HomeMy WebLinkAboutCapriotti's 12/31/2016 (2)Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment;
Type: CATERING LICENSE
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:.
SEAN OLSON, PRESIDENT
Whose place of business is:
OLSON RESTAURANT GROUP MANSFIELD DBA CAPRIOTTI'S
321A SCHOOL STREET #140
PERSON(S) IN CHARGE
NICK ARONE
Permit Expires: December 31, 2016
License Number: C-8
Food Fee: $12.50
BOARD OF HEALTH
'AlichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Permit# Issu
Date Inspected: Approved By: ed
C-8
FOOD ESTABLISHMENT PERMIT APPLICATION
(Appy fl—on —musrue esu mi �ea�feastaO-cl-a-y-s-bbfor�nt-ie—d-op—eni-ng da- e
1) Establishment Name OLSON RESTAURANT GROUP MANSFIELD DBA CAPRIOTTI'S
2) Establishment Address 321A SCHOOL STREET #140
3) Establishment Mailing Address (if different) 163 MAIN STREET #2
MEDWAY, MA 02053
4) Establishment Telephone No
5) Applicant Name & Title: SEAN OLSON, PRESIDENT
6) Applicant Address 163 MAIN STREET #2, MEDWAY, MA 02053
7) Applicant Telephone No.: (508) 533-3030 24 Hour Emergency No.: w i -7
8) Owners Name & Title SEAN OLSON, PRESIDENT
9) Owner Address (If different from applicant) 163 MAIN STREET #2, MEDWAY, MA 02053
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.
EJ A Corporation Name Title Address
D An Individual
0 A Partnership
V Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)_
1 Name -& —Title-_:TNICK ARONE
Address:
163 MAIN STREET #2, MEDWAY, MA 02053
24 Hour Emergency No:
Telephone No: I(508) 533-3030
--- -_ - - -_ -_ f- ____ - - --- - - -_ --- - --- -_ --- -
FAX: (508) 533-3010
E-mail:
NICKAftOLSONRG_.COM
�r
Alt E -Mail: ROBYN Eft-FIVEOLSONS.COM
13) District Or Regional Supervisor (if applicable)
Name & Title:
I Address:
Telephone No: i
FAX: j E-mail:
4 Hour Emergency No:
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 10
17) DAYS/HOURS: MON-SUN i I
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): 0 t,
20) Location: W Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
Annual
❑ Seasonal
Seasonal Dates:
J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
❑ Retail ( Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $62.50
❑ Food Service up to 101 -200
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
NICHOLAS ARONE
Caterer $12.50
❑ Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12,50 # of Pushcarts: 0
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
23) Food Operations Definitions: PHF - Potentially hazardous food (time/lemperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
;Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non -PRFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
_ - - ------ - - - ----- for More Than a Single Meal Service
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PRFs For Hot And
------ -- - - ---- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
❑ Delivery of Packaged PHFs ff Susceptible Population Facility
Reheating Foods for Service Within 4 Hours ❑Sale of Raw Prepared
Y I Foods Intended - - - J
❑ 9 Y to be Pre ared b Consumer ❑Vacuum Packaging/Cook Chill
Processe
use of Process
❑
Customer dSelf Service of Non PHF and Non- ❑ Customer Self -Service -- ❑ and/or +HACCPjPlan (including Variance
❑
Perishable Foods Onry - - - ❑ Ice Manufactured and Packaged r'or ccontact ontrol) alternative, time as a public heath
Preparation of Non-PHFs Retail Sale
Other Food Operations ❑ 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
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
— — -
Total Permit Fee: $12.50
Payment is due with application
E] waived
i
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comp) 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how i obtain op 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: Z4 v
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 state taxes required under law.
25) Social Security Number or Federal ID: 46-156673 ? ®_
26) Signature of Individual or Corporate Name: ) <0g