HomeMy WebLinkAboutGuru Grub - 12/31/202161 i —'s � ;
P€ rmit Foe
Appmod By
(Appbcatirm must be submitled at least 94 husiriess days befistO the /rt<lnrx ci eta
1) MFEName:
2) Applicant/Owner Flame & Yikle: ��4�`..�
AppltcanUUwnei Address kF . ti
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Applicant/Ownei IPle Jhone No: "
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Applic mt/Otrnei Email adder ss (ks r c a L - k"-
3) Person in Charge of onsite Operation R Yule
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PIC Adder s:� E '�..� F rgenrt4lon ttl�rhor e N r-
PIG Ic.iqph.,ne N".t),{
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Weis) if applicnbio.
Event Name if applicable:
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5 Length of Permit: w./ 6f d avusCe €#I p09.i (urr. rp
[annual
Cl 1Velnporai y
Dates:_ tt t` 2
71 watdr sourow
0) Food Vrifl Zee pre/pared:
t Ormile for irwnectato norrsumption
IJ 6nsita and held 5t proper hof/eold ho(dittg temperatures
t 1 off ife and held at proper hoU cold holding tempefafutes
r.;k k" c6olvd and reheaied Uri s to
8) Sewage disposal plan:
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16J plodeo a€f^isFi a u>iatiu ear a a✓ete; }te 1rnNr f6 €lid t rersu ar g4vei .a brie€ 465feeif OOn Of the food to be served
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.fr) ksn Vou hwr- €>iopanc frV ol.,tar,, anTat ;ran, . m Voui took? _..
If ,,cis, you muss Pu_f he wTeaNd and appmve i Pw tP; t,5 nou ld l u • Depal hunt Phony munimn 006-201-7321
We C)Gi)a mont ;i nakno of Apl;rov al:
15) it applicable, yahoos^ do cribs your FOG mann9 ment g .rn nr aurae a Hw wflr«i: 1 playa:
16) I ocauon of Base of Opmataons w C.ornaussnry
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Please attach colves of Base of Operahons or Commis smy f'arrnif.
1.7) Plcase list additienol communRie . whowe a Mad pwmH 4 held:
as Me
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I, Me undomoned, attest to the a aaurary of the information proydef? ir! 4hI - n ppI..... a, nand ! aH,, M,j of f, ,u°
establishment operation mill comply witheI01 C'MR 520 000 and all other applicable law. I have boon instructed by
Lire bo.iul of health off Flow to olxtlin copi,as f ,5 CIMR 590.000 acid tiro.: fede ml Food coda.
1S)Signatufe of
Pursuant to IBGL. Ch 62C. sec. 49& t cortwfy under Me penaltics of perjury that I, to my he. t knowledge and heliet,
hwo filed all ntato tax returns and paid state We,, rcq(Jgod andol law,
I Soo mlSee nHV Nurn tier or Federal
20) Signstuto of Individual of C;orlaorate Name,:
I Hat CA I I ON VOW"VI
1 a ,0 ;J vit dI I,, )OIIj I I ik,, if I wrpi r\ I ILI! I, 10 IH I brat 1a J 6: I If A if \ I,'( I �, ,
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ihiq epoikirmlion clan is shnned
by [lie applicarn.
4, )� Aaf StJl rai .,.tjQ oundwr will he kimislivil w IS "Jow"NOWN'
I Tpartment cif ROW"HO to determh it, %vi "I Or ym We iml lax f Huy, Air
taX pay n1opnf ()I)QaIiO1I4 t i"qNITS \VIV) fad to mnva dikr iumi fill ig on,
dowlinqueno will be subject to license suspension or revocation. 1 his,
iN "Wer flirt awlmrd, (if w"mchmew ( OuTAI 1 a",
Chaph't, 62( , wchon 49A.
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I ty9)'tl fv ()iIV,,t, iV I' 11, ut,) 10 C iai. BY AS
all fens. , ,I'l1) 1i,1,1 la . y;crl... litf is Pr oasfi 61 I h, alth [h p,utmrant:
H re'n 'A'Al, 1+ urn 04C raivz?yfenr t rnft rlMi It* "rtioir foal Plo�ln yfl,atvls srio 1 f{rtiurlfefi. A copy
�4 ea �,�aw , an Lined fi ' u r rr Ix.i ;ui!ity of II r 1pfou end Poi<' f,l and a urea irdfli
b/I:nvs.
i �ir aP, ry flue Ai na 11u' f€rlioilfnl ate nieros 11 ,i lbe pr"rnuitod Shodt 1011 .
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t l;,ve tt'f l'iv' a copy of till• Vi.,>nl vlfa'fl h_ tour f ilm bylaw. l urd. r;i ved my fH .Inala>Ibiflh,r ro
rf ,�.t� flat thr, lip .rtv is aril �'c�i to �aP (I 1= heist If fl 9 loot? `i =fl'r:;hi nu'n d. I unrn r ,i.ind v� f
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nauMp fuod <.revur con auu In And r utlery, and oilhinif po .,ible bloc lc'I;f.id dale, r of np osbabl:'
aiter'r.tr�l Cali llao,E..uLn Ali tn"! . Wol '~,IM f.Aaj r„i( If `;01101v01 tbt, lottl.�ivatirni. Anquoithoi't
{oi 'l l ml; and PAN of win) 41 .and ank lot 1 ompnu Mbillty.
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it p urlbillIt, Yu �jI'm 0 di' t ilwi bylaw fs adharI'd to It tfn' pnnuneoft food J hoot `„ d'Is1.ifid
vio9;r'iow; of tlu: bylaw win ds salt fit I fft-,.
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PLndc how4ape suawq and p4lic stura'f n shzr(I nul ho usr-d ail dr .lensed or soul excepi upon tratlof-A in
conponction with Ow "o hour by bu;ina ', usiahlichiorud; of of any toAMu ,ponsoi od overt of fquid,
:curry, flo7f-p; ``)olul frozen, of other iolun, of hfwoial;e s to iho public irn i otv;uiopiion.
€ ��I Ifave 1r r eyed a cWW of the FILM Straw/',ha yr Redifilian b0a"r I unliri >iami my
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Department of Inspectional Services
25 Meade Street, Worcester, MA 01610
Phone:(508)-799-8539
FOOD ESTABLISHMENT PERMIT
PIN: FM-19-87
EFFECTIVE DATE: January 01, 2021
PERMIT EXPIRES:December, 31,
2021
PERMIT FEE: $250.00
In accordance with Regularions promulgated under authority of M.G.L. c. 94, ss 305A; c. 111, ss. 5 123A,
105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to:
Name of Permit Holder SAKET LOHIA
Address of Permit Holder 217 Dewey St, Worcester, MA 01610
Name of Food Establishment FANTASTIC PIZZA AND CAFE
Address of Food Establishment 910 A MAIN ST
OPERATIONS PERMITTED
Food and Drink Establishment 1 - 100 Occupancy
Comments: Restrictions:
Common Notes:
Renewal of Permit:
DURATION OF PERMIT
Annual
An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the
expiration of the permit.
Notification of Changes:
This permit is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If this
business is to close or there is a change in ownership, The DIS must be noted at least two weeks prior to
closing and this permit must be returned to the DIS.
Director of Housing and Health Inspections
Town of Mansfield
Board of Health
To Operate a:
Mobile Food Establishment
In accordance with Regulations promulgated under authority of Chapter g¢, Section
3o5i and Chapter in, Section 5 of the General Laws, a Permit is hereby granted to:
Grub Guru
Whose Base of Operations Located:
910A Main St, Worcester MA 01610
Location of Services:
Xfinity Center Concert Series
Person(s) in Charge:
Saket Lohta
In the event of change in the permit holder, the Health
Department must be notified of change within io business days.
Permit Expires: 12/31/2021
License Number: M F-6
Chair, Board of Health
Fees Paid: $ 175.00
THIS PERMIT SHOULD BE POSTED CONSPICUOUSLY