HomeMy WebLinkAboutHissho Sushi @ Stop & Shop - 12/31/202144125y
FOR BOARD OF HEALTH USE ONLY _ j Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION'S
(Application must be submitted at least 30 days before the planned open4g ate) dvl/
Establishment Name � Wo _ lC)EA L '�2 1)hc/- CGS
Ic4 MA
Establishment Address 3�� �� ntT.�11
Establishment Mailing Address (if different) 4Q
GG tiIOirZ 1x4 z "2-
Establishment Telephone NoC Cl(p p
Applicant Name & Title: Cx Co vA - �� j
Applicant Address (4Ct L(Ct � � 2e{ � C `0 (G IWi Ow o /, - MC,
Applicant Telephone No.: 24 Hour Emergency No.: 2 7 CC
Applicant Email rCt TX
Owner Name & Title (If different from applicant) L-wvn
Owner Address J1K q (�WC-G(r CtL k �L1 (GYx `�G7% - QL 2- 2 �J
Owner telephone number )GPI Ci20 Z ZCC)
Owner email: C:E n l rC 'rxL (,,- hbv-3 v
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
El An Association
partner.
Corporation
O An Individual1Y1'E»
Name Title Address _
O A Partnership
O Other legal Entity
Person Directly Responsible ForDaily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title: tii F-ee�' ec� c � //ma�c,a-
Address;
Telephone No: 24 Hour Emergency No:
FAX: /
E-mail: CDT3 )P'O7X8
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: Tu
SEWAGE DISPOSAL: (j/�(iC
DEP Public Water Supply No: (if applicable)
No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training
Name inspecting the for of co'I'w 10
of pest control company routinely premises evidence
pestso-Do
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 H I A,
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
Lv1 Retail Food $125.00
Mobile Food Consession
Q Temporary
E] 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:
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
0 Residential Kitchen $100.00
Rain Date:
0 Milk &Cream $10.00
El Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
El Sale of Commercially Pre -Packaged Non-PHFs ❑ To Order
Hot PHF Cooked and Cooled or Hot Held
PPHFCooked
Sale of Commercially Pre -Packaged PHFs V Preparation of PHFs For Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service
El PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer
Se of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
and/or HACCP Plan (including bare hand
'^
customer Self -Service of Non PHF and Non- us omer elf-ervic8— a
contact alternative, time as a public health
Perishable Foods Only ❑ Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
�ffers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
ll 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 vdll comply th 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain coleof 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 or Federal ID: 1
Signature of Individual or Corporate Name:' ")-c v, 3 -}�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
o Boston, MA 02111
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: C-WO `�Ot M; A Co , a( --
I o neeAP 124
City/State/Zip: N c Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
5. ❑ detail
LR
I am a employer with 1-J employees (full and/
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.❑
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.
g• ❑ Non-profit
3.❑
[No workers' comp. insurance required]
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
4. ❑
no employees. [No workers' comp. insurance required]*
We are a non-profit organization, staffed by volunteers,
11.❑Health Care
with no employees. [No workers' comp. insurance req.]
12.❑ Other �UrJ
*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.
I am an employer that is providi g workers' compensation insurance for my employees. Below is the policy information.
Insurance Comnanv Name: I o ev ! f
Insurer's
City/State/Zip:
4610 -W' 2)og SOOT 60-cf , �)vi-F zoo
Policy # or Self -ins. Lie.
r—L 59Cl
j Ibq t °74LP1j
Expiration Date: 0 bo 120)-1
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
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, and If the pains and penalties ofperjury that the information provided above i truet. 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
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.
ii
Signature of Individua or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"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:\Usetm\steite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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