HomeMy WebLinkAboutHilliard's House of Candy, Inc. - 12/31/2021du
FOR BOARD OF HEALTH USE ONL)�5 Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
o.
Establishment Name H a i S`e of Carr) Y l flc: dh(1 4A I I I I C Q-J E GjC_-
Establishment Address � jC,hcd �S+, ( n i j 6150,
Establishment Mailing Address (if different) 3 (� M Ct, n (t C Ea S Zf) 1Y) R e> 335L,
Establishment Telephone No
Applicant Name & Title: �) j+h 1' }) c-n+
Applicant Address Z5�L- fnaC n { Ncr-4-h'FEaS En (imA 0-435
Applicant Telephone No.: 5 0,?-- _a 3 [ 24 Hour Emergency No.: 0�- �-} 7 (- - 4 C) L),
Applicant Email 'ia, hi11Ic'n�_s—c 'nay, Cory)
Owner Name & Title (If different from applicant) % a
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
An Association
partner.
QUA Corporation
O An Individual
Name Title Address
�ac)i N {tiCC C?C�F�Y !°i2E>ic � { 3i(> I�iCun� hd �QS
C,VlCdCs1 C -h4 Infasw-�?_r Sc;k rne-
El A Partnership
O Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: TLLj1`4 , 1�. Mc1 Cc r+hy cUJne_,r
Address: Ilv i1iCL(r 1VO Vh EC S 3`->Lc,
Telephone No: 5C)�,- 3 24 Hour Emergency No:
FAX:
E-mail: ,J L 1 i i Q ^cE ` GCS Y cI y o C_O rY l
Alt E-Mail:
District Or Regional Supervisor (if applicable) ^ij
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
3`�tc:
Food Establishment Information
WATER SOURCE: i Ole
SEWAGE DISPOSAL:( }
DEP Public Water Supply No: (If applicable)
No. of Food Employees: j
DAYS/HOURS: mGTyC�� i ��LY�iGLS
Name of Person(s) In Charge Certified in Food Protection Management: -l- Y�f} Ci , rn pnc n C
Name of Person(s) In Charge Certified in Allergen Awareness Training C TM F(06 C
CZY7if`Ck,{'� 'C
Name of pest control company routinely inspecting the premises for evidence of pests C ufri��.
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. El Yes N I A
Does this establishment require a FOG permit? / if yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
MAnnual
[Vf Retail Food $125.00 Mobile Food Consession
Temporary
Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
EJ Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 ❑Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 ❑Caterer $35.00
Food Operations: Definitions:PHF- Potentially hazardous food(fimerremperature controls required)
Non-PHFs -non-pofentially hazardous food(no time/temperature controls required)
Check all that a I
( PP y) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
9Sale of Commercially Pre -Packaged Non-PHFs [I PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs ❑Preparation of PHFs For Hot And
Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs Susceptible Population Facility
Sale of Raw Animal Foods Intended
E] Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer Self -Service health
Customer Self -Service of Non PHF and Non - contact alternative, time as a public
control)
Perishable Foods Only ❑ Ice Manufactured and Packaged for
Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of
0 Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale Vacuum Packaging / Cook Chill
Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the accuracy of the information provided in this application and 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.
Signature of Applicant:
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.
Social Security Number oi-Federal to: 0 `-E _ � 7 5,_�,_7 1 U-"
Signature of Individual or Corporate Name: -li f M i C'if7".) ` -H c us (f - J C.Lf1C� l rx' CkC"i C'hoCG i CL
Signature of Individual or Corporate Name
Fzf) # 0---,�73�7t
"Social Security No. (Voluntanj) or Federal
Identification Number
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.
-H,Ncur�JL-46LISe C4 C(tr)�ly Sr)C
dbQ 4, lf,C ram` U)CCCJC(f:� iftrruu f/ ;,),)t
By: Corporate Officer (Mandato ,/, if Applicable)
-H. rn(_,Car--4-hy
*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:\Usm\sleite\Desklop\Sco"'s Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
W-j 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leuibly
Business/Organization Name: -H i )1 � CtQj S H C;t cSC 0 'C U QKA y ( oc c-b« -� J I I o nds Ch cc I Ct i tLS
3 ! (,_� fy) cL 1 n S {
City/State/Zip: N i -QS 0n M , 0,�,35(n
Are you an employer? Check the appropriate box:
1. Er I am a employer with employees (full and/
or part-time).*
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 are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
Phone #:
Business Type (required):
5. ❑Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (met. real estate, auto, etc.)
8. ❑Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
**If die 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: l f } 4'}('1(1oye r �_rns aiZ L(1Cc c xx _i')t-I
Insurer's Address: H i-4Ci i. i n Cc d 1"l Sf-
City/State/Zip: l Cab t'C� S}� �� MA O i L 53
Policy # or Self -ins. Lic. # LL) H N i (o S q — 0-" 0'q Expiration Date: O
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 of perjury that the information provided above is true and correct.
S— 1,?—(i,�,3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6.Other
Contact
Permit/License #
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Phone
www.mass.gowata
NOTICE
TO
EMPLOYEES
WHM160789
NOTICE
TO
EMPLOYEES
MOM
DEPARTMENT OF INDUSTRIAL ACCIDENTS
Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.stlate.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will
give you notice that I (we) have provided for payment hour injured employees under the
above -mentioned chapter by insuring with:
THE HANOVER INSURANCE COMPANY
NAME OF INSURANCE COMPANY
440 Lincoln Street, Worcester MA, 01653
ADDRESS OF INSURANCE COMPANY
MORSE INSURANCE AGENCY INC
HILLIARDS HOUSE OF CANDY INC
285
316 MAIN STREET
MEDICAL TREA
The above named insurer is required in cases of personal it
employment to furnish adequate and reasonable hospital and
provisions of the Worker's Compensation Act. A copy of the
the injured employee. The employee may select His or her o%
services provided by the treating physician will be paid by the
reasonably connected to the work related injury. In cases requirin
notified that the insurer has arranged for such attention at the
hies arising out of and in the course of
nedical services in accordance with the
first Report of Injury must be given to
i physician. The reasonable cost of the
isurer, if the treatment is necessary and
hospital attention, employees are hereby
NAME OF HOSPITAL i ADDRESS
TO BE POSTED BY EMPLOYER
3202338
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 establishment. 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.
J 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.
1 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 ( /, +f 7 (6: ? % Date: c ,fir 41.2 T
Applicant Name (please print clearly)