HomeMy WebLinkAboutGreat Woods Baking Co. - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION ,
(Application must be submitted at least 30 days before the planned opening
Establishment Name c..a YDaVW\5 CCMPWL-�
Establishment Address 2 MOn �*
Establishment Mailing Address (if different)
Establishment Telephone No CZa- 7aq&-(n2(n
Applicant Name & Title: SCl-rQ ti �m�p al\ , CU_V R= xr
Applicant Address 2 Mom, v\ � S\ 1 ��SFr o f i KkA 02-0 Q b
Applicant Telephone No.; Cy01�',Q(p„ 24 Hour Emergency No,: n}k
Applicant Email C_Iq \Ua�S s7 � L r1 Lp Yyin e (.. CG,(i')
Owner Name & Title (if different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned Sy:
If a corporation or partnership, give name, title, and home address of officers or
lL_ An Association
Corporation
partner.
Name Title Address
r �An Individual
-- -
P51, A Partnership—_---
1[1 Other legal Entity
Fcrson Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: SGvo, —\ , Ct LV'Lkr
Address: 2 �AWV1l 5-� , tkCUA�:,S VC) 4 AA C)ZCL? nG
TelephoneNo:(�cj) v %2rob 24 Hour Emergency No: Jam+"` `•-
FAX:
E-mail: C:'��-Wc3 `s \-3av"%vI COLT\0'1A - co-n
Alt E-Mail: rl�SiQZy, S p�)® . CCCY�
yak
District Or Regional Supervisor (if applicable)
N ime & Title;
A -"cress:
T '.rphone No: 24 Hour Emergency No:
E
FAX:
E .mail:
Food Establishment Information
VV/\TER SOURCE: SEWAGE DISPOSAL: C C�•e-Xl
DEP Public Water Supply No: (if applicable) '1"CLI n 1 No. of Food Employees: 1
DRYS/FiOURS- f g_ f to —
Na ne of Person(s) In Charge Certified in Food Protection Management:
Minne of Person(s) In Charge Certified in Allergen Awareness Training �)a.u. 0. —V"VN I'DL
Name of pest control company routinely inspecting the premises for evidence of pestsV12 ONQ
I' - ere is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
fr ' s being prepared. n Yes
D(:F:s this establishment require a FOG permit? If yes, please attach the FOG permit application.
1, ,ih of Permit:
Establishment Type:
r.. miai
M Retail Food $125.09 c4 Mobile Food Consession
Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 ® Manufacture Frozen Desserts/loe Cream
-:pc,rary Start Date:
Food Service up to 101 •200 $260.00 $25,90/freezer
-°.:,nrary End Dale:
FM-1 Food Service up to 201 + $300.00 Q Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 �i Residential Kitchen $700.00
Rain Date:
® Milk &Cream $10.00 Eal Caterer $35.00
I -.: 4crations: DeBnitlons: PHF -Potentlaity hazardous food (17mefiomperature controls required)
fC. :,til that a I Non•PHPa- nonpofentfa/ly hazardousloodfno dmmp eAeerafure controls required)
apply): RTE - rsadyto-sat hods (Ex. avrrJwchos, salads, m Xna ,Mich need no furthor procossing)
[ 'dic of Commercially Pre -Packaged Non-PHFs [I PHFCooked To Order i11 Hot PHF Cooked and Cooled or Hot Hold
for More Than aSingle Meal Service
a Commercially Pre -Packaged PHFs Preparation of PHFs Hot nervice
rMeal
Cold Holding For Single SD PHF and RTE Foods Prepared For Highly
....wary of Packaged PHFs Susceptible Population Facility
_ no Sala of Raw Animal Foods Intended
of Commercially to be Prepared by Consumer ® Use of Process Requiring A Variance
-tl:;tssed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
[] Customer Self -Service
'-su:fnnr Self -Service of Non PHF and Non- contact alternative, time as a public health
r:r:�te Foods Only E�s foe Manufactured and Packaged for control)
Retail Sale dt Offers Raw Or Undercooked Food Of
F£. of Non-PHFs �.
1� :Tattoo
J?n Juice Manufactured and Packaged for Animal Origin
rood Operations Retail Sale
Vacuum Packaging /.Cook Chill
no Offers RTE PHF In Bulk Quantities n Prepares Food/Single Meals for
,91 Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
11 it "'.lgned, attest to the accuracy of the Information provided in this application and affirm that the food
esl .:nt operation will comply with 105. CMR 590.000 and all other applicable law. I have been instructed by the
bn< �u ' alth on how tcygbtain copies of 105 CMR 590.000 and the federal Food Code.
Solr.- - Applicant:. '�Vt I ) �_t I I --
Pur ) MGL Ch.62C sec. 49A, I carilfy under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns
an.; r statc..taxes required under law..
Sr- city Number or Federal IQ: ^^s�
Sir ;:1vidual or Corporate Name: f go - bo \-Zone` tC.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.
SiEgiture of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
t1-1�-Ex�a 1z�sG
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this certification clause is signed
by the applicant.
x * 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.
t'. dQsem\sleite\DesktoplScoa's Documents\Fmd Establishments• Temp\TAX CERTIFICATION FORM.doc
Y`-n \ lIiu YVtfilliVflfYuiisRii. V�. ATl.iu„µi.tiftiJuif,}
Department of Industrial Accidents
- ` Office of Investigations
r� w�
j) 600 Washington Street
1 Boston, MA 02111
wipmmoss gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Annitt .tl, 1ul=,rndation Please Print Legibly
Busin , cuzation
Addic- 2 �4000 \ 'j{—
t� ;°,1;:
e you n
i, , er? Check the appropriate box:
Business Type (required):
1
1yer with employees (full and/
5, Retail
2
*
Q or and have no
6. QRestaurant/Bar/EatingEstablishment
Proprietor partnership
7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
e ,8r. <:.
working forme in any capacity.
S• []Non-profit
(
3,❑ ,. ,
;' comp, insurance required)
poration and its officers have exercised
9. ❑ Entertainment
exemption per c, 152„ § 1(4), and we have
10.❑ Manufacturing
4.n t
s. (No workers' comp. insurance required)*
:-profit by
l l,n Health Care
m
organization, staffed volunteers,
`oyces. [No workers` comp. insurancereq:]
12.� ether 4t t1 tiC3 i Y k~
"Any applya;
.,. s box #l: most also fill out the section below showing their workers' compensatlonpolicy information.
"If the cw
have esompted themselves, but the corporation has other empioyecs, 4 workers' compoeration policy is required and such an.
otgnniaaii
box#l..
I am at)
., «t is providing workers' conrpensaaon insuranee for -my employees. Below is the policy information.
fnsurant
Name:
Insurer's Yr
City/si;l '/
Policy l=
Attach
Failure : eu
fine upt _'_5`
of up to ti24 "t,u
Invesi: :i, ._
ldolia,.e .
Phone h:
Lic.:0 Expiration Date:
workers' compensation policydeclaration page. (showing the policy number and expiration date).
crage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a=fine
ty against the violator. Be advised that a copy of this statement may be forwarded to the Office of
MA for insurance coveraee verification.
,ader the. pains and penalties of perjury that the information provided above is
OJi rt Ili Do nit write in this area, to be completed by city or town official.
Cit r w
Isd, .r� Lun
I. f#s•at' 1::
6.Otirrr
Permit/Licensc ii
}• (circle one);
tit 2. Building Department 3. City/TownClerk d. Licensing Board S. Selectmen's Office
www.mass.gov/din
Phone
TOWN OF MANSFIELD LOCAL BYLAWS
he following bylaws apply to all food establishments permitted by the Mansfield Health Department:
V isfic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy
o ` each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws.
p' r<se indicate by Initialing the following statements that the permitted food establishment will adhere
t all applicable bylaws. The applicant and associate corporation are subject to fines associated with
v
C' `=r' is Waste Reduction
N , etail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out
L ;,: to customers.
I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to
c rc that this bylaw is adhered to at the permitted food establishment. I understand violations of this
, will result in fines.
I' ; >,tyrene Container Reduction (effective January 1, 2021)
1 - establishments are prohibited from dispensing prepared food and drink in disposable food service
Hers made from expanded polystyrene. All food establishments are strongly encouraged to use
;le food service containers and cutlery, and when possible biodegradable, compostable
,afives. Compostable materials must meet ASTM (American Society of the International Association
f sting and Materials) Standards for compostability.
_ ST i have received a copy of the Polystyrene Container Reduction bylaw. 1 understand my
sibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
11 . ons of this bylaw will result in fines.
i 'c Straw/Stirrer Reduction (effective January 1, 2021)
ic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in
action with the serving by business establishments or at any town -sponsored event of liquid,
frozen, semi -frozen, or other forms of beverages to the public for consumption.
_I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my
risibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand
ions of this bylaw will result in fines.
P:cant Signature�rtoJ I1 1041Q Date: Lx
cant Name (please print clearly) t r1r t �Ct(1
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