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Home My WebLink AboutPalagi's Ice Cream 08/03/2016Commonwealth 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: TEMPORARY MOBILE FOOD 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:. ALEJANDRO ARTEAGA Whose place of business is: PALAGIS ICE CREAM SIX PARK ROW ON THE SOUTH COMMON PERSON(S) IN CHARGE: ALEJANDRO ARTEAGA Permit Expires: August 03, 2016 License Number: T-75 Food Fee: $25.00 BOARD OF HEALTH wlichaeCwicCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishmenj Type: TEMPORARY MOBILE FOOD 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:. ALEJANDRO ARTEAGA Whose place of business is: PALAGIS ICE CREAM SIX PARK ROW ON THE SOUTH COMMON PERSON(S) IN CHARGE ALEJANDRO ARTEAGA Permit Expires: August 18, 2016 License Number: T-75 Food Fee: $25.00 BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishmenj Type: TEMPORARY MOBILE FOOD 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:. ALEJANDRO ARTEAGA Whose place of business is: PALAGIS ICE CREAM SIX PARK ROW ON THE SOUTH COMMON PERSON(S) IN CHARGE ALEJANDRO ARTEAGA Permit Expires: August 30, 2016 License Number: T-75 Food Fee: $25.00 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued T-75 - FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted atleast 30 clays before theplanned opening date) 1) Establishment Name PALAGIS ICE CREAM 2) Establishment Address SIX PARK ROW ON THE SOUTH COMMON 3) Establishment Mailing Address (if different) 55 BACON STREET PAWTUCKET, RI 02861 4) Establishment Telephone No (401) 728-0180 5) Applicant Name & Title: ALEJANDRO ARTEAGA, OWNER 6) Applicant Address 237 SUFFOLK AVENUE, PAWTUCKET, RI 02861 7) Applicant Telephone No.: (401) 663-1204 24 Hour Emergency No.: (401) 486-4887 '8) Owners Name & Title ALEJANDRO ARTEAGA 9) Owner Address (If different from applicant) 237 SUFFOLK AVENUE, PAWTUCKET, RI 02860 Owner's telephone number 4016631204 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association I or partner. A Corporation Name Title Address An Individual • 412T/ �2 Q�Q�i 0 e,v f 3F7 41l �✓L . A Partnership ld� Z Ae. f O9 C(V/ r(1 %Ole /Zo/I/a Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ALEJANDRO ARTEAGA Address: 55 BACON STREET, PAWTUCKET, RI 02860 Telephone No: 1(401) 728-0180 24 Hour Emergency No: (401) 466 -4867 FAX: E-mail:ALEX(cD-PALAGISICECREAM.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 6 PM - 8 PM 18) Name of Person In Charge Certified in Food Protection Management: ALEJANDRO J. ARTEAGA 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): 20) Location: Permanent Location 22) Establishment Type Caterer $12.50 Mobile Moblie Start Date: �� 2o�G Retail ( Sq. Ft) Milk & Cream $5.00 Mobile End Date: Food Service up to 100 or obile Food & Consession $37, Mobile Comments: up to 10' PHF display $62.50 Manufacture Frozen Desserts/ice Cream 21) Length of Permit: Food Service up to 101 -200 $12.50/freezer Annual or up to 25' PHF display $75.00 ! Pushcart $12.50 # of Pushcarts: Seasonal Food Service up to 201 + Residential Kitchen $50.00 or 25'+ PHF display $137.50 Retail Food $50.00 Seasonal Dates: Temporary g - �(� Food Service - Institution Retail Snack Food $12.50 Temporary Start Date: 71-29/Yti45 ( Meals/Day) Tobacco Products $12.50 Temporary End Date: Z129f�8a�— emporaryTime: 6:00 PM - 8:00 PM �' ---Rain Date: _ 44 - -- Definitions: PHF - Potentially hazardous food (limeAemperature controls required) 23) Food Operations Non-PHFs - non-potentially hazardous food(no time/temperature controls required) '(Check all that apply): I RTE - ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre-Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held t-- -- — -- -- for More Than a Single Meal Service Sale of Commercially Pre-PackagedPHFs Preparation of PHFs For Hot And I i Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs _ _ ___ --- -- Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially i to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours — - _ Use of Process Requiring A Variance Customer Self-Service of Non PHF and Non- Customer Self-Service I and/or HACCP Plan (including bare hand Perishable Foods Only I Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale i control) d Operations __ Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of or ' Retail Sale Animal Origin__ MMON Offers RTE PHF in Bulk Quantities �:17CREAM TRUCK CONCERT ON THE . __ __- — -- --Prepares Food/Single Meals for 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: $25.00 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 co ie of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I rtify under the penalties of perjury tpgt 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: 05 05000811 26) Signature of Individual or Corporate Name: 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 gPIndividual or Corporate Name (Mandatory) / 2 4: By: Corp ate Officer (Mandatory, if applicable) 0 3- (9 J�Qd-V'/% **�S_o- ',L evx4ty-N-um 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 wfvw.mass.gov/dia Workers' Compensation Insurance Affidavit: Genelral Businesses Applicant Information Please Print Legibly Business/Organization Name: � L'% �� . C xq CP4,4_— t� 0 Address: City/State/Zip: G-- t ��Phone #:Y/0V �) t7 _9 T t%� U Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. [ etail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] S. ❑Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per e, 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp, insurance required]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp, insurance req.] 12.0 Other *Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. **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/ 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Ile- 0) -we 1), YZ,14L �LA� E:61A✓t_",(' e Cd Insurer's Address: D 4Z4 &0 ,C(2- � C City/State/Zip: — �,/ /L l � V 0 2 d' Policy # or Self -ins. Lic. # 0 42' Z 2 Expiration Date: ® 9-. 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 DTA for insurance coverage verification. Ido hereby certify, in�dd e the pains annddd penal t/i/j/p/^j{� of perjury that the information provided above is true and correct 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 1 NCCI Carrier Code: 30325 Account Holder: Palagis 2000 Inc Address: Palagi's Ice Cream 55 Bacon Street Pawtucket, RI 02860-4537 Date: February 11, 2016 Policy Number: 0000065312 Agent Number: 00065 Agent Name: Chatterton Insurance Inc Agent Address: PO Box 1146 Pawtucket, RI 02862-1146 Phone: (401) 722-6010 Named Insured: Palagis 2000 Inc Dec Type: Renewal Group Affiliation: Endorsement Reason Policy Number Endorsement Effective Date uaaoaa.uvu Endorsement Expiration Date llalc. V6/ 1 1l6V 1 V Account Number 0000065312 04/11/2016 04/1112017 F20497400 2 Policy Period 3 From To 04/11/2016 04/11/2017 12:01 a.m. standard time at address of named insured 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: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE C. Endorsements & Schedules: Endorsement �- Endorsement Endorsement Endorsement WC_00_04_21D - BE_00_00_40 - OFAC BE_00_00_06 - Officers and WC_00_04_22B - Terrorism Catastrophe (Other than Trade Sanctions Notice and Other Exclusion Risk Insurance Program Certified Acts of Terrorism) Endorsement Endorsement Reauthorization Act Premium Endorsement Disclosure Endorsement This is riot an Invoic Insured BE_00_00_14_V7 Page 1 of 2 4Beacon Mutual Insurance Co. This is riot an Invoic Insured BE_00_00_14_V7 Page 1 of 2 ORA F 7 UJ 'Z V to V`,_,' to U UJ � lU r bA r � C w tJ vt V � to m � lJ v ,3-- tn Q u � i�1 V) U w W C www �" I OC7D.cn ! O O. 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