided by a store to a customer at
the point of sale. Check-out bags shall not include bags, whether
plastic or not, in which loose produce or products are placed by the
consumer to deliver such items to the point of sale or check-out area
of the store.
DEPARTMENT — The Mansfield Health Department.
HEALTH AGENT — The Health Agent for the Mansfield Board of
Health or their designee.
RECYCLABLE PAPER BAG — A paper bag that is 100% recyclable and
contains at least 40% post -consumer recycled content, and displays
in a visible manner on the outside of the bag the word "recyclable"
or a symbol identifying the bag as recyclable and a label identifying
the bag as being made from post -consumer recycled content and the
percentage of post -consumer recycled content in the bag.
RETAIL ESTABLISHMENT — Any business facility that sells goods
directly to the consumer, whether for or not for profit, including,
but not limited to, retail stores, restaurants, pharmacies, convenience
and grocery stores, liquor stores, seasonal and temporary businesses.
REUSABLE CHECK-OUT BAG — A sewn bag with stitched handles
that is specifically designed for multiple reuse and that:
A. Can carry 25 pounds over a distance of 300 feet;
B. Is machine washable; and
C. Is either:
(1) Made of natural fibers (such as cotton or linen); or
:1
§ 180-17
(2) Made of durable, nontoxi
§ 180-20
c
THIN-FILM, SINGLE -USE PLASTIC CHECK-OUT BAGS — Those
bags typically with handles, constructed of high -density polyethylene
(HDPE), low -density polyethylene (LDPE), linear low -density
polyethylene (LLDPE), polyvinyl chloride (PVC), polyethylene
terephthalate (PET), or polypropylene (other than woven and
nonwoven polypropylene fabric), if said film is less than 4.0 mils in
thickness.
§ 180-18. Regulated conduct.
A. No retail establishment in the Town of Mansfield shall provide
thin-film, single -use plastic check-out bags to customers.
B. If a retail establishment provides or sells check-out bags to
customers, the bags must be one of the following:
(1) Recyclable paper bag; or
(2) Reusable check-out bag.
C. Retail establishments with a floor area equal to or exceeding
3,500 square feet or with at least two locations under the same
name within the Town of Mansfield that total 3,500 square feet or
more, that make available thin-film, single -use plastic check-out
bags, with or without handles, that are exempted under this
bylaw are required to provide for in-store collection and proper
recycling of returned thin-film, single -use plastic check-out bags.
Retail establishments with a floor area less than 3,500 square feet
that make available thin-film, single -use plastic check-out bags,
with or without handles, exempted under this bylaw, are required
to provide for in-store collection and are required to properly
recycle collected thin-film, single -use plastic check-out bags if an
in -Town dropoff location or other no -fee option is available. In-
store collection locations must be prominently displayed and
easily accessible.
§ 180-19. Exemption.
Thin-film plastic bags typically without handles which are used to
contain newspapers, produce, meat, bulk foods, wet items, dry
cleaning, and other similar merchandise are not prohibited under this
bylaw.
:2
§ 180-20 § 180-23
§ 180-20. Enforcement; violations and penalties.
A. The Board of Health and its Health Agent shall have the authority
to administer and enforce this bylaw.
B. For the first violation, the enforcing authority, upon a
determination that a violation has occurred, shall issue a written
warning notice to the establishment specifying the violation.
C. The following penalties shall apply:
(1) A fine of $50 shall apply for the first violation following the
issuance of a written warning notice.
(2) A fine of $100 shall apply for the second violation and each
additional violation of this bylaw after the issuance of a
written warning notice.
D. Fines shall be cumulative, and each day on which a violation
occurs shall constitute a separate offense.
§ 180-21. Effective date.
This bylaw shall take effect six months following approval of the
bylaw by the Attorney General or on November 1, 2018, whichever is
later, for retail establishments with a floor area equal to or exceeding
3,500 square feet or with at least two locations under the same
name within the Town of Mansfield that total 3,500 square feet or
more. This bylaw shall take effect one year after passage for retail
establishments less than 3,500 square feet. The Director may exempt
a retail establishment from the requirements of this section for a
period of up to six months upon a finding by the Director that:
A. The requirements of this section would cause undue hardship; or
B. A retail establishment requires additional time in order to draw
down an existing inventory of thin-film, single -use check-out
plastic bags.
§ 180-22. Rules and regulations.
The Board of Health may adopt and amend rules and regulations to
effectuate the purposes of this bylaw.
§ 180-23. Severability.
If any provision of this bylaw is declared invalid or unenforceable, the
other provisions shall not be affected thereby.
3
INGREDIENT LIST
Unsalted sweet cream butter (pasteurized cream, natural flavorings)
Granulated sugar
Eggs
Low fat milk (vitamin a palmitate and vitamin d3)
Unbleached, all purpose flour (wheat flour, malted barley flour, niacin, reduced iron, thiamin
mononitrate, ribo-flavin, folic acid)
Salt (calcium silicate)
Baking sodium (sodium bicarbonate)
FROSTING
Powdered sugar, cornstarch
Unsalted sweet cream butter (pasteurized cream, natural flavorings)
Vanilla extract (water, alcohol (130/6), vanillin, citric acid)
Sweetened condensed milk
Low fat milk (vitamin a palmitate and vitamin d3)
Icing color (corn syrup, sugar, glycerin, water, food starch, agar, citric acid, potassium sorbate,
sodium citrate)