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Home My WebLink AboutSeg's Heavenly Delights - 12/31/2021JAN Ibr)0 i FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name S %V-er,,\`l\ Establishment Address Establishment Mailing Address (if different) Establishment Telephone No '1 t Applicant Name & Title Applicant Address su pT �c d , it i1 an s `fie . ✓t% �-� `� g Applicant Telephone No.: C1 t u r) t S-, O Z t 24 Hour Emergency No.: Applicant Email S�� S((��\� G-0M Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: >' An Association L-i A Corporation ,,�k%n Individual [A A Partnership a' Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: (20'-f—C'C,t\0., C*C.,'N2 + Address: -'U �crr\e d Telephone No: q t `� S- V 2 R I 24 Hour Emergency No:s�- FAX: E-mail: Sect S (j�a,\ "cJy` +S (�r"—A Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE �EWAGE DISPOSAL' `� �� ull, - DEP Public Water Supply No. (If applicable) No ees of Food Employees: to p Y DAYS/HOURS: Adh-Oc Name of Person(s) In Charge Certified in Food Protection Management: KS2 L Name of Person(s) In Charge Certified in Allergen Awareness Training ti-ri '_'i,52 L"F Name of pest control company routinely Inspecting the premises for evidence of pests ✓ Gic d(L 104- k_ - - - --- 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. 51 Yes Does this establishment require a FOG permit? J--�k U If yes, please attach the FOG permit application, --------------------- --._..._-------- Length of Permit: T--- Establishment Type: {Annual W Retail Food $125.00 — ;si Mobile Food Consesslon =] Temporary [al Food Service up to 100 INCLUDING - NO PHF PREPARED ON SITE $100.00 Temporary Start bate: FOOD TRUCKS $175.00 (_i,71 Manufacture Frozen Dessertslice Cream l]sj Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ! [] Food Service up to 201 + $300.00 t7f Pushcart $50.00 # of Pushcarts: Temporary Time: (sa Supermarkets $400 residential Kitchen $100.00 Rain Date: I=el Milk &Cream $10.00 jri Caterer $35.00 Food Operations: Definitions: PHF - Potenfallyhazardous food (emeRempereture controls required) (Check all that apply): Nan-PHFs- non-potendally hazardous/oodino timeRemperatune controls required) RTE- ready -to -eat foods fEx, sandwiches, salads, muffins which need no further processing) j Sale of Commercially Pre -Packaged Non-PHFs [b] PHFCooked To Order 1=] Hot PHF Cooked and Cooled or Hot Held 41': Sale of Commercially Pre -Packaged PHFs in] Preparation of PHFs For Hot And for More Then a.Single Meal Service ''a+] Delivery of Packaged PHFs Cold Holding For Single Meal Service iai PHF and RTE Foods Prepared For Highly tea; Sale of Raw Animal Foods Intended Susceptible Population Facility ,—&I Reheating of Commercially to be Prepared by Consumer Use i?i Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours � 1 Customer Self -Service of HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- contact alternative, time as in public p blic health Perishable Foods Only [] Ice Manufactured and Packaged for control) ,Nil Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of j^l Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale i°t1 Vacuum Packaging 1 Cook Chill ffers RTE PHF in Bulk Quantities (iy1 Prepares Food/Single Meals for �f tom.,\Pn (vl S jug Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service ,J µ or Reconditioned Food I, the undersigned, attest to the accuracy of theffnfoation provided in this application and affirm that the food establishment operation will com Ith 105 C.000 and all other applicable law. I have been instructed by theboard of health on how to obtai cc i s of 10 o.o00 federal Food Code. Signature of Appllcant: Pursuant to MGL Ch.52C, slig,49A. I certify under th enaities 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 10: D 1S Signature of Individual or Corporate Name: 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. ignature of lXdividual or Corporate Name 6� C�/y "*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. C:\Users\sleite\Desktop\Scott's 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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name 'C AC (- a Address: —SD "" 6 D t D2b4oY Phone #: 6) 4 q • q 1 S_ - D 2-- & I Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail orpart-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. 8. ❑ Non-profit [No workers' comp. insurance required] 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.❑Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12. Other with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. `brA 6LC 61006( ..5 **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' c npensation policyr^is required andsuchan "/ organization should check box #1. eM (]n j"}q- 9 U,5 [p of, ( d I am an employer that is providing workers' compensation insurance for my employees, Below Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: the policin/brmation. vP rvLAnq1&4f On I in 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 5ofo, undepthepainstattst penalties ofperjury that the information provided above is true and correct Phone #: /' ld Z,-& 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 r Italian Pas erl!es Angel Anisette Cookies $12 2dz Chewy Ginger Molasses Cookies $12 dz Pignoli Cookies $12 dz Fried Oreos $12 dz Jelly Filled Bow Ties $12 dz Fig &Almond Cookies $13 dz Cream Cheese Cookies $13 dz Limoncello Cookies $13 dz Italian Ricotta Cookies $13 dz Peanut Butter/Chocolate Kisses $13 dz Thumbprint Cookies $13 dz Italian Butterhorn Cookies $14 dz Almond Biscotti $15 dz Ike-aVenly-C mny_Crearn-Puffs $15 dz Berry Cream Cheese Pastry $15 dz Mini Apple Pies $16 dz Nutella Pastry Tree $20 Cinnamon Walnut Roll $20 Contact: Carmela Garieri Email: SEGsDelights@gmail.com � 5 Uavenfy .)ero � Coconut Macaroons $10 dz Almond Flour Cookies $10 dz No Bake Butter Cookie Energy Bites $10 dz Almond Zucchini Fritters $10 dz Cloud Bread (Everything Seasoning Optional) $8 dz Sabrina's No Bake Peanut Butter Cheesecake $24 Almond/Vanilla Loaf $20 Banana Loaf $20 Lemon blueberry Loaf $20 Cranberry Orange Loaf $20 Spica-eh-Qrricjlre-with--Almond-C-ru-st $20 Apple Crumble $18 Other Favorites Almond Maraschino Cherry Cupcakes $24 dz Chocolate Cupcakes filled with Peanut Butter $24 dz Red Velvet Cupcakes $24 dz Vanilla Strawberry Shortcake Cupcakes $24 dz Hot Chocolate Bombs $5 each Contact: Carmela Garieri Email; SEGsDelights@gmail.com 8 y s �{ppcYnfy n `, Mansfield, MA Angel Anisette Cookies Flour, Sugar, Eggs, Butter, Baking Powder, Salt, Anise Flavoring 12 count Contains: Wheat