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FOR BOARD OF HEALTH USE ONLY Permit it issued
FOOD ESTABLISHMENT PERMIT APPLICATION,
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name zl\x Od W-i 4c fl
Establishment Address Tg} ChG1U�t S B-3 .mune a'
Establishment Mailing Address (if different)
Establishment Telephone No 85t-A_ Z0Z-G5
Applicant Name & Title:" \-1G p(xJC\'.N -Owctr
Applicant Address Zg } C AW S} V363 trt Gn field t fn �07()u8
Applicant Telephone No.: 135'} • ZU Z- C(5(p`+ 24 Hour Emergency No.: 86�- Zb% Z - Q 5(0 i-
ApplicantEmaii OSn+�cft�llarncnaC�1(� gM'k',(0M
Owner Name & Title (If different from applicant) RQ&N a �\('\M ^^Mcv) — OU-W*r
Owner Address Z81 CY`UON SA B-303 n-aml 1e(i]t imfj 0700
Owner telephone number 3k5- ?JU `{O
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Owneremail: r(jC�11�hOY�1tl�C�(� Y1LGl+1 Carn
Establishment Owned By: If a corporatio or partnership, give name, title, and home address of officers or
EJ An Association partner.
El A Corporation Name Title Address
XAn individual
APartnership
0 Other legal Entity
Person Directly Responsible For Dairy Operations (owner, person in charge, supervisor, manager etc.)
Name & Title± " ,AuY'{l"vAc
Address: W� O\U()`nq JCS 1 -303 MA5; e(d + M)T) 0
Telephone No: $5e.- ZLjZ-C(5(01 24 Hour Emergency No:
FAX:
E-mail:
avA fYtiV'(YlMQrA 1 Dia I . co-n
Alt E-Mail: V
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No;
FAX:
E-mail:
Food Establishment Information
WATER SOURCE; oo,,, (r^ SEWAGE DISPOSAL: t�o„„(r
DEP Public Water Supply No: (ir opplicable) No of Food Employees: z _ ------------
DAYSIHOURS: Q�
Name of Person(s) In Charge Certified in Food Protection Management:
P&\Qg vAn mmch Rckch i a PoMMCO)
Name of Person(s) In Charge Certified in Allergen Awareness Training
0810 0NrnaLl) , Rachl� (�Gi vn i`YICt ch
Name of pest control company routinely inspecting the premises for evidence of pests-peY
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. ® Yes
Does this establishment require a FOG permit? �_ If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
19 Annual
Rl Retail Food $125.00 ON Mobile Food Consession
® Temporary
Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $176.00 Manufacture Frozen Desserls/lce Cream
Temporary Start Date:
ta Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
NO Food Service up to 201 + $300.00 QN. Pushcart $50,00 N of Pushcarts:
Temporary Time:
99 Supermarkets $400Residential Kitchen $100.00
Rain Date:
Q Milk a Cream $10.00 ®Caterer $36,00
Food Operations: Degnffbns;PHF- Porentfvryhamnbusfwdfama7onpemIum controls mqulmd)
Abn-PHFs-non-WenHatlyhazallous food(no ttna7emperafure controls required)
(Check all that apply): RTE-reedy-toeatroods(Ex. SditdWchss,setads. Mfflosahlchneedrro furtherPocessfng)
Sale of Commercially Pro -Packaged Non-PHFs ES] PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held
4
FMI Sale of Commercially Pre -Packaged PHFs L Preparation of PHFs For Hot And !or More Than a Single Meal Service
(] Delivery of Packaged PHFs Cold Holding For Single Meal Service L] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
U Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer L Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand
[� Customer Self -Service
Customer Self-service of Non PHF and Non- contact alternative, time as a public health
control)
Perishable Foods Only L] Ice Manufactured and Packaged for
Retail Sale
Preparation of Non-PHFs Emij Offers Raw Or Undercooked Food Of
® Julce Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
ON Vacuum Packaging /Cook Chill
® Offers RTE PHF In Bulk Quantities EM] Prepares Food/Single Meals for
® Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Recondltioned Food
I, the undersigned, attest to the accuracy of the Information provided In this application and affirm that the Mod
establishment operation Wit comply with 105 CMR 590.000 and all other applicable law. I have been Instructed by the
board of health on how to obtainFopips of 105 CMR $90.000 and the federal Food Code.
Slgnatureof Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certlry under the penalties of perjury that I, to my est knowledge and belief, have filed all state tax returns
and pald state taxes required under law. c� �(
Social Security Number or Federal 10: 00 v— t)r
Signature of Individual or Corporate Name:
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.
Signature Vf individual or corporate Name By: Corporate Officer (Mandatory, if Appticabte)
f 10 Q��9
**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:\Usen1s1eite\Deslhop\Scotrs DocumentsT'ood Establishments• Tamp\TAX CERTMcATioN mium.,im
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Bavion, MA 02111
im o. mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annlicant Information Please Print Leeibiv
Business/Organization Name: D11e U1
City/State/Zi
Are you an employer? Check the appropriate box:
1,❑ t am a employer with employees (lull and/
or parmimc).*
2. I am a sole proprietor or partnership and have no
employees working for me in any capacity,
[No workers' comp. insurance required]
3,❑ We are a corporation and its officers have exercised
their right of exemption per c, 152, § 1(4), and we have
no employees, [No workers' comp, insurance required)'
4. ❑ We ate a non-profit organization, staffed by volunteers,
with no employees. [No workerss' comp. insurance req.)
Phone #:
Business Type (required):
5, ❑ Retail
6.❑Restaunmt/Bar/EatingEstablishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑Non-profit
9. ❑Entertainment
10.❑ Manufacturing
11. Healdt Caere
12. Other 05 I c1ert+ i G, ki tih2ri
*My applicant that checks box #1 must also rill out Iho sectimr below showing theirworkers* compensation policy inlomtatlon.
"If the corporate officers have exempted aromselvas, but the corporation has other employees, a workers' wmpenaetion policy is required mid such an
organization should check box ill,
I am an employer that is providing workers' compensation insurance for my employees. Reloly is the policy information.
Insurance Company
Insurer's
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 forth 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 cerpfy, udder the pains and penahies of perjury that the information provided above 4 true and correct
Ojfuial use only. Do not write in this area, to be completed by city or imun ojlrcial
City or Town: Permit/License k
IssuingAuthority (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.msss.goWdia
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.
�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 estabilshment. 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.
AVNW 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.
POA 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 i/ " //W V �— Date: I
Applicant Name (please print clearly) `� �� i M t m Mac