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HomeMy WebLinkAboutThe Cod Squad 4/17/2016Received FOR BOARD OF HEALTH USE ONLY Date Inspected Approved By ^� .-, ,II Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: a 6 , U4, Cod -"-�p A dAW,�-a 2) Establishment Address: 36 '7c w(,j w s,,yvg U d MA 0) oe-i 3) Establishment Mailing Address (if different) 2-141 Livi(4o Slw-c,•k HP 62, �Z. 4) Establishment Telephone No: (0 I _ 1�4 5) Applicant Name & Title: �J& V,6, &�l C7 44 Gi f () VV Vj 6) Applicant Address: 2�7 zGl L w)(40 iAO- UZ LI 92- 7) Applicant Telephone No. �� �� Z��� i (� G� 24 Hour Emergency No.: --7 (-12- 12-8) 8)Owner Name & Title (if different from applicant): j) Owner Address (if different from applicant): 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers orpartner. Cy p ❑ An Association UA Corporation ❑ An Individual ❑ A Partnership ❑ Other legal entity 4')\ Parenn nirorfiv Raennneihia [=nr nnilw Onarnfinne (Ownar narenn in rharno RunANiSnr Mi' ncinpr Mr. N Name & Title: Address: CJ �� t�111/ �� �''� GI �� dC✓��Q Telephone No:i IK _ �c^� _ -� a 0-� Fax: I g- 1, 3 -2 Emergency Telephone No: 13) District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: BLANK FOOD PERMIT APPLICATION Food Establishment Information 14.) Water Source -1k(1ke, l'q . V"V?S+"VV0l1 15) Sewage Disposal DEP Public Water Supply No: (if applicable):j(/Vih d,. PVe kW d Days and Hours of Operation: — I 17) No. of Food Employees Ll 18) Name of Person In Charge Certified in Food Protection Management: A -Yid re vv L't v in I !� iv f�Qvw 1,n( s M a cl o vi i) e -i I Re uired as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach co 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) ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) took Sr6vot-e. I oKe 66 21) Length Of Permit: (check one) nnual Seasonal/Dates 19 Temporary/Dates/Times IN 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, salad muffins which need no furtherprocessing) ale of commercially Pre- PHFCooked To OrderHot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Holding For Single Meal Service Susceptible Population Facility ❑ 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 Onl . Preparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Retail Sale Events oService El RTE PHF in Bulk Quantities To be completed by the Board of Health Other (Describe): ❑ Retail Sale of Salvage, Out -Of -Date or Total Permit Fee: Reconditioned Food Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I 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 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under returns and paid state taxes required under law. penalties of perjury that I, to my best knowledge and belief, have filed all state 25) Social Security Number or Federal ID: i Inn 26) Signature of Individual or Corporate Name: BLANK FOOD PERMIT APPLICATION 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. &,(t, v I zt I V1�w2Ce.i�'S� -���r a t * Signature of Individ al ort' Corporate Name (Mandatory) �JU " I By: Corporate Offi er (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number ()2- * 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, MA 02111 °�M s• www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: k / rel Vit, Le n ` S - a CWT Address: .2-7 Gf Lf r ? GL ill <� �-P City/State/Zip: VW 1 k ," M& ���� � Phone M A I Z -�' -6 U,4 6, d AT01111 an employer? Check the appropriate box: 1. am a employer with 0 — 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. E' estaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11. ❑ Health Care 12.©Other kdbt'���dG{ *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 my employees. Below is the policy information. Insurance Company Name: !� ws5a-cl�wtS.`S 12A&i �GvGl2d� vtr i%Vl�i �i $ CG'j Li {;�• l�''u�� Insurer's Address: -3 Oy ilf)f -KY6 0 (,e- City/State/Zip: KAI n ",( I tili Policy # or Self -ins. Lic. # i q G 0'2--33 Expiration Date: 1 24�-,) / j G 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. Ido hereby certify, under the pains and penalties of perjury that the information provided above is true and correct~ -- )V4,4 -1,, -✓4A %AA�/, , 7iarP• 2.1 /I (, Phone #: % - 1-34 —Gv<,� C, 0 / -2 12 -- 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/dta p k . . . -� .� � \ LSJ fo p k CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: ANDREW LIVINGSTON Certificate Number: 2225283 Date of Completion: 21211r20,8 Date of Expiration; 2M'12021 _ a Thr above-named person is hereby issued this cert�ficate %r completing an allergen awareness training progrmn recognized by the Massachusetts Department of Publir Health in accordance with 105 CMR 590.009(G)(3)(a). This cert ficate will be valid for five (5) years from date oftonrPletion. Issued By: RES�URANT ASSOCIATION Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 %v + v.restaurant.org Southborough, MA 01772 508-303-9905 www.marestaurantassoc.org