HomeMy WebLinkAboutSarcastic Sweets 10/15/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
permit to Operate a Food Service Establishment
Type: TEMPORARY FOOD PERMIT
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:.
NINA REED, OWNER
Whose place of business is:
SARCASTIC SWEETS - 5TH ANNUAL FIRE TRUCK PULL & FOOD TRUCK FESTIVAL @
THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE
NINA REED, OWNER
Permit Expires: October 15, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee:
License Number: T-161
BOARD OF HEALTH
Michaecg4cClean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Date lnspe6M Approved By Permit # Issued
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening �a
1) Establishrnmit Narnie. �
2) EstablishmtmtAddress: j j( Ll"(u
G V
3) Establishment Mailing Address (if different),
4) Establishment Telephone.No.
6) Applicant Flame & Title:
6) Applicant Address: r
7) Applicant Telephone No: I` j _
j1 1� 24 Hotr Emergency Not
�1 f
8) Owner Name & Title (if different from ,applicant):
9) Owner Address (if different from applicantj:
'ia) Establishment Owned By:
0i An :association
ED A corporation
tai rindivi"ua' -
41 pain&' r ip
lb Other Ee`gal entity
11) If a corporation or partnership, give name, tit4e, and hoinle address of
off cert or partner.
Mame Tithe Hone Address
12 person Directly Res ainsible For Daily Operations
Owner, Person.in Charge, Supervisor,
Manager etc,
Fume & Title:
Address:
Telephone No:
Fax: .
Emergency Telephone Ho:
13 District Or Regimial Supervisor if a licabfe
Name & Tale:
Address:
Telephone No:
Fax:
aFp tattoo oc
Food Establishment Information
14) Water Source:
15) Sewage disposal.•
REP Public Water Suliply No: ( it sppllcabte)
16) Days And Hours of Operation:
17) No. of Food Employees:
18) Name of Person In Charge Cedified.iii Food Protection.Management:
Re uired as of f 0/1/2001 in aaaordanca girth 105 CUR 590.009 A
191 Person Trained iii Anti-Chokind Procedures (if 25 seats or more); 0 Yes .10 No
20) Location:
22) Establishment Type(check all that apply)
D Caterer
(Check one)
to Retall.( aq. Ft)
o Food Delivery
❑ ermanent structure
0 )od Service = ( Seats)
cl Residential Kitchen for Retail Sale
I Mobile
W Food Service—Takeout
❑ Residential K'itclietYfai Bed and Breakfast
❑ Food S.eivice institutiai
Home
( MealslDay)
❑ Residential Kitchen for Bed and Breakfast
Establishments
Other (Describe)
d Frozen Dessert Manufacturer
21j Lehgth Of. Permit;
(check on -p)
n Anrivat
Q SeasbnallDates:
E3 TemporarylDates/T(nle:
Definitions: PHF—: porendaLoy hazardous food(timehra
emperure eoi)rrols required),
23) Food Operations:
Noh1 pflFa— non• porendally,hazardous food
(no 6M&Itemperature conrrofs required)
cIWCk aY,that
RTE— ready-ro-eatfoods (Ex. sandwiches, salads,, mufffins which need no funberpr6cessing}
[� Sale of Commercially Pre-
❑ PHF Cooked To Order
a Hot PHF Cooked and Ccoled or Hast Held for
Packaged tion -PRFs .
More Than a S Ingle MaaCService'.
'❑ Sale of Commercially Pre-
.'❑ Preparation'Of PHFs For Hot And
a PHF and RTE Foods Prepared For highly
Packaged PHFs
Cold Hoid'if)g For Slagle Meal
86SceptlNe Population Facility
S eNice.
❑ Delivery of Packaged PHFs
.0- Sale Of Raw Animal Foods Intended
❑ Vacuum Packaging/Cook Chill
to be Prepared by Consumer.
❑ Reheating of Commercially
°a Custorrw Self -Service
'❑ Use Of Process Requiring A Variance AndlOr
Processed Foods For Service
HACC:P Plan (including Dare ltand.contact
Within 4Hourc:.
aftemative, time as.a public health control)
❑ Customer +elf -Service Of Non-
a Ice Manufactured and Packaged for
a Offers Raw Or Undetcooked Food :Of Animal
PHF and Non-Perfstiable Foods
Retail Sale
Orin_
Onl .
a Prepdration Of Non-PHFc
a Juice Manufactured and Packaged
a Prepares FoodlSingte Meals for Catered
for Retail Sale.
Events or Institutional Foca Service
a Offers RTE PHF in Hulk. Quantities
Other (Describe): To be conrpdc tf7ct tr}i the Board of Heahh
:a ReUil Sale of Salvage, Out -of Date or. Tofal Pei uutFee;
Reconbitioned Food PaVinent is due pith ippUcatiou
1, the undersigiierl, attest to did accvra43l"iii iitfomiati9rfprovfct, in fltfs aliplic:ttiois and t affirm fliaf the foot!
estauiishment operation will `co* mply vAth 105, IAR 590.1600 and all titer applicable lava, 1 have hee' insfructed by the board of
health on how.to obtain coliies of 105 CMR 580.000 dn6 the f de a1 Food Co e.
e
24) Signature of Applicaltt:.
Pursuant: to MGL.Ch: GLC, sec, I er
49A, tify udder the p nalties of perjury.that If to my Est knowledge and
belief, have. filed all state taX returns lid pald state tax reytlired tttider law.
1,
25) Social. Security Nuinlier'or Federal 1D:.
26) Signature of Individual or.Corporate Name;
TAX CERTIFICATION FORM
I certify tuider the penalties of pex7tn)r that I, to nay best know=ledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
or Corporate Name By: Corporate Officer (Mmi atoq, if ApplicabW
45- ucla,3�
"Sal Security No. 01ohadary) or Federal
Melti�kcrdimxr ulther
*This license will not be issued unless this certification clause is signed
by the applicant.
Your social security number will be fLu-nished to the Massachusetts
Department of Revenue* to determine whether you have islet 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'.1LTs�r:`sieiae'S?e:Lto�i ucota's D.5[tmYnts'Fued Estabii - Temp% A X CERT F€C-An0,N F0RNL c
NINA W C REED
SARCASTIC SWEETS
834 CHARLES ST APT 3R
PROVIDENCE, RI 02904
Your identification number is 455207239 00
The identification number listed on your permit may contain x's
in the first five digits. This is for security purposes only. Please
detach at the perforation and retain this portion for your records.
FEE: $10.00
ID: XXXXX7239 00
NAMEAN'D
LOCATION OF
HI ;S1.NESS
IIF NOT SA M E
AS RPLOW)
State of Rhode Island and Providence Plantations
DEPARTMENT OF REVENUE
DIVISION OF TAXATION
Permit to Make Sales at Retail
UNDER THE SALES AND USE TAX ACT
ISSUED
TO: NINA W C REED
SARCASTIC SWEETS
834 CHARLES ST APT 3R
PROVIDENCE, RI 02904
This permit. witicil autitortzes the holder to collect the sales/use tax,
is not assignable and is valid only for the pet:Son in whose natue it is
issued wid for the transaction of business at the place designated.
Whets the holder of this permit ceases to conduct tile business for which
I( is issued at the place named, the permit trust be returned to the
Tax Administrator for cancellation. The ID Nutuber, which appears
in thetipper left-hand corner, should be shown its all sales and tow
tax returns all([ ill correspondence relative to the tax.
THIS PERMIT MUST AT ALL TIMES BE
CONSPICUOUSLY DISPLAYED AT THE
PLACE FOR WHICH IT IS ISSUED.
NEENA S. SAVAGE ACTING TAX ADMINISTRATOR
DATE: 06/27/2016 EXPIRES 06/30/2017
AAL The C6.1111110711veallh ofAlass.achitsetts
Del)wifinent ofludushidlAccidews
Office of Investigations
600 IFftAhgtonStreei
Boston, :JL4 02111.
wo-w.wass.govIdia
Xllorker.§' Compensation InsuranceAffid-Mit: General Buginesses
Buslii&ss/Grgan.ization Name:
Cit. Stute.!Zil
Are.3-01ua,u. emplo-yer? Check the appropriate box;
i - El I ama. o4loyer with emplo�rees (Ul and/
2. 1 am a sole pioixietor'or partnership and have no
employees woi*j*fbr lite in' a4y., capacity.
[No workers., * cqmp , insurince*1-41ired]
3�- El we ire,.a c6 c' e*
rporation on. ift officers. have exercised
their right of exenipt'on Per s:152, 1(4), and we have
i
110 employee -S... [No -,A'0A-eW C.0mix.
4,[] �Ve area iion= . rofitorganization,--stdffed by volunteers,
with no emp�loyees: [No woricers, comp.. insurance. req.]
`AnY applicant fliatchecks box #1 mint also fill out the section below showiug thein
e Print L
Business Type (required);
5. ❑ Retail -.,-
7. ❑ Office and/or Sales (incl. real estate,, auto, etc'.)
8. n Nan -profit
9,. E.] Eute.it i.ulu.ent
10.n Nianufacturigg,
ILEI Health Core
12.0 Other
'If the Corp. oiate officen.have- exempted themselves, but -the coxponion Us other employees, a workers' coiapeus ation policy is rKpired =d such M
shoidd.check bok # * 1,
ITaim all elliployei, Mat fs'providing WoPkerVeourpensation iusurancefir nky eltiployee-T, Bdoiji i's the Policy info),11.1atioli.
Ins-urance Company Name:
1b.-suref.'s Addres,-A
city/Sfatelzip:
Policy 9- or Self -ins_ Lie.
E:tpiration Date:
Attach a copy of the workers' cotnpensatioit pbficy declaradou page (shoxiing the poliq number and t�!pjration date).
Failure to.secure coverage as required under Section I 25A of MGL- c. 152 can lead to the ini o��:itiou of criminal penalties of a
.1p
fine up to $1,500.00 aud(6y one-7yeafinpnsopm ut, as. well as civil penalties in the form of a -STOPWORK ORDER and a -firie
k
ofupto$2.00ad9
Clay ainst.the v iolator. Be advise4j*hat a copy of this statement maybe fbiwaided to the Office of
.
lnve�tigatious of the.*DIA.f6 nc�e. coverage verification.
Official, zise only. Do iiot;r.At_-Ju tha area, to be cotilpleted by city y or toirn official.
City or Town:
FerinitlLicense P
Issuing AutltoriW (circle.oui):
1. Board of Health 2. Etiflding*Deparrinent 3. City)Towri Clerk- 4. Licendug BoA.rd 5.. Selectmen's Of&6
6. Other
Contact Person: Phone 9:
www,niass.govtdia
Mansfield Board of Health
Waiver 2016 for Food Permit
Date
*Put the name of your restaurant on first line then sign the form.
We, — I( I !r CO f �) D C J��( 1/ 0 6 T:�) request a waiver of the
Food-�S-ervice Permit Fee for the?ollowinq reason_
Thank you,
Xfinity Center Food Truck Festiv6l and Fire Truck Pall
to benefit Special Olympics
Formw-9
Request for Taxpayer
Give Form to the
(Rev. August 2013)
identification Number and Certification
requester. Do not
Department of the Treasury
such business. Further, in certain cases where a Form W-9 has not been received,
send to the IRS.
Internal Revenue Service
to be issued),
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
2. Certify that you are not subject to backup withholding, or
Name (as shown on your income tax return)
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
Nina Reed
applicable, you are also certifying that as a U.S. person, your allocable share of
Business name/disregarded entity name, if different from above
any partnership income from a U.S, trade or business is not subject to the
Sarcastic Sweets
°
Check appropriate box for federal tax classification:
Exemptions (see instructions):
c
o
[a Individual/sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
CL o
Exempt payee code (if any)
0
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) 1►
Exemption from FATCA reporting
CN
code (if any)
p o
❑ Other (see instructions)1
:z
Address (number, street, and apt, or suite no,)
Requester's name and address (optional)
q (p )
U
COL
834 Charles Street
a�
City, state, and ZIP code
un
Providence, RI 02904
List account number(s) here (optional)
11 Taxpayer Identification Number (TIN)
Enter your TiN in the appropriate box. The TIN provided must match the name given on the "Name" line
social security number
avoid backup withholding. For individuals, this is your social security number However, for
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on pogo 3. For other
re page
�❑ _
❑�
entities. it is vour emolover identification number (EINI. If you do not have a number. see How to aet a
TiN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines ot) whose FEmpI-yer identification number
number to enter.
4 1 5 -- 5 1 2 1 0 1 7 1 2 3 9
Certification
Under penalties of perjury, 1 certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S, person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that 1 am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign Signature of
}sere U.S. person ► " A ! � �y {• �tJ v pate � (e
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted,
Future developments. The IRS has created a page on IRS.gov for information
about Form W-9, at www.irs.gov/w9. information about any future developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your
correct taxpayer identification number (TIN) to report, for example, income paid to
you, payments made to you in settlement of payment card and third party network
transactions, real estate transactions, mortgage Interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct.
Note. if you are a U.S, person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester's form if it is substantially
similar to this Form W-9.
Definition of a U.S, person. For federal tax purposes, you are considered a U.S.
person if you are:
• An Individual who is a U.S, citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or organized in the
United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S. person (including a resident alien), to
Special rules for partnerships. Partnerships that conduct a trade or business in
provide your correct TIN to the person requesting it (the requester) and, when
the United States are generally required to pay a withholding tax under section
applicable, to:
1446 on any foreign partners' share of effectively connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been received,
1. Certify that the TIN you are giving is correct (or you are waiting for a number
the rules under section 1446 require a partnership to presume that a partner is a
to be issued),
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
2. Certify that you are not subject to backup withholding, or
U.S. person that is a partner in a partnership conducting a trade or business In the
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income,
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S, trade or business is not subject to the
Cat. No. 10231X Form W-9 (Rev. 8-2013)