HomeMy WebLinkAboutThe Savory Spread - 12/31/20214�' 16 4
FOR BOARD OF HEALTH USE ONLY
Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
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Establishment Address n �o�
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Applicant Name & Title:S�1
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Applicant Address 3r) WC LC* `J
Applicant Telephone No.(' (Q (Q ZZ—alf' 1 U 24 Hour Emergency No.:
Applicant Email �— Qu ,5 ��� 1 MISL1 CO�'}'}
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Owner Name & Title (If different froapplicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and ho a address of officers or
F' An Association
partner.
i] A Corporation
Name Title Address
An Individual
U A Partnership
1 Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, sup rvisor, manager etc.)
Name &Title: � �
Address: 0 Z_L
Telephone SV — 24 Hour Emergency No:
FAX:
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E-mail: iS
Alt E-Mail:
District Or Regional Supervisor (if a,(pplicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
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Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
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DAYS/HOURS:'-MVU —SU �P -/\t �,4
Name of Person(s) In Charge Certified in Food Protection Management:
KAM <�"'v,
Name of Person(s) InCharge Certified in Allergen Awareness Training
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Name of pest control company routinely inspecting the premises for evidence of pestscAy
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. =7 Yes
Does this establishment require a FOG permit?ht �v birease attach the FOG permit application.
Le th of Permit:
Establishment Type:
. Annual
[ Retail Food $125.00 � Mobile Food Concession
Temporary
�ood 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 [I Pushcart $50.00 # of Pushcarts:
Temporary Time:
0 Supermarkets $400 Residential Kitchen $100.00
Rain Date:
LMilk & Cream $10.00 Caterer $35.00
Food Operations: Definitions: PHF-Potentially hazardous food f6me/tempemture controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous foodino fimeRemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order L:g Hot PHF Cooked and Cooled or Hot Held
..I Sale of Commercially Pre -Packaged PHFs lmrl'81'PAFs"For Hot Anyy for More Than a Single Meal Service
£fl Deliveryof Packaged PHFs ColUHeldirag For SinalelNeal"�ervice PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
i Sale of Raw Animal Foods Intended
1� Reheating of Commercially to be Prepared by Consumer Fgfi Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer Self -Service
Customer Self -Service of Non PHF and Non- contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for control)
�] Preparation of Non-PHFs Retail Sale [I Offers 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
II 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 obt@in copies of 105 CMR 590 00 nd the federal Food Code.
Signature of Applicant: T,y V 1 1� V \,AV XJV N
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:
Signature of Individual or Corporate Na°I've. `,n ( �(A yty�:A.
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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 By: Corporate Officer (Mandatory, if Applicable)
StO-Ou21 0(_�
**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:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: The
Address: 30 Riverwood DR
City/State/Zip: Mansfield, MA 02048 Phone #:
8606229416
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. Retail
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.
[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.� Manufacturing
no employees. [No workers' comp. insurance required]* 11.Q Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.Fl 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 Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration
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 andpenalties ofperjury that the information provided above is true and correct
3/11/21
8606229416
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
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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.
j4LI 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.
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.
0`I 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 Date:
Applicant Name (please print clearly)
Christopher George
From: Lisa Morin <gm9203@gmail.com>
Sent: Thursday, March 18, 2021 10:30 AM
To: Christopher George
Subject: Re: Automatic reply: Mansfield Food Permit for The Savory Spread
Hello, Chris
I am writing you to affirm that Ashley's business, The Savory Spread, will be renting kitchen space at my
business and will therefore be included in my pest control and FOG.
If you need additional information, please let me know.
Thank you.
Lisa Morin
Sent from my iPhone
On Mar 18, 2021, at 8:48 AM, Christopher George <cgeorge@mansfieldma.com> wrote:
Hi Ashley,
An email works just fine. I just need something from her saying she takes responsibility for your
businesses FOG and Pest Control; since you're operating out of her establishment.
Thank you,
-Chris George
Administrative Assistant,
Public Health Department, Town of Mansfield
508-261-7366, Ext. 66463
From: Ashley Smith[mailto:thesavoryspreadl@gmail.com]
Sent: Thursday, March 18, 2021 8:46 AM
To: Amy Donovan -Palmer; Christopher George; gm9203@gmail.com
Subject: Fwd: Automatic reply: Mansfield Food Permit for The Savory Spread
Hi Chris,
I will drop off a check for 175 today or tomorrow. Do you need anything more than an email
from Lisa regarding the pest control and FOG a permit?
Thanks,
Ashley
---------- Forwarded message ---------
From: Christopher George <cgeorgegmansfieldma.com>
Date: Thu, Mar 18, 2021 at 8:33 AM
Subject: RE: Automatic reply: Mansfield Food Permit for The Savory Spread