HomeMy WebLinkAboutAahhh Roma 4/17/2016Commonwealth 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 FOOD ESTABLISHMENT
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:.
SUE LUPI (CO-OWNER)
Whose place of business is:
AAHHH-ROMA LLC - NEFFA
MANSFIELD SCHOOL COMPLEX - EAST STREET
PERSON(S) IN CHARGE
SUE LUPI (CO-OWNER)
Permit Expires: April 17, 2016
License Number: T-93
Food Fee: $75.00
BOARD OF HEALTH
NichaeCvicCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATIO'
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
Aahhh-Roma LLC
2) Establishment Address:
92 Hamilton Avenue, Quincy, MA 02171
3) Establishment Mailing Address (if different)
617.462.3352 Fax:
4) Establishment Telephone No:
617.462.3352
5) Applicant Name & Title:
Sue Lupi (Co -Owner)
6) Applicant Address:
92 Hamilton Avenue, Quincy, MA 02171
7) Applicant Telephone No.: 617.462.3352
24 Hour Emergency No.: 617.462.3352
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
❑ An Association
❑ A Corporation
® An Individual
❑ A Partnership
❑ Other legal entity
12) Person Directly Responsible For Daily Operations (Owner, person in charge, Supervisor, Manager, etc.)
Name & Title:
Sue Lupi (Co -Owner)
Address:
92 Hamilton Avenue, Quincy, MA 02171
Telephone No:
617.462.3352 Fax:
Emergency Telephone No:
617.462.3352
BLANK FOOD PERMIT APPLICATION
r
MAR 2 3 2016
CHECK# � �..
Food Establishment Information
14.) Water Source Bring our own water
15) Sewage Disposal
DEP Public Water Supply No: (if applicable):
16) Days and Hours of Operation:
Friday, April 15 — Sunday, April 17,
17) No. of Food Employees 4
2016
18) Name of Person In Charge Certified
in Food Protection Management: Sue Lupi
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy
i
of certificate
19) Person Trained in Anti -Choking Procedures (if 25 seats or more):
20) Location:
22) Establishment Type:
® Caterer
❑ Retail ( Sq. Ft)
❑ Food Delivery
❑ Food Service — ( ) Seats
❑ Residential Kitchen for Retail Sale
❑ Permanent
❑ Food Service - Institution
❑ Residential Kitchen for Bed & Breakfast Home
® Mobile (Dates) 04/15/2016 —
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast
04/17/2016
Establishment
❑ Frozen Dessert Manufacturer
Other (Describe)
21) Length Of Permit:
(check one)
❑ Annual
❑Seasonal/Dates
® Temporary/Dates/Times
04/15/2016 — 04/17/2016
23) Food Operations:
Definitions. PHF — Potentially hazardous food (time/temperature controls required)
(check all that apply):
Non-PHFs — 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-
® PHFCOoked To Order
❑ Hot PHF Cooked and Cooled or Hot Held for
Packaged Non -PRFs
More Than a Single Meal Service
❑ Sale of Commercially Pre-
® Preparation Of PHFs For Hot
❑ PHF and RTE Foods Prepared For Highly
Packaged PHFs
And cold Holding For Single
Susceptible Population Facility
Meal Service
❑ Delivery of Packaged PHFs
❑ Sale of Raw Animal Foods Intended to
❑ Vacuum Packaging/Cook Chill
be Prepared by Consumer
❑ Reheating of commercially
❑ Customer Self -Service
❑ Use of Process Requiring A Variance and/or
Processed Foods For Service
HACCP Plan (including bare hand contact
Within 4 Hours.
alternative, time as a public health control
❑ Customer Self -Service of Non
❑ Ice Manufactured and Packaged for
❑ Offers Raw Or undercooked Food Of Animal
PHF and Non -Perishable Foods
Retail Sale
Origin
Only.
❑ Preparation of Non-PHFs
❑ Juice Manufactured and packaged for
❑ Prepares Food/Single Meals for Catered
Retail Sale
Events o institutional Fo Service
Other (Describe): U Offers RTE PHF in Bulk Quantities III To be completed by the Board of Health
Retail Sale of Salvage, Out -Of -Date or
Reconditioned Food
Total Permit Fee:
Payment is due with application
I, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment
operation will comply with 105 CMR 590.000 and a(I other applicable law. I have been instructed by the board of health on how to
obtain copies of 105 CMR 590.000 and the federa(Food Code.
of Applicant:
BLANK FOOD PERMIT APPLICATION
Pursuant to MGL Ch.62C, sec. 49A, 1 certify under the,penalties of perjury that 1, to my best knowledge and belief, have filed all state
returns and paid state taxes required under law.
25) Social Security Number or Federal ID: _45-47794096
26) Signature of Individual or Corporate Name: g
x°
BLANK FOOD PERMIT APPLICATION
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
+� www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
A
¢ I LLCBusiness/Organization 1�am�. �'t � f -- I� 1
Address: r �)AIt tv t ✓4
City/State/Zip: LLMu4 , 111' - 0101 Phone #:
Are you an employer? Check the appropriate box:
L ❑ 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
l l.w Health Care 1)
12. Other ( V ` _ i)✓7 0 bi cc
Fav annlicam that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
`flit 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 my employees. Below is the policy information.
Insurance Company Name:
insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. i;
Lxniratton 1)a-,4.
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 certify, under the pains and penalties 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
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)
** Social Security Number (Voluntary) or
Federal Identification Number
45-4779409
* 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 ding 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.
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