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Home My WebLink AboutSiddi's Bakeshop - 12/31/202100/ H FOR BOARD OF HEALTH USE ONLY Permit# Issued Cla �,1 FOOD ESTABLISHMENT TION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 5i,d dy'S $akeSkop Establishment Address 10 Ucaiyt. Ave Mans FfBld okogg Establishment Mailing Address (if different) Establishment Telephone No 79 1-4''4 S_- 041 L) Applicant Name & Title: Applicant Address ID, Sd d CA lU `D e-S h r" k�A'1 pp ( 0 LQ nil -f - - -- . QCLp ye pfv W I'lQ.{'l5 Yloi] 020f g Applicant Telephone No.: a g I �j-4 S 0-+14 24 Hour Emergency No.: Applicant Email S�dd'vsbakeAD.p L iamcl.i Itco ri ...... 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 O An Association partner. O A Corporation VAn Individual Name_ Title Address ___.........................__ F� A Partnership 0 Other legal Entity - — Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: O��dLd'�i,u T"Vlnn-tk^k-h (� Clowns) i✓ 6it Address: ID le e „ I r `anS k P (d O LDIi Telephone No: -4919. -1 S OTI q 24 Hour Emergency No: FAX: E-mail: s;ddti'I •deShr"kh 88®Ilwu1, CDDi Alt E-Mail: SiddyS b0.�e3kOP ®. {�ryILU �� LO 1111 District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No. - FAX: E-mail: Food Establishment Information WATER SOURCE: '(D Q9 yl tit me(".9 1�1 C IQ I SEWAGE DISPOSAL: OEP Pubur Water Suppty q: Ulappilwble) No. of Food Employees: DAYSIHOURS Cigyi IL(O In Charge Certified In Food Protection Management .. - I,:.I. LI I I Name of Persons) In Charge Certified in Allergen I S�ctdhi Peshnwbh Name of pest control Company routinely inspecting the premises for evidence of If there is setting for 25 people or more, a person (mined in manual choke saving procedures will be onsite at all times food is being prepared. UlYes Does this establishment require a FOG permit? Will If yes, please allach the FOG permit application. Len/plh of Permit: Establishment Type: .Ig{Mnual (d Rebit Food $125.00 Mobil¢ Food Concession []Temporary 0 F¢W Service op to IN INCLUDING NO PHF PREPARED ON SIM$t0aG0 Tem Sbd Date: Pomtl FOOD TRUCKS SI 7500 nMnnufadure Finaen Desselladce Cmam Tempura End Dab' (] FOM SeMce uD l0101 -200 $R50.00 325AOHreeter or - FOM SeMwup1o20i*$30000 ❑jPuahrad$50 o0 "Pushwm: Tom Rain Dale I�SuwrmaNels YICO UvjR ald.IFI Kitchen$1W.W ._... _�n MtlkBCream Sf0,00 ❑Clever$3500„ FOW OPemdorts: O. nnaacmM-wrerw+a/nuarewarootlrymnmswWrernwgsmluaep) (ChlWr all Nat appM: ��a-'P-`�n'��'�aNava/ar/lro MMempzaNm cmbo'a mprved) FiE-a Wr W aer M1pl4 (Fi. aewv[a aa, aap0a manna mlkn nttvl no 0Me-prceaaXpl Q Sale of corovoelry Pa -Paned Nor-PHF5 []"FCookrd To Order Q Hot PHF Cooked and Cooled or Hot Held I]sele olCommorgalyP2PachaOed PHR [J Pmparalbn UPHFs �orHorvid 'for Mom ThaXaGinole Meal Service o cteu,,"ofproom,WPHF. Cab Hokotq For Skele Meal Selviw n PHF eM RTE FOWS Prepared For Hbhly [] SMe of R. Anlmal Foods lnlend,d Suswptibie Population Fa¢Bily ReNetlirg of Cam martially lobe Piwaredby Consumer ] Dr. of P.. RN.film A Vadanw Prowsr., foods for No. SoMw WMind ndror HACCP Plan dnrzov., e hand par I]Cuslomer SelfSeMwof Non PHF eM Non jJ Cuatolner SeMSeMw aoontad e110maMe, lime a. a puhk health Pedsheb@ FoWS Only [j lw Menufdooduep PaQa9ed ton Ioproll .ar &"rrCtbnof Nor-PHF9 Futhosale Offers Raw 0I Und&goketl Fart Of R [i .1I llanuhflmed eM Pir&a,Nd for Animal Odgln Olper FCW Operelbns ebll $ale - GlOffersRTEPHF In6ulkQuarm,,s El El vaaam PacNFoN081,1v Cool, Chid Prepares v..I,.neb Mealsfor I-.o RS dRio DtSFNI Out DLDate CalerM Events or lnslXutlonai Food Service ar RecondilbnW Food I, no uMarsgned attest to M. awusac .Hhe inlmmatbo provldad In Ilan aPMlwllon end Mort not Ne tole esiabllahmentopem0on wJlwmpywnh 105 CMR 6011.000 aM aA other appliaebla lawn Ihavebeen InsWctadbythe boardofMaMonhmtooblalamPb otiMCMRSW,MeMthefOomi Food Cade. agnaWm of Appliwnl _ ..._-_ aunuanl to MGl CM1.02C, sec 1aft,1 ceNty under Ne penaXias of PoOury bat , to my best knowf Woe antl bevel, have 0bd oil stele lax returns M paA elate tacos reymred ulMerlaw. Sodal Securely Npmbefar FedemHO: 48G 1`4u86 Signaler- of IrdWoal or Comorala Name: TAX CERTIFICATION FORM ,_.,...r,., .. . . I certify under the penalties of penury. that L to,cgy best knowledge and belief, have filed all state tax returns and paid all state taxes requiied trader law. . , I 1 ' .. ' ; 11, 11 Ja ' Signature of Individual or Corporate Name Ltgo-'}1-4486 "Social security No. (Voluntary) or Frdeml IdenNjimtion Nn aber' By: Corporate Officer (Mandatory, ll(Appfimbie) *This,license will met be issued unless this certification clause is signed bytheapplicant. '- "* Your social security number will be furnished to the Massachusetts Department of Revenue todetermine whether you have met tax filing or' tax payment obligation's, ,Licensee9 who,fail to correct their r1op,-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. CUUFsVIlminakmpl5ep@ UocuInuNoel EgabI —al"WTm,VrAX CIUMPIATION ronntnu Ilie Lo" ntonlveatin of mnss'aetiusens Department t f Industrial Accidents Office of luvestigations 600 Washington Street Boston, MA 02111 rvivrenlass.govIdia Workers' Compensation Lmun Rare Affidavit: General Businesses Applicant Information Business/OrganizationName: is Q Sly7 Address: 10 OCA, Y ---A- C._._NVAII$ i-I CU ___ __--______ Are you an employeR Cbechtho appropriate box: I.❑ I Bmincss 7�pe(required)n 5.,[,7i Retail rddshmem am a employerwith_,-_employees(full auto mpm4ime).' I 21 lama sole propsietori m artnerehip mtd haven. 6. OR, cgm-Mra/Iislingl 7, ❑ Office enevor Sit" line]. seal esmte, auto, eta.) employece working for me in any capacity. [No worker' comp. insurance required] -- ' S. ❑No;,mdb 3.❑ Werra a oo@mathro nd its officers have exercised 9. ❑Rrumaimncm the', dgldofexemptiaeperc. 152,§I(4hmndwehove 100blannfactoring no employees. [toe worker' comp. insurance required]. 4.❑ We me a namprofit ingratiation, sleRed by volunteers, I 1,C] Health Care .,osswsn.a rhaeld chuk 60�p1. I —au ",player that is prorlding uarken'remDrournen t„vaa.fr,,y m,,b,,ees. Refmr is lhn palfey b f merlon. Policy h or SelGms. Lic. D expiration Dam: Attach. ropy afihe porkers' eompeusatien policy dedantion page (showing the policy number and expiration dale). Failure to seems coverage as required under Section 25A oFMGL c. 152 can lead tothe imposition of criminal pdialties are fineup io $1,500.00 and/or one-year imicca mneny as well es civilpenalties in the done -to SIDP WORK OROCR and a fine efup to$250.00 a day against the violator. Be advised that. copy ifflim statemerrany be forwarded to the Office of OJjefal,seenly. Da nohvrlle in lGk area, to be aoupleted by drymtmwt offiefnl. City or Town: reran"U'r se a Issuing Authority (circle one): L Board ofHearld. 2. Building Department 3. City/Town Clint 4. Lic... top Board S. Selectmen's Office 6. Other Contact Peron:—.— Phone Menu Keto friendly cupcakes cake Keto friendly Brownies Keto friendly chocolate chip cookies Sugar cookies Snickerdoodle cookies Double chocolate chip cookies Chocolate chip cookies Hot cocoa milk chocolate bombs salted caramel Milk chocolate bombs Masala dude bombs vanilla cupcakes and cake Chocolate cupcakes and Cake Vanilla egg free cake Vanilla egg free cupcake Chocolate egg free cake Chocolate egg free cupcakes Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Vanilla keto cupcakes Egg 170 g Butter melted 54 g Coconut flour 25 g Almond flour 12 g heavy cream 10 ml Flax meal 2 g Baking powder 2 g Salt 0 g Vanilla buttercream Butter 60 g Erythritol monkfruit extract 60 g Vanilla extract 2 IVQ vanilla bean extractives in water, alcohol 35%) Net weight 300 g 6 cupcakes Contains : tree nuts, eggs Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Keto brownies Ingredients erythritol 70 g Butter 65 g Eggs 60 g Cocoa powder with alkaline 40 g Almond flour 35 g Dark chocolate chip (Unsweetened cocoa, Erythritol in Ewing organic soil lecithin sunflower lecithin vanilla extract Stevia extract )12.5 g flaky salt 1 g net weight 270 g — 4 browines Contains : tree nuts, eggs Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Hot chocolate milk chocolate bombs Milk chocolate 16 g (Sugar, Palm kernel oil ,whole milk solids, whey powder, nonfat dry milk solid soy lecithin ,salt, artificial flavor) Cocoa powder with alkali 2.5 g Sugar granulated 2.5 g Marshmallow mini 1 g (Corn syrup sugar modified cornstarch dextrose water gelatin tetrasodium pyrophosphate natural flavor and artificial flavor blue one) Net weight 23 g 1 hot chocolate bomb Contains: Dairy, soy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Hot chocolate salted caramel bombs Milk chocolate 16 g (Sugar, Palm kernel oil ,whole milk solids, whey powder, nonfat dry milk solid soy lecithin ,salt, artificial flavor) Cocoa powder with Alkali2.5 g sugar Granulated 2.5 g Salted Caramel drizzle (Sugar bomb kernel oil, hydrogenated palm oil, whey protein, whole milk powder,salt, soy lecithin, artificial color (FD&C yellow 6 lake, FD&C yellow 5 Lake FD&C blue 2 Lake ) natural flavor and artificial flavor) Salt 0.5 g Net weight 23 g Contains: Dairy, soy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Masala doodh (Milk) bombs White chocolate 16 g(Sugar palm kernel oil whole milk powder nonfat dry milk soy lecithin vanilla extract) Milk powder 5 g Milk masala (Almonds, Cashew, Pistachio, cardamom, nutmeg, nut mace, saffron) I White chocolate drizzle pistachios saffron 1 g Total net weight 23 g Contains: Dairy, tree nuts, soy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Sugar cookies All-purpose flour 90 g Butter 56 g white granulated sugar 50 g Milk 15 ML Vanilla extract 0.5 ml ( vanilla bean extractives in water, alcohol 35%) Baking powder 1g Salt 0.2g Net weigh 240 g 12 cookies Contains: wheat, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Snickerdoodle cookies All-purpose flour 180g Butter 113 g white granulated sugar 100 g Milk 30 ML Vanilla extract 1 ml ( vanilla bean extractives in water, alcohol 35%) Baking powder 1g Salt 0.5g Cinnamon ground 5 g white sugar 20 g Total net weight 300 g 12 cookies Contains: wheat, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Double chocolate chip cookies Chocolate chips 85 g(Sugar chocolate cocoa butter milk fat soy lecithin natural flavors) All-purpose flour 60 g Cocoa powder with Alkali 15 g Baking powder 1/4 teaspoon Butter 57 g Light brown sugar 42.5 g(sugar molasses) White sugar 25 g Yogurt 14 g Vanilla extract 1ml ( vanilla bean extractives in water, alcohol 35%) Net weight 287g 6 cookies Contains: wheat, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Chocolate chip cookies All-purpose flour 180 g Chocolate chips 170g(Sugar chocolate cocoa butter milk fat soil lecithin natural flavors) Butter 113 g Brown sugar (Sugar and molasses) 106.5 g Sugar 94 g Oil (sunflower) 30 mL Water 14.79 mL Baking soda (sodium bicarbonate)1 teaspoon Vanilla extract 1ml ( vanilla bean extractives in water, alcohol 35%) Net weight 640g 12 cookies Contains: wheat, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Dinner rolls all-purpose flour 580 g Milk 215 mL Butter 58 g Sugar 45 g Water 85 mL Yeast (sorbitan monostearate)7 g salt 12 g oil (sunflower)20 mL Net weight 970 g 12 dinner rolls Contains: wheat, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Vanilla cupcakes cake All purpose flour 158 g sugar 150 g Buttermilk 118.29 mL Unsalted butter 113 g Eggs 70 g Baking powder 2g (Cornstarch sodium bicarbonate mono calcium phosphate) Salt half a teaspoon Vanilla extract 2ml (Vanilla bean extractives In water alcohol 35%) Vanilla buttercream Butter 60 g Powdered Sugar 120 g Vanilla extract 2 ML( vanilla bean extractives in water, alcohol 35%) Net weight 720 g(12 cupcakes) (8inch cake ) Contains: wheat, egg, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Vanilla cakes cupcake egg free All purpose flour 158 g sugar 150 g butter 113 g Buttermilk 118.29 mL Egg replacer 30 g (Potato starch, tapioca flour, baking soda, psyllium husk fiber)+water 60 IVIL Baking powder 2g (Cornstarch sodium bicarbonate mono calcium phosphate) Salt half a teaspoon Vanilla extract 2ml (Vanilla bean extractives In water alcohol 35%) Vanilla buttercream Butter 60 g Powdered Sugar 120 g Vanilla extract 2 ML( vanilla bean extractives in water, alcohol net weight 720 g(12 cupcakes / 8 inch cake ) contains: wheat, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Chocolate cupcakes cake sugar 207 g All purpose flour 130 g Buttermilk 120 ML Oil (sunflower) 120 ML Water 120 ML cocoa powder with alkali 43 g Egg 35 to 45 g Vanilla extract 3/4 teaspoon( vanilla bean extractives in water, alcohol 35%) Vanilla buttercream Butter 60 g Powdered Sugar 120 g Vanilla extract 2 ML( vanilla bean extractives in water, alcohol 720 g net weight(12 cupcakes / 8 inch cake ) Contains: wheat, egg, dairy Siddy's Bakeshop 10 Claire Ave Mansfield MA 02048 Chocolate cake and cupcake egg free Sugar 207 g all purpose flour 130 g Buttermilk 120 ML oil (sunflower)120 mL Water 120ml egg replacer powder 10 g(Potato starch, tapioca flour, baking soda, psyllium husk fiber)+water 30mI cocoa powder With alkali 43g Baking powder 2g Salt 0.5g Vanilla extract 2ml ( vanilla bean extractives in water, alcohol 35%) Vanilla buttercream Butter 60 g Powdered Sugar 120 g Vanilla extract 2 IVQ vanilla bean extractives in water, alcohol Net weight 720 g (12 cupcakes / 8 inch cake ) contains: wheat, dairy