HomeMy WebLinkAboutSugary Moon Pastry 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: 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:.
DIANNE RICHARD, PRESIDENT
Whose place of business is:
SUGARY MOON PASTRY, LLC
456 ELM STREET
PERSON(S) IN CHARGE:
DIANNE RICHARD, OWNER
Permit Expires: December 31, 2016
License Number: RK -03
Food Fee: $50.00
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
RK -03
FOOD ESTABLISHMENT PERMIT APPLICATION
—(Application must be submitted at least 30 days before the planned opening date)
i
1) Establishment Name SUGARY MOON PASTRY, LLC
1 2) Establishment Address 456 ELM STREET
1 3) Establishment Mailing Address (if different) P.O. BOX 833 ' x
MANSFIELD, MA 02048
4) Establishment Telephone No (855) 784-2253
5) Applicant Name & Title: DIANNE RICHARD, OWNER
6) Applicant Address P.O. BOX 833, MANSFIELD, MA 02048
i 7) Applicant Telephone No.: 24 Hour Emergency No.: (508) 208-2591
�8) Owners Name & Title DIANNE RICHARD, PRESIDENT
9) Owner Address (If different from applicant) 456 ELM STREET, MANSFIELD, MA 02048
Owner's telephone number 8557842253
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
0 An Individual
❑ A Partnership
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: DIANNE RICHARD, OWNER
Address: 1456 ELM STREET, MANSFIELD, PIRA 02048
Telephone No: (855) 784-2253 24 Hour Emergency No: (508) 208-259s
FAX: I
E-mail: DIANNE@SUGARYMOON.COM
Alt E -Mail: DIAN NERICHARD21 (cD_YAHOO.COM
13) District Or Regional Supervisor (if applicable)
Name &Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
14) WATER SOURCE:
Food Establishment Information
15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
117) DAYS/HOURS: I
F
18) Name of Person In Charge Certified in Food Protection Management: DIANNE RICHARD
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: ❑d Permanent Location F22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: ❑ Food Service up to 100 or
Moblie Comments: up to 10' PHF display $62.50
21) Length of Permit:
F%%,] Annual
❑ Seasonal
Seasonal Dates:
J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Check all that apply):
❑ 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)
❑ 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
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non -PRFs
❑ Sale of Commercially Pre -Packaged PRFs
❑ 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
❑ 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
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
❑Ice Manufactured and Packaged for contact alternative, time as a public health
Retail Sale control)
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin -
❑— - -- -
Offers RTE PHF in Bulk
- Quantities ❑ Prepares Food/Single Meals for
Retail Sale of Salvage-,- Out Of -Date Catered Events or Institutional Food Service
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee: $100.00
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 copies of 105590.000 and the federal Food Code.
f/
24) Signature of Applicant:
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: 81-1321334
26) Signature of Individual or Corporate Name: ,1� ,
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 Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
!®/,32/334
** 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, AM 02111
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeLlibly
Business/Organization Name:
Address:
PQM+K-A . L L
City/State/Zip: M d M�- 02 -KY Phone #: <�S-5 - 7E--1- Z2-53
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2. VI 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
10.0 Manufacturing
11. ❑ Health Care
12.V216ther SI&40� K i ffy
*Any applicant that checks box #I 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 #l.
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 DTA for insurance coverage verification,
I do hereby certify, der the painsenalties of perjury that the information provided above is true and correct
Si ature: Date: i �/
Phone #: SSS- -79-'4-2253
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
www,mass.gov/dia
Phone