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Home My WebLink AboutThe Live Right Way (N. Antonucci) - 12/31/2021FOR BOARD OF HEALTH USE ONLY FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) I Establishment Name � { { �'� 1�� J / /� Establishment Address i�(P�2Lt;Vv\� 1V � I��(S�lYIr�"V�o`/ Establishment Mailing Address (if different) /J Establishment Telephone No 7b t " 95 �-- aq l I- -- y n—t v--' — — Applicant Name & Title: / xtV n t i (/ ri vt (j 0&u n ,e r/� �n Applicant Address ' fCV n� Ili Applicant Telephone No.: 24 Hour Emergency No.: U„ i nr� ''v� Applicant Email j�CQ @ILP✓l.)U2 e l�it�t v�f rCDM j Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: i Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 01 An Association partner. i 10 A Corporation Name Title Address XAn Individual _ 12 A Partnership 0 Other legal Entity Person Directly Res ons�i�ble.F)o�r D/aiilyy O erations (owner, person in charge, supervisor, manager etc.) �%/U �t%b k*t� Name & Title: d Y TIi�}�) /O Address: (J i Telephone No: 2,4/ Hour Emergency No: //�� FAX: t�t'/4 V L E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: I Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: I Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: -� — j O'y DEP Public Water Supply No: (If applicable) V �' ' No. of Food Employees: (� DAYS/HOURS: -- _. - .___ - -- -- -- Name of Person(s) In Charge Certified inj�F000/d� Protection Management: ff j O,ON, Name of Person(s) In C arge Certified in Allergen Awareness Training �'1:OO ii� - ' 11 L Name of pest control company routinely inspecting the premises for evidence of pests ` AP 6 Ptsf ipn fifP 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. O Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: 0 Annual 0 Retail Food $125.00 0 Mobile Food Consesslon 2 Temporary 0 Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 En Manufacture Frozen Desserts/Ice Cream Temporary Start bete: Q Food Service up to 101 -200 $250.00 $25.001freezer Temporary End Date: Q Food Service up to 201 + $300,00 0 Pushcart $50.00 # of Pushcarts: Temporary Time: ij Supermarkets $400 Residential Kitchen $100.00 Rain Date: !;a Milk & Cream $10.00 Caterer $35.00 � Food Operations: Dofinilions:PHF-Potentially hazardous food(ame4emperafum controls required) (Check all that apply): Non-PHPs - non-pofentlallyhazardous tood(no tome/temperature controls required) RTE-mady-tout foods (Ex. sandwiches, salads, mufins which need no further processing) :❑7 Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service L] Delivery of Packaged PHFs Cold Holding For Single Meat Service Q PHF and RTE Foods Prepared For Highly ry Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to he Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer SelfService t customer self-service of Non PHF and Nan- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale Fig Offers Raw Or Undercooked Food Of 0 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sala Vacuum Packaging 1 Cook Chill is+ Offers RTE PHF in Bulk Quantities L,�j Prepares Food/Single Meals for iEg 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 obtFopies of 105 CM90.00 derai Food Code. Signature of Pursuant to MGL Ch.62C, sec. 49A, I certi6 Ander the penalties of -perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under Social Security Number or Federal Signature of Individual or Corporate Name: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: r, City/State/Zip:_ Phone #: —51,0q) Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. Retail T-Y7 x�- or part-time).* 6. RestauranVBar/Eating Establishment 2. $ 1 am a sole proprietor or partnership and have no 7. E] Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* I.Q Health Care 4.n We are a non-profit organization, staffed by vetnnteers> ® /3 i s with no employees. (No workers' comp. insurance req.] 12. Other *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 providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: 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 cer(fy, under the pains and penalties of perjury that the information provided above is true and correct. U95e— 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 Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact www.mass.govrma Phone 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. lr Signature of lr#vidual or Corporate Name By! Corporate 61fticer (Mandatory, if Applicable) Elk � Y/ -- 3g1,57q� "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. CAUsecs\.cleile\Desktop\SeotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc