HomeMy WebLinkAboutCity Girl Cupcake - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit# Issyied, '
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted of least 30 days before the planned open n� gdate)..
Establishment Name
Establishment Address�y �� `' '`" ��- �P ✓ �� l �`�
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title:
Applicant Address
Applicant Telephone No.: x$ G 24 Hour Emergency No.: � y�
Applicant Email
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
0 An Association
partner.
El A Corporation
Name Title Address
Ik''An Individual
A Partnership
0 Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
etc✓,,�e�®� arm.. G ��j
Address: r /3c�� ✓ r
Telephone No: t!576 f ��� 24 Hour Emergency No:
FAX:
E-mail:m % • r� . / om
Alt E-Mail'
District Or Regional Supervisor (if applicable)
Name & Title:
Address: ,
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: 8
SEWAGE DISPOSAL: '
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS:—
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 7r, --'
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. Ed Yes
Does this establishment require a FOG permit? >,, If yes, please attach the FOG permit application.
th of Permit:
Establishment Type:
7Len
Annual
U R tail 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
O Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
(] Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End bate:
Food Service up to 201 + $300.00
Pushcart $50.00 # of Pushcarts:
Temporary Time:
EJ S permarkets $400
EJ Residential Kitchen $100.00
Rain Date:
-. Milk &Cream $10.00
[] Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food thmeRemperefure controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous foud(no timelemperature controls required)
RTE -reedy-to-eaffoods (Ex. sandwiches, salads, muffins which need no ahtnerprocessing)"
Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order
El Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs [f Preparation of PHFs For Hot And
for More Than a Single Meal Service
Cold Holding For Single Meal Service
[] PHF and RTE Foods Prepared For Highly
E] Delivery of Packaged PHFs
FI Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer
[] Use of Process Requiring A Variance
Processed Foods for Service Within Hours
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
Perishable Foods Only [J Ice Manufactured and Packaged for
control)
Zpreparation of Non-PHFs Retail Sale
0, Offers Raw Or Undercooked Food Of
0 Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
01 Vacuum Packaging /Cook Chill
U Offers RTE PHF in Bulk Quantities
0 Prepares Food/Single Meals for
El Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, efts
establishment opera o
board of health on ho
Signature of Applicant:
Pursuant to MG VI Ch.
and paid state t oxe e
Social Security W mbe
aracy of the information provided in this application and affirm that the food
with 105 CMR 590.000 and all other applicable law. I have been instructed by the
Ties of 105 CMR 590.000 and the federal Food Code.
sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
ad under law.
or Federal ID:
Signature of Individual or Corporate Name: `% i- �3��
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leuibly
Business/Organization Name: f i�
City/State/Zip:
Phone
cam,.-i c-•v,��.;,��s�
Are you an employer? Check the appropriate box: Business Type (required)':
1. ❑ I am a employer with employees (full and/ 5. 0 Retail
or part-time).* 6. FjRestaurantBar/Eating Establishment
2. 1 am a sole proprietor or partnership and have no y. Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. F1 Non-profit
3. We are a corporation and its officers have exercised 9. nEntertainment
their right of exemption per c. 152, § 1(4), and we have 10.Q Manufacturing
no employees. [No workers' comp. insurance required]* 110 Health Care
4.❑ We are a non-profit organization, staffed by volunteers, �� r✓r Ems- z
with no employees. [No workers' comp. insurance req.] 12.0Other
*Any applicant that checks box # l 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 pen an employer that is providing workers' compensation insurance for pry employees. Below is the policy information.
Insurance Company Nan
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic.
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 o£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 agains�t the v olator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fur'insurance coverage verification.
I do hereby certii* undef ijt pains and penalties of perjury that the information provirded 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
Phone
www.mass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: e + e5T
Address:
Mailing Address: '"
Phone/Fax Number:
Email: �G%m q�x� <e(�
Contact Person/Title for Grease
Name of Company scheduled to pump internal grease trap(s) monthly:- "' =Ii
r
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments Fee
3 grease interceptors/traps or less and/or 1 yellow grease collection $50
container
Each grease interceptor/trap over 3 $50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018.
In consideration of fh"r ranting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges thaWthe information submitted in these documents is true, accurate and complete.
Date /,I - der-.-'d
Print Name"��
[gntrusm7umnim♦ . L. .
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday Tuesday Wednesday
Thursday Friday Saturday
Sunday ,ly'� �i�//_®—, �<r/✓a
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attacKed to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
/
3 compartment sink
/
Handwashing sink
Commercial Dishwasher
Bar sink
%
Mop Sink
Garbage Disposal
Ice Making Machines
Fryolators
Grills or Ovens
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed? r/- Yes No
If yes, at what station/sink?
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to each grease trap
Grease Trap 1
Grease Trap 2
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes ✓ No Size gallons
Where is the existing outdoor GRU located?
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators?
Where is the grease storage unit located?.
How often is this grease storage unit emptied?
Please list the vendor who removes the waste:
3
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 initialiing 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 establishrfient in the Town of Mansffeld shall provide thin-film, single -use plastic check-out
bags to customers.
'' y" 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
bylawwill 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.
6,i' I 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.
f I 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 resu )#fines.
a - ao-.rd
Applicant Signature
Applicant Name (please print clearly)
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.
of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"*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.
CAUsen\sleite\Desktop\Scott's Doo ments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc