HomeMy WebLinkAboutThe Rolling Tomato 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 Establishment
Type: FOOD SERVICE
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:.
ROBERT CURRIER
Whose place of business is:
THE ROLLING TOMATO @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
ROBERT CURRIER
Permit Expires: December 31, 2016
License Number: FS -77
Food Fee: $62.50
BOARD OF HEALTH
'A4ichaeC-'A4cCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted
at least 30 days before the planned opening date)
1) Establishment Name P
AUG 11
2) Establishment Address
3) Establishment Mailing Address (if different)
e
4) Establishment Telephone No
5) Applicant Name& Title:
6) Applicant Address
7) Applicant Telephone No.:
24 Hour Emergency No.:
8) Owners Name & Title
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
LJ An Association
or partner.
M --'A Corporation
Name
Title Address
11 An Individual
El A Partnership
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
Alt E -Mail:
24 Hour Emergency No:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE: �: _ , ,
DEP Public Water Supply No: (if applicable)
r
15) SEWAGE DISPOSAL...
16) NO. Of Food Employees: '`y F y
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):
20) Location: E] Permanent Location
22) Establishment Type
E] Caterer $12.50
'N''Moblie Mobile Start Date:
0 Retail ( Sq. Ft)
E] Milk & Cream $5.00
Mobile End Date:
Food Service up to 100 or
E] Mobile Food & Consession $37.50
Moblie Comments:
up to 10' PHF display $62.50
0 Food Service up to 101 -200
Manufacture Frozen Desserts/ice Cream
$12.50/freezer
21) Length of Permit:
yam` Annual
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
E] Pushcart $12.50 # of Pushcarts:
0 Residential Kitchen $50.00
E] Seasonal
Seasonal Dates:
or 25'+ PHF display $137.50
Retail Food $50.00
F1 Food Service - Institution
M Retail Snack Food $12.50
M Temporary
Temporary Start Date:
( Meals/Day)
F�j Tobacco Products $12.50
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no Ume/te nperaturo controls required)
(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
F
Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly
Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non- E] Customer Self -Service U Use of Process Requiring A Variance
Perishable Foods Only and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for contact alternative, time as a public health
Preparation of Non-PHFs Retail Sale control)
Other Food Operations Juice Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Q Offers RTE PHF in Bulk Quantities E] 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:
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 copief of 105 CMR 59 000 and the federal Food Code.
24) Signature of Applicant: s
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:
26) Signature of Individual or Corporate Name:
14) WATER SOURCE:,, 5
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS:
15) SEWAGE DISPOSAL: v ., .( ,-{,_, (-'—/
16) No. of Food Employees:
.d _4
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 901112009 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: El Permanent Location
PMoblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
'f Annual
L] Seasonal
Seasonal Dates:
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
F] Food Service - Institution
( Meals/Day)
Caterer $12.50
Milk & Cream $5.00
n Mobile Food & Consession $37.50
Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
Pushcart $12.50 # of Pushcarts:
Residential Kitchen $50.00
Retail Food $50.00
n Retail Snack Food $12.50
Ej Tobacco Products $12.50
Definitions: PHF - Potentially hazardous food (limeltemperature controls required)
23) Food Operations
r Non-PHFs -non-potentially hazardous food(no timeJtemperatura controls required)
Check all that apply): j RTE - ready -to -eat foods (Ex sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs
�] Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
----------
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
[] Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
Preparation of PHFs For Hot And _
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
U 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
L] Vacuum Packaging / Cook Chill
[7] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
[ Juice Manufactured and Packaged for I] 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
L_'i Retail Sale of Salvage, Out -Of -Date I-- ____ --- -_ - --- - -- _._-- . ___ -_ . _. .., I
or Reconditioned Food ( To be completed by the Board of Health
Total Permit Fee:
Payment is due with application Lj waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food ^ u�
establishment operation will cor�plyivit 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to ohtafn copie of 105 CMR 5000 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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 .
ff
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.
y
f
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
'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 Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
si www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: '
Address: w £:
ro
Ci /State/Zi Phone # f r ,
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2❑ I 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, §1(4), and we have
no employees. [No workers' comp. 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. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
1L❑ Health Care
12.❑ Other
*Any applicant that checks box #1 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.
I am an employer that is providing workers' compensation insurance for nay employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. #.
Expiration
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 ce Wfy,,#ndelr the pains an4penalties of perjury that the information provided above is true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
r F f
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 #•
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