HomeMy WebLinkAboutPelaggi's Ice Cream Co. - 12/31/2021FOR BOARD OF HrALTH USF ONI.
Date Received Permit Fee
Approved By
AUG2 9 71i7t (ffl
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: P Z4 C �/�
Establishment Address: w" / C
Establishment Mailing Address (if different):
Establishment Telephone No:
2) Applicant/Owner Name & Title: 4 I
Applicant/OwnerAddress:
Applicant/OwnerTelephone No:
Applicant/Owner Email address:
3) Person In Charge of Onsite Operations & Title:
l�
PIC Address:
PIC Telephone No:
Emergency/onsite Telephone No:
PIC Email Address:
4) Event Attending: '14C
Date(s):
Event Name:
Event Location:
Event time: T 14-7 .
5) Check one
Iof Food Truck
(--I Caterer
o Other:
6) Solid waste disposal plan:
7) Water Source:
8) Sewage disposal plan:
9 ) Please give a brief description of the food to be served:
10 ) Food will be prepared:
ED Onsite for immediate consumption
M Onsite and held at proper holl cold holding temperatures
EYerOffsite and held at proper hot/ cold holding temperatures
O Offsile, cooled and reheated on site
v Other:
11) If PHF Is being served, please list the person who has completed the following trainings and attach appropriate
certificates: T
Food Safety Manager: Q// L/ /< J /�4/j/ QQ O / /nC�
Allergen Awareness: /Y zf V/V P Q 6 41 7-
12) Please describe on site hand washing facilities that will be utilized:
13) Please list all sanitizing solutions that will be on site:
14) If applicable, please describe your FOG management plan or attach the written plan:
15) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the Base of Operations
or Commissary permit:
I, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law.1 have been instructed
by the board of health on how to obtain 'c ies of 105 CMR 590.00000 And t e federal Food Code.
19) Signature of Applicant: ��
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best
knowledge and belief, have filed all state tax returns and paid state taxes required under law.
20) Social Security Number or Federal ID: 9 'S L-) 5- rid F //
21) Signature of Individual or Corporate Name:��
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
tinder law.
Signatur f Individual or Corporate Nam
"Social Security No. (Voluntary) or Federal
Identification Number
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.
The Commonwealth of Massachusetts
Department of'Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
ivww.rnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
P
Business/Organization
0
Address: `r i 1 4 C 041- - '/ . ,A� tG Cf�t . 4� T-
City/State/Zip: E ,.5. Phone
0
Are you an employer? Check the appropriate box: Business Type (required):
La I am a employer with employees (full and/ 5. Q Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.0 1 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 WE] Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization, staffed by volunteers, I LE] Health Care
with no employees. [No workers' comp. insurance req j 12.❑ Other 1 ✓//o L ,
*Any applicant that checks box HI must also fill out the section below showing their workers' compensation policy inf'onnation.
**If the corporate ollicers have exempted themselves, but the cogroration has other employees, a workers' compensation policy is required and such an
m'ganizetion should check box Yli.
I aat an employer that is providing workers' compensation insurance for ray
employees.
Below is the policy information.
Insurance Company Name: c /
6, a /v Z:� L- q,
/
A<,
Insurer's Address: n
1/2 C 0 4i C'
City/State/Zip:
22 �
Policy # or Self -ins. Lic. # Expiration Date: L //
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 ofperjury that the information provided above is trite and correct.
,
�1 2 f
Si> »afore: �y/,1> _J ( Date:
"/ 2 0
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
Mutual Insurance Co.
1
Agent Name:
Account Holder: Palagis 2ce Inc Cream Agent Address:
Address: Palagi's Ice
55 Bacon Street
Pawtucket, RI 02860-4537
Phone:
Agent Number:
NCCI Carrier Code:
Named Insured: Palagis 2000 Inc Dec Type: Renewal Group Affiliation:
Endorsement Reason
12
P
Maurice R Loiselle Agency Inc
PO Box 1148
Pawtucket, RI 02862-1148
(401) 723-8510
00142
30325
3
A. Workers' Compensation Insurance: Part one applies to the Workers' Compensation law of Rhode island.
B. Employers' Liability insurance: Part two applies to work in Rhode Island. The limits of our liability are:
....,... errtn RNT
1'1
C. Endorsements & Schedules:
Endorsement Endorsement
Endorsement BE 00 00 06 - C
BE 00 00 01 - WC and BE 00 00 01A ius
other -
Employers Liability Policy Cancellation Endorsement Endorsement n
This is not an Invoice
insured
The Beacon Mutual Insurance Company
One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com
Underwriting: 401.825.2667 I Toll Free: 1.88B.886.4450
a�and BE 00 00 40 - UFHI.
Sanctions Notice and
BE_00_00_14_V9
Page 1 of 3
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Food Protection Questionnaire for Catered Events
Date of Event:_
Location of Event:
Event Time:
List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location:
On ice/Refrigerated Cooking Reheating
Food Manager Certification Person Trained On Site? u Yes o No
Allergen Awareness Menu Label Present? o Yes o No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41 °F? _
How will the PHF be kept at or above 140°F?
Time of PHF? Setup Served Removed
Please describe hand washing and sanitizing supplies that will be provided on site:
List all equipment that will be supplied for an event, including but not limited to food
thermometers, cleaning wipes, utensils, non -latex gloves, heating utensils, ice etc.