HomeMy WebLinkAboutNancy Antonucci 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishmeni
Type: RESIDENTIAL KITCHEN
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
NANCY ANTONUCCI, OWNER
Whose place of business is:
NANCY ANTONUCCI
186 STEARNS AVENUE
PERSON(S) IN CHARGE
NANCY ANTONUCCI, OWNER
Permit Expires: December 31, 2016
License Number: RK -08
Food Fee: $50.00
BOARD OF HEALTH
Michael-McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
191 Pprqr)n nirpr.tiv RP.-nnnqih1P. For Dailv Operations (owner. person in cnarqe, supervisor, manager etc.)
9
Name & Title:
1) Establishment Name
2) Establishment Address Ave,NCa A 0j M,
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title:
6) Applicant Address /-I L
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title VA 11 er
9) Owner Address (if different from applicant)
Owner's telephone number
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
An Association
or partner.
A Corporation
Name Title Address
)(An Individual
A Partnership
Other legal Entity
191 Pprqr)n nirpr.tiv RP.-nnnqih1P. For Dailv Operations (owner. person in cnarqe, supervisor, manager etc.)
9
Name & Title:
0 00 0 W K e -r
Address:
_W7 _� 4,:M I bw 0C C) 4�
S:Fearn�:-) Ave,-./ kAam<�'
Telephone No:
24 Hour Emergency No: 7 91 - 60
FAX:
E-mail:
bj t/1 0'tj , ctn +Vn afei-ec
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
hj A
Address:
24 Hour Emergency No:
E-mail:
Telephone No:
FAX:
Food Establishment Information
14) WATER SOURCE: -(� 15) SEWAGE DISPOSAL:
l'>
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no timeRemperature controls required)
20) Location: Permanent Location
22) Establishment Type
Caterer $25.00
Moblie Moblie Start Date:
Retail ( Sq. Ft)
Milk & Cream $10.00
Moblie End Date:
Food Service up to 100 or
' Mobile Food & Consession $75.00
Moblie Comments:
up to 10' PHF display $125.00
Manufacture Frozen Desserts/Ice Cream
—
$25.00/freezer
,Vacuum Packaging /Cook Chill
21) Length of Permit:
Food Service up to 101 -200
- -
X, Annual
or up to 25' PHF display $150.00
Pushcart $25 # of Pushcarts:
Customer Self -Service of Non PHF and Non-
Food Service up to 201 +
Residential Kitchen $100.00
Seasonal
i Ice Manufactured and Packaged for
ri
Retail Sale
or 25'+ PHF display $275.00
Retail Food $100.00
Seasonal Dates:
Food Service - Institution
Retail Snack Food $25.00
i Temporary
',
Temporary Start Date:
( Meals/Day)
Tobacco Products $25,00
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no timeRemperature controls required)
(Check all that apply):
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
ale of Commercially Pre -Packaged Non-PHFs
] PHFCooked To Order
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
Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
-- ---- -
Delivery of Packaged PHFs
--
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
—
----
Reheatingof Commercially Y
,Vacuum Packaging /Cook Chill
Processed Foods for Service Within 4 Hours
- -
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
[_-', Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
control)
i Ice Manufactured and Packaged for
ri
Retail Sale
Preparation of Non-PHFs
Other Food Operations ! Juice Manufactured and Packaged for i'' Offers Raw Or Undercooked Food Of
jRetail Sale Animal Origin
ra ( t r Prepares Food/Single Meals for
Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
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 copi" 105 CMR 590.000 p4,q the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under t enalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law. -
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
f
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 I dividual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV www.mass.gov/dia
Workers' Compensation insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization N
Address: 1 ZS Uo VZ Oi
City/State/Zip: d't A
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2,19) 1 am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § I (4), and we have
no employees. [No workers' camp, insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
Business Type (required):
5. ❑ Retail
6. D Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11. [] Health Care
12.❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy mtormation.
**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 Address:
City/State/Zip:
Policy # or Self -ins. Lic. # Expiration Date:
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 cert , under the pains d penalties of perjury that the information provided above its tru/e and correct.
C;a Qfi,rp. Date: 87 /S / 1!
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person
Permit/License #
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
www.mass.gov/dia
Phone #: