HomeMy WebLinkAboutCupcake City 8/31/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishmenj
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:.
KRISTIN CATALDO & KARIN DINAPOLI
Whose place of business is:
CUPCAKE CITY - XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
KRISTIN CATALDO
Permit Expires: August 31, 2016
License Number: T-90
Food Fee: $100.00
BOARD OF HEALTH
MichaecmcCtean, Chairman
m
Date received: Date Inspected: Approved By: Permit # Issued
T-90
FOOD ESTABLISHMENT PERMIT APPLICATION
mijstbesdbihittdd at least 30 days before the planned opening date)
1) Establishment Name CUPCAKE CITY - XFINITY CENTER
2) Establishment Address 885 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 137 MAIN STREET
READING, MA 01867
4) Establishment Telephone No (508) 339-2331
5) Applicant Name & Title: CUPCAKE CITY
6) Applicant Address 137 MAIN STREET, READING, MA 01867
7) Applicant Telephone No,: (70119x9-0460 24 Hour Emergency No.: (617) 612.9108
8) Owners Name & Title KRISTIN CATALDO KARIN DINAPOLI
9) Owner Address (if different from applicant) 46 SUNSET ROCK LANE, READING, MA
Owner's telephone number 7817791062
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
An Individual
A Partnership
Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 1KRISTIN CATALDO
Address: 146 SUNSET ROCK LANE, READING, MA
No. , 81)7-7-9--10-62--
Telephone lj7 24 Hour Emergency No: (6171512.9108
FAX:
E-mail:G®c-iyLy
Alt E -Mail:
x k i S A ;+ ca -f 7-t Wo /(' t P", -Li
A
13) District Or Regional Supervisor (if applicable)
Name - & Title: 1KAR_1N_ DINAPOLI(OWNER),
Address: JU FAIRCHILD DRIVE, READING, MA
Telephone No:
FAX:
24 Hour Emergency No:
E-mail:
6 /7
PL-
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: 6
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 101112001 in accordatwo with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained In Anti -Choking Procedures (if 25 Seats or more): n
20) Location: IJ Permanent Location
["' I Mobile Mobile Start Date:
Mobile Comments:
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date: A
Temporary End Date: 74=um
Temporary Time:
Rain Date,
22) Establishment Type
I -,'I Retail ( Sq. Ft)
Li rood 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)
r _ I Caterer $12.50
U Milk & Cream $5.00
[_ I Mobile Food & Consession $37.50
Manufacture Frozen Desserts/Ice Cream
$12,50fireezer
[ I Pushcart $12.50 # of Pushcarts: 0
LJ Residential Kitchen $50.00
t I Retail Food $50-00
t I Retail Snack Food $12.60
[_1 Tobacco Products $12,50
liefinillons: P11F - Potentially hazardous food controls required
23) Food Operations
i Non-PHF's - non -potentially hazardous food(no 11rWarnperalum controls required)
�Check all that appift I RTE - ready -lo -oat foods (Ex, sandwiches, salads, muffins "kh need no further processing)
I._i Sale of Commercially Pre -Packaged Non-PHFs D PHFCooked To Order 11, Hot PHF Cooked and Cooled or Hot Held
F ] Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs Susceptible Population Facility
nSole of Raw Animal Foods Intended
F] Retreating of Commercially I to be Prepared by Consumer I F_] Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
JUse of Process Requiring A Variance
F-] Customer Self-service of Non PHF and Non- Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only
U toe Manufactured a Packaged for contact alternative, time as a public health
and Pe
(-1 Preparation at Non-PHFs i Retail Sale control)
Other Food Operations
U Juice Manufactured and Packaged for offers Raw Or Undercooked Food Of
t
Retail Sale Animal Origin
CUPCAKES BAKED IN RETAIL OVEN IN
Prepares Food/Single Meals for
READING, MA r] Offers RTE PHF in Bulk Quantities ILJ
Catered Events or Institutional Food Service
r] Retail Sale of Salvage, Out -Of -Dale
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee: $100.00
Payment Is due with application F1 waived
1, 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
"y
board of health on how to obtain cc I of 105 CMR 690.000 and the federal Food Code.,
24) Signature of Applicant: &9 . L L C_ hm - 7
Pursuant to MGL Ch.62C, sec. 49A, I Ably under the penal of perjury that 1. to Ubast jknlWedtq�end ballef, h7c"Jtel all st I x returns
N
c
and paid state taxes required under law. '\c t e
26) Social Security Number or Federal ID: 45-31639 C11 U-1) 0j C
26) Signature of Individual or Corporate Mame: _Li rat //,'A, L C.
':11zlUl
Y: Corpora cer
�a_
(Mandatory, if applicabl�
Social Security Number (V lu tary) or
Federal Identification Number
If-Ms—ndd—nse Will not ne tss)-,-eo-77M�
V,
1he 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 delinquen
will be subject to license suspension or revocation. This request is made undel
the authority of Mass. General Laws, Chapter 62C, Section 49A. I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AIA 02111
fivww.mass.gov1dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant ilnformation Please Print Lpj4,bly
Business/Organization Name:
/7
4
city/state/zip;_ 0 lkirp, / — Phone a: L/orb
I am an employer that Is providlay workers' cotppensadon insurance far my emplayees. 4elow is the policy lnformaflon.
Insurance Company
Insurer's
City/State/Zip:
Policy Y or Solf-ins. Lic. Expiration Date: a CI7-
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 MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisortment, 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 certify, under the pains and penalties of perjury Jhof (he infotknaday,9kvided above is true and correct
r_ZEL;1dJM1A_1A&0_
Official use only, Do not write /it this area, to be completed by city or town offlaint
City or Town:
Permit/License 9
Issuing Authority (circle onv),.
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone N:
www,inass.gov/dia
Are you an employer? Check the ropriate box:
n " ,
Busines ypc (required):
1. [��l am a employer with ___77 employees (full and/
5. Retail
or parttime).*
6. El Restaurant/Bnr/Fating Establishment
10 1 am a sole proprietor or partnership and have no
7, E] Office and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity,
8, [j Non-profit
[No workers' comp. insurance required]
3. El We are a corporation and its officers have exercised
9. U Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
I LEI Health Care
4.0 We are a non-profit organization, staffed by volunteers,
_Iher fy'c'
with no employees. [No workers, comp. insurance req.]
L12.
*Any applicant that checks box # I must also fill out the section below showing their
workers' commsation policy information'
4tirtho Corporate officers have exempted themselves. but the corporation has other
employees, a workers' compensation policy is required and such all
organization should check box 01.
I am an employer that Is providlay workers' cotppensadon insurance far my emplayees. 4elow is the policy lnformaflon.
Insurance Company
Insurer's
City/State/Zip:
Policy Y or Solf-ins. Lic. Expiration Date: a CI7-
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 MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisortment, 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 certify, under the pains and penalties of perjury Jhof (he infotknaday,9kvided above is true and correct
r_ZEL;1dJM1A_1A&0_
Official use only, Do not write /it this area, to be completed by city or town offlaint
City or Town:
Permit/License 9
Issuing Authority (circle onv),.
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone N:
www,inass.gov/dia
34 (Policy Provisions: WC 00 00 0 1 0 11 B)
-71
CI INFORMATION PAGE
WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155
NCCI Company Number: 20605
Company Code: G
HE
.ARTFORD-
Suffix
LARS RENEWAL
POLICY NUMBER: 08 WEC CI7134 04
Previous Policy Number: 108 WEC CI7134
HOUSING CODE: SB
1. Named Insured and Mailing Address: CUPCAKE CITY LLC
(No., Street, Town, State, Zip Code)
137 MAIN ST
FEIN Number: 001060532 READING, MA 01867
State Identification Number(s):
The Named Insured is: LIMITED LIABILITY COMPANY
Business of Named Insured: BAKERY STORE WITH COOKING
Other workplaces not shown above: SEE ATTACHED SCHEDULES
2. Policy Period: From 02/09/16 To 02/09/17
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name• GILBERT INSURANCE AGENCY INC
137 MAIN STREET
READING, MA 01867
Producer's Code: 087867
Issuing Office: THE HARTFORD
301 WOODS PARK DRIVE
CLINTON NY 13323
(800) 962-6170
Total Estimated Annual Premium: $1,975
Deposit Premium:
Policy Minimum Premium: $326 MA (INCLUDES INCREASED LIMIT MIN. PREM.)
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized representative.
•
Countersigned by <, 12/26/15
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page I (Continued on next page)
Pr Date: 12/26/15 Policy Expiration Date: 02/09/17
R