The URL can be used to link to this page

Home My WebLink AboutSEG's Heavenly Delights - 12/31/2021JAN �06(00' FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name G\(-ers\..A 1�C'i�sti�S Establishment Address S-0 Establishment Mailing Address (if different) Establishment Telephone No 1 1 t q, F)� E; . 0-2- 8, li D204W Applicant Name & Title: Applicant Address s V pr�c c, �l Awn s �` e l� . ✓1�� t v y g Applicant Telephone No.: C, t t S () Z� t 24 Hour Emergency No.: JZ _ Applicant Email Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: An Association -' A Corporation ,>_)0An Individual El A Partnership Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: k Address: Sv l t o r\c Telephone No: 0-1-$ I 24 Hour Emergency No: 4�5zMp" FAX: E-mail: 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 l lb"� 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: KS 4, Name of Person(s) In Charge Certified in Allergen Awareness Training L-F Name of pest control company routinely inspecting the premises for evidence of pests ✓ �1Q t!l Mi�L% 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. [PI Yes Does this establishment require a FOG permit? Length of Permit: Annual t._] Temporary Temporary Start Date: Temporary End Date: Temporary?ime: Rain Date: Establishment Type: If yes, please attach the FOG permit application.. 1 Retail Food $125.00 i—', Food Service up to 100 INCLUDING FOOD TRUCKS $176,00 ',Jj Food. Service up to 101 -200 $250.00 L] Food Service up to 201 + $300.00 [] Supermarkets $400 [pit Milk & Cream $10.00 '.].Mobile Food Consession NO PHF PREPARED ON SITE $100.00 L� Manufacture Frozen Desserts/Ice Cream $25.00/freezer Ffl Pushcart $50.00 # of Pushcarts: esidenfial Kitchen $100,00 (] Caterer$35.00 Food Operations: Definitions: PHF Potenfiellyhomadous food (fimeRempereture controls required) (Check all that apply): Non-PHFs- non -potentially hazerdousthod(no limaltemperetum controls required) RTE- reedy-fa-eet foods (Ex. sandwiches, sateds, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs [EI PHFCooked To Order Fv] Hot PHF Cooked and Cooled or Hot Held �f Sale of Commercially Pre -Packaged PHFs I Preparation of PHFs For Hot And for More Than a Single Meal Service f7j Delivery of Packaged PHFs Cold Holding For Single Meal Service i`7I PHF and RTE' Foods Prepared For Highly Reheating of Commercially i Sale of Raw Animal Foods Intended Susceptible Population Facility .�1 vi Processed Foods for Service Within 4 Hours 10 be Prepared by Consumer [i Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand [u9] Customer Self -Service of Non PHF and Non- [a] Customer Self -Service contact alternative, time as a public health Perishable Foods Only [r] Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale [] Offers Raw Or Undercooked Food Of [x] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale [l Vacuum Packaging I Cook Chill p .1 I'' ffers RTE PHF In Bulk Quantities ' Efl Retail Sale of Salvage, Out -Of -Date [El Prepares Food/Single Meals for Catered Events or Institutional Food Service (h- lit or Reconditioned Food 1, the undersigned, attest to the accuracy of the InfoLWation provided in this application and affirm that the food establishment operation will comp ith 105 C 5 900 and all other applicable law. I have been instructed by the. board of health on how to obtai co i s of 10 M 590,000 federal Food Code. Signature of Applicant: Pursuant to MGL Ch.52C, s 9A, I certify under th enalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal 10: to Signature of Individual or Corporate Name: L) J 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. r— ignature of dividual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc LIS 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 Please Print Legibly Business/Organization Name: f ve r Address: —SD i> t City/State/Zip: DI&4S Phone M(91 t q • q I S- D 2- R Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. Ig 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, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12. Other *Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information. 7:4 `(t 60ods **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' npensation policy is required andsuch an �/ organization should check box#l. �ioyl; (]n ' �� (dJ/�fAon4ri I am an employer that is providing workers' compensation insurance for my employees. Below ids� thepolicy information. Insurance Company Name: ! e bt ✓i } inrt{��tl ,jve j el Insurer's City/State/Zip: Policy # or Self -ins. Lic. # _% Expiration Date: t 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, undue fiainsW penalties of perjury that the information provided above is true and correct Phone #: 9 ) ` - ®s—' P / Z.& / 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 #: www.nmss.gov/dia eaventy Italian Pasteries Angel Anisette Cookies $12 2dz Chewy Ginger Molasses Cookies $12 dz Pignoli Cookies $12 dz Fried Oreos $12 dz Jelly Filled Bow Ties $12 dz Fig & Almond Cookies $13 dz Cream Cheese Cookies $13 dz Limoncello Cookies $13 dz Italian Ricotta Cookies $13 dz Peanut Butter/Chocolate Kisses $13 dz Thumbprint Cookies $13 dz Italian Butterhorn Cookies $14 dz Almond Biscotti $15 dz Ileav nIy-C-rmmy-Cream--PUffs �o� ` c'e� $15 dz Berry Cream Cheese Pastry $15 dz Mini Apple Pies $16 dz Nutella Pastry Tree $20 Cinnamon Walnut Roll $20 Contact: Carmela Garieri Email: SEGsDelights@gmail.com avenfy 2) Coconut Macaroons Almond Flour Cookies No Bake Butter Cookie Energy Bites Almond Zucchini Fritters Cloud Bread (Everything Seasoning Optional) Sabrina's No Bake Peanut Butter Cheesecake Almond/Vanilla Loaf Banana Loaf Lemon blueberry Loaf Cranberry Orange Loaf Sp-nacfrQui-ch-e-with Almon-d-Crust Apple Crumble Almond Maraschino Cherry Cupcakes Chocolate Cupcakes filled with Peanut Butter Red Velvet Cupcakes Vanilla Strawberry Shortcake Cupcakes Hot Chocolate Bombs Contact: Cannela Garieri $10 dz $10 dz $10 dz e. e $8 d.z $24 $20 $20 $20 $20 $20 M $24 dz $24 dz $24 dz $24 dz $5 each Email: SEGsDelights@gmail.com 1111 x_ 9N"T x { 3 ' rt 3 c l�� fa.,11111"O I-tx'x u. Mansfield, MA Angel Anisette Cookies Flour, Sugar, Eggs, Butter, Baking Powder, Salt, Anise Flavoring 12 count Contains Wheat