HomeMy WebLinkAboutSweet 16 Ice Cream - 12/31/2021Ir;`
BOARD OF HEALTH USE 0 I
Mobile Food Establishment (MFE) Permit Application
(Application must be submitted at least 14 business days before the planned opening date)
1) MFE Name: c7W t
2) Applicant/Owner Name & Title: GUfl?-`Il Vv hU . . A
Applicant/OwnerAddress: CAS �O C. cA hero /"'4 O i3`n
Applicant/Owner Telephone No: )� ) _2 L,_&
Applicant/Owner Email address:
3) Person In Charge of Onsite Operations & Title: �v �-y-) F rc ,,) e-,
PIC Address: (0U /AS ^ o — M 0 ZO L•
PIC Telephone No: }� _ t , .-OCA ` Emergency/onsite Telephone No: --7,i? I 2 �'�/ —Oq
PIC Email Address: "A (,U r l
4) Location of Service:
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Date(s) if applicable:
Event Name if applicable:
Event/ Service Location:
Event/ Service time:
5) Length of Permit: 6) Solid waste disposal plan:
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Dates:
7) Water Source: 8) Sewage disposal plan:
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9) Food will be prepared:
o Onsite for immediate consumption
o Onsite and held at proper hot/ cold holding temperatures
=1 Offsite and held at proper hot/ cold holding temperatures
o Offsite, cooled and reheated on site
IV other: LkMl rc y c1, ek r'j �Kov-,f-v
10) Please attach a menu or a website link to the menu or give a brief description of the food to be served:
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11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates: ,r]
Food Safety Manager. ) A Y'G ✓k 0 re n rn C�L 11/
Allergen Awareness: L'A h '?" nety-rc,, V
12) Please describe on site hand washing facilities that will be utilized:
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13) Please list all sanitizing solutions that will be on site:
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14) Do you have propane, fryolators and/or hoods on your truck? Cp
If yes, you must first be Inspected and approved by the Mansfield Fire Department. Phone number: 508-261.7321
Fire Department Signature of Approval:
15) If applicable, please describe your FOG management plan or attach the written plan:
16) Location of Base of Operations or Commissary:
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Please attach copies A Base of Operations or Commissary Permit.
17) Please list additional communities where a food permit is held:
I, the undersigned, attest to the accuracy of the information provided in this application and I 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.
18)Signature of
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all state tax returns and paid state taxes required under law.
19) Social Security Number or Federal ID:
20) Signature of Individual or Corporate Name: S W eC"%
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 of Individual or Corporate Name
Q,L�—L�-J 1A( i �
"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\Scott's Documcnts\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
^" The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
— l ) 600 Washington Street
l' Boston, MA 02111
�Y�
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 5v- r u b I Ce k t e C V esti t`�
Address: V) (kSe y"
City/State/Zip: Shnyy,— MA 02OC JPhone #: ( c_;9D`9 ) I & y - 3001—
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
2. Ndor part-time). * 6.❑RestaurantBar/EatingEstablishment
I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (irel. 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.Q Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12PM Other I U
*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 #1.
Ialn an employer that is providing workers' compensation insurance for aly employees. Below is the policy information.
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie.
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 Person: Phone #:
www.mass.gov/dia
Name of Vendor(s)
Address of Vendor(s)
60 Aspen Road
Lauren Prenaveau
Sharon, MA 02067
THIS CARD SHALL BE CONSPICUOUSLY
DISPLAYED AND CLEARLY VISABLE ON THE
WINDSHIELD OF THE OPERATING VEHICLE
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