HomeMy WebLinkAboutConditer LLC - 12/31/20217
FOR BOARD OF HEALTH USE ONLY Permit # Issued
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FOOD ESTABLISHMENT PERMIT APPLICATION (11
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(Application must be submitted at least 30 days before the planned opening date) l
Establishment Name: (-Uh aAer 11 f"_
Establishment Address: � )\ IQ Mu r SV
Establishment Mailing Address (if different):�A G1-06 7
Establishment Telephone No: G\l-SOCJ .)�GCAS
Applicant Name&Title: Gu-r-er
Applicant Address: 'dL3ctik ��, S1aro� P l� G1G67
Applicant Telephone No.: 24 Hour Emergency No.:
Applicant Email:
Owner Name & Title (If different from applicant):
Owner Address: Sc,e C�S
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.
11 A Corporation Name Title Address
❑ An Individual fir, ra IN c,'k\.urc,4-tit' Par o-eY. \-Z/,�V_N
R6 A Partnership 51 q rcti G�6 7
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: �i✓� \3a� \Zb_ S1 atic ,1J� G�G('�
Telephone No: 6\-7 - ? JG laoti5 24 Hour Emergency No: 1-kGctS
FAX:
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable) ' f\
Name &Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: lou. A 11atisS e\a pwb\< L
uV e5
DEP Public Water Supply No: (If applicable) 1-1ok
SEWAGE DISPOSAL: t+nt-s&e\'�
No. of Food Employees: G
DAYS/HOURS: Mti4e 'u�'
Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ pip
Location: ❑ Permanent Location Establishment Type:
Mobile Mobile Start Date: &-7 I CX f \ ❑ Retail -No FOOD PREP ( Sq. Ft) $125
Moblie End Dale: GT' G I a a
Food Service up to 100 seats
Mobile Comments: INCLUDING FOOD TRUCKS $175.00
L ngtn Of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Service for 101 -200 seats $250.00
Food Service for 201+ seats $300.00
Supermarkets $400
Caterer $35.00
Milk & Cream $10.00
El Mobile Food Consesslon
NO PHF PREPARED ON SITE $100.00
Ei Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $50.00 if of Pushcarts:
El Residential Kitchen $100.00
Tobacco Products $150.00
Retail Snack Food $50.00
Food Operations: Definitions: PHF - Potentially hazardous food (time/temperalure controls required)
Non-PHFs non potentially hazardous foodino time/temperature controls required)
;Check all that apply) RTE- ready -to -eat foods (Ex sandwiches, salads, muffins which needno further processing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
YJ Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHFand Non -
Perishable Foods Only
�] Preparation of Non-PHFs
Other Food Operations
il PHFCooked To Order
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
❑Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (Including bare hand
contact alternative, time as a public health
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
- -- -- ❑ Prepares Food/Single Meals for
❑ Offers RTE PHF in Bulk Quantities
' Catered Events or Institutional Food Service
LJ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application ❑waived
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: up,WV�`
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 slate taxes required under law.
Social Security Number or Federal ID: �� �p''�`` y \ 7 l��
Signature of Individual or Corporate Name: O)'�+etdkkv� �'�� (�r'* \J.1
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.
Signa e of Individual or Corporate Name
FS')-\ - `-1 I )Az,<
"Social Security No. (Voluntary) or Federal
Identification Nwnber
By: Corporate Officer (Mandatory, if Applicable)
*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:\Uscis\sleite\Desktop\Scott:+ DocumontsTood Bstablishmcnts- Temp\TAX CERTIFICATION PORM.doc
Monday, June 7, 2021
Re: FOG — Conditer Ilc
Dear Chris,
I am writing to confirm that Ilona Znakharchuk, owner of Conditer Ilc will be renting kitchen space from
me at City Girl Cupcake 311 N Main Street, Mansfield MA 02048. Her business will therefore be included
under my pest control and FOG.
Please let me know if you have any questions or need additional information.
Thank you,
Lisa Morin
508,243.5946
Gm9203@gmail.com
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i ne c ommontveattn of massacnusetts
Department of Industrial Accidents
- Office gfInvestigations
600 Washington Street
Boston, MA 02111
wwminass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name: Cp+� \ �pe `-�-�
Address:
City/State/Zip: S "-a , t , Ga�- 7
Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
I. ❑
1 am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.
1 am a sole proprietor or partnership and have no
?, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ Non-profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its officers have exercised
9. qEntertainment
their right of exemption per c. 152, § 1(4), and we have
10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
l En Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.❑ Other
"Any applicant that checks box 411 must also till out )lie section below showing their workers' compensation policy infornmtion.
*"If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compeusation policy is required and such an
organization should check box M.
I ant an employer that is pirovitlitig )porkers' cutnpetsation iusitrance. for my enipioyeev. Below is the policy tnforination.
Insurance Company Name:
nn
Insurer's Address: 1 1/
City/State/Zip: 1- IL
Policy # or Self -ins, Lic. # t' (A Expiration Datc: ti � P
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 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 anti penalties of perfaty that the inf n-ination provided above is true and correct.
6\7 -e)o -L\GCI5
Official use only. Do not ivrite in this area, to be completed by city or ttnpa 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.mnss.gov/dia
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