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HomeMy WebLinkAboutSimply Cannoli 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 J 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:. MARK BLAIN & DEBRA BLAIN Whose place of business is: SIMPLY CANNOLI - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE TERMP-MiT 1 Permit Expires: April 17, 2016 License Number: T-54 Food Fee: $75.00 BOARD OF HEALTH michaeCvicCtean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued €' _ ' i-1 1�IpLe FOOD ESTABLISHMENT PERMIT APPLICATION t (Application must submitted at least 30 days before the planned opening date) A 1) Establishment Name: _ G %l // 2) Fstahl shment Address: % % ) j% 3) Establishment Mailing Address (if different) f� 4) Establishment Telephone No: 5) Applicant Name & Title: "a'Irk Ald 61 Applicant Address Apphcani Telephone No.: - 24 Hour Emergency No.: 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 Qorporation [ nn Individual ❑ A Partnership ❑ Other legal entity r , D re dly Responsible For Qaily Operations (Owner, person in charge, Supervisor, Manager, etc.) Na111e &Titie Address: i 1 zM Telephone No: L` tr 7L Fax: Emergency Telephone No: ?1 ;)Islnct Or Regional SupewisorLapplicable Name & Title. Address: Telephone No: Fax: I.1 "I 1 flail PI K\111 \I'I'I 1( :\ ril),\ Food Establishment Information 14.) Water Source 15) Sewage Disposal DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: '_ `' © f(%l� xCf (%17 No, of Food Employees 3, Name of Person In Charge Certified in Food Protection Management: Required Ls 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 �ent ✓/ ".a �t El Food Service -Institution ❑ Residential Kitchen for Bed & Breakfast Home U Moble (Dates)' ( Meals/Day) ElResidential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) r Annual =S<a a1,Dates Te o, rlDat s e— s 23) Food Operations: Definitions: PHF — Potentially hazardous food (timeAemperature controls required) (check all that apply): Non-PHFs — non -potentially hazardous food (no time/femperature controls required) RTE — ready -to -eat foods Ex. Sandwiches, salads, muffins which need no furtherprocessing) Saie of commercially Pre- ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service [1"Sale of Commercially Pre- ElPreparation 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 'A',th,n 4 Hours alternative, time as a public health control er Self -Service of Non ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Animal PHP and Non -Perishable Foods Retail Sale Origin Only. ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered R S e e or institutional Food Service ❑ Offers RTE PHF in Bulk Ciitantities o ue comp etea by the tsoar of gem' n .o[ P—mif Paz• a"11 L_I Retail Sale of Salvage, Out -Of -Date or Re ramorte(7rocr• ayrT Is ue 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: /l✓Ci e .G< :! ,,a a tc MCF Ch 62C sec 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state ,- f naso slate taxes required under law. _ 25) Social Security Number or Federal ID: 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. * Signa ure of Individtial or Corporate Name (Mandatory) By: Corporate Off i er (Mandatory, if applicable) ** 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office df Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organizati \ddrc,"� /V_____1__ City/State/Zip: Are you an employer? Check the ppropriate box: i. ❑ 1 am a employer with employees (full and/ or hart time).* _ 1 .w l :I �k le proprietor or partnership and have no employees \yorking for me in any capacity. No workers' comp. insurance required] 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]*' ❑ We are a non-profit organization, staffed by volunteers, �\ illi no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑'detail 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 �n applicant that checks box 41 must also till out the section below showing their workers' compensation policy information. *I I'the corporate ot'licers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: V! h , City/State/Zip: Policy # or Self -ins. Lic. #, Expiration Date: 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 ur, lip to � l .s00, 0 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ui' 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 certifyyynder the pains and penalties ofperjury that the information provided above is true and correct. Simature U.ficiul use only. Do not write in Nris area, to be completed by city ortown 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 0. 0111cr Contact Person: Phone #: www.mass.goWcita M T— z O 0 N Q z_ O < X ' 0 W O0 0 w q w c E o CY 0 N C O � N NCc e /1 L l l r LC) U w p i LL O o EN 977i � 73I 1 � Z1: 111 I G n00 •ro N .�T�• c � D S k lD lD (D o c o m Z w C3 a a m c m u m 2 i 9 w V2 o