HomeMy WebLinkAboutSante Mobile Cafe 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:.
STEVE GILMAN, OWNER
Whose place of business is:
SANTE MOBILE CAFE - NEFFA
MANSFIELD SCHOOL COMPLEX - EAST STREET
PERSON(S) IN CHARGE
SCOTT HAVILAND
Permit Expires: April 17, 2016
License Number: T-92
Food Fee: $50.00
BOARD OF HEALTH
MichaeCMcClean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
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FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: Sante Mobile Cafe
Scott Haviland
2) Establishment Address: 1180 Great Plain Ave,
126 Acorn St, Millis, MA
Needham, MA
774-217-1676 Fax:
3) Establishment Mailing Address (if different): 53
Same
Fottler Rd, Hingham, MA 02043
4) Establishment Telephone No: 781 775 4804
5) Applicant Name & Title: Steve Gilman, Owner
6) Applicant Address: 53 Fottler Rd, Hingham, MA
7) Applicant Telephone No.: 781
24 Hour Emergency No.: 781 775
7754804
4804
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned By: Havigil Corp
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
Steve Gilman 53 Fottler Rd Hingham
Scott Haviland 126 Acorn St, Millis, MA
❑ An Association
X❑ A Corporation
❑ An Individual
❑ A Partnership
❑ Other legal entity
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Name & Title:
Scott Haviland
Address:
126 Acorn St, Millis, MA
Telephone No:
774-217-1676 Fax:
Emergency Telephone No:
Same
13 District Or Regional Supervisor if applicable)
Name & Title:
Address:
Telephone No: Fax:
Food Permit App
Food ,Establishment Information
14.) Water Source: Mansfield
15) Sewage Disposal:
Mansfield
DEP Public Water Supply No: (if applicable):
16) Days and Hours of Operation: Sat & Sun 10am-6pm
17) No. of Food Employees
18) Name of Person In Charge Certified in Food Protection Management: Scott Haviland
Required 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
x❑ Mobile (Dates) 4/15-4/16/16
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast
Establishment
❑ Frozen Dessert Manufacturer
Other (Describe)
Temp space in school caf.
21) Length Of Permit:
(check one)
❑ Annual
❑Seasonal/Dates
❑ Temporary/Dates/Times
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
X Sale of commercially Pre-
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held for
Packaged Non-PHFs
More Than a Single Meal Service
❑ Sale of Commercially Pre-
X 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
Only'—
X Preparation of Non-PHFs
❑ Juice Manufactured and packaged for
❑ Prepares Food/Single Meals for Catered
Retail Sale
Events
Other (Describe):
❑ Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date or
Reconditioned Food
To be completed by the Board of Health
Total Permit Fee:
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 the penalties of perjury that I, 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: 47-3730061
26) Signature of Individual or Corporate Name: Havigil Corp
Food Permit App
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.
Havigil Corp
* Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
47-373006
** 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.
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N H
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: Scott H
Certificate Number: 184611
Date of Completio ,`1/20/2011
Date of E. lration: 1/20/20 1 6
The above named person is her eGy issued this e< rtrpuate
for completing as aIle igen awar en ss tr aening pr ograni
rec ognixed by the Massa, husetts Department of Public Heedth
in accordance -with 105 CJWR 590.009(G)(3)(a).
This certificate will be valid for/ive (5) yeensfrorn date oftompletion.
Issued By:
-1—
IM MR21
NATIONAL <%
ASSOCIATION,S
Massoehusetts Restaurant Association
$00.765.2122
3337urnpike [toad, Suite 102
%""vaestaurant.mg
Southborough,MA 01772
5081-303-9905
www.marestaurintissoc.org
The Commonwealth of Massachusetts
Department of Industrial Accidents
a Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name
Address
53 Fottler Road
Sante - Mobile Farmhouse Cafe
City/State/Zip: Hingham, MA 02043 Phone #: 781-775-4804
Are you an employer? Check the appropriate box:
1. I am a employer with 5 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
11.❑ Health Care
12. ❑ Other
*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 41.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: MA Retail Merchants WC Group, Inc.
Insurer's Address
City/State/Zip:
PO Box 859222-9222
Braintree, MA 02185
Policy # or Self -ins. Lic. #
014005033831116
Expiration Date: 1/1/2017
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.
Signature: Date: 3/11/16
Phone #:
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 Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person:
www.mass.gov/dia ass.gov/dia
Phone #:
d
TOWN OF NEEDHAM, MASSACHUSETTS
C
PUBLIC HEALTH DEPARTMENT
(781) 455-7500; Ext. 511 Prevent. Promote. Protect,
2016 Food Establishment Permit
In accordance with 105 CMR (Article X of the State Sanitary Code), a permit to operate a
retail / food establishment is hereby granted to:
Establishment: Sante Mobile Farmhouse Caf6
Manager: Scott Haviland
Address: 1180 Great Plain Ave,
Phone: 774-217-1676
Type of License: Food Service -Commissary / Annual
,January 1, 2016 December 31, 2016
Tara E. Gurge, R.S., C.E.11T., M.S. Issue Date Expiration Date
Health Agent
NON -TRANSFERABLE POST CONSPICUOUSLY
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: Steve Gilman
Certificate Number: 1424434
Date of Completion' 5/27/2014
Date of Expiration: 5/27/2019
The above-namedperson is hereby issued this ez rti/icate
for completingttrr allergen awareness training/irograrn
recognized by the Alassachnsetts Department of'Public llcrzlth
in accordance with 105 011R 590.009(67)(3)(a).
21Jir certificate u:illbe vatirlfoz Jive (5) yearsfzorzz date of completion.
Issued By:
NATIONAL C
3
RESTAURANT
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ASSOCIATION,
Massachuwtts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
wmv.restaurant.org
Southhorough,MA 01772
506-303-9905
ahvw. mare stair rantassoe.org