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Home My WebLink AboutHometown Bakery 12/31/2018Commonwealth 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: RESIDENTIAL KITCHEN 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:. ARLENE COCCIA Whose place of business is: HOMETOWN BAKERY, LLC 60 STEARNS AVENUE PERSON(S) IN CHARGE: ARLENE COCCIA, OWNER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RK-01 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued RK-01 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name HOMETOWN BAKERY, LLC 2) Establishment Address 60 STEARNS AVENUE F 3) Establishment Mailing Address (if different) 60 STEARNS AVENUE (� MANSFIELD, MA 02048 7 17U1 j 4) Establishment Telephone No (508) 254-9733 x 5) Applicant Name & Title: ARLENE P. COCCIA, OWNER ------- 6) Applicant Address 60 STEARNS AVENUE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-2362 24 Hour Emergency No.: (508) 254-0134 OR (508) 339-2362 8) Owners Name & Title ARLENE COCCIA 9) Owner Address (If different from applicant) Owner's telephone number 5083392362 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers I An Association or partner. 1 A Corporation Name Title Address ICI An Individual CI A Partnership -- D Other legal Entity-_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ]ARLENE COCCIA, OWNER Address: I60 STEARNS AVENUE, MANSFIELD, MA 02048 Telephone No: I(508) 339-2362 ___---L--___ .--- 7-10 E-mail: iAPCOCCIA(cDVERIZON.NET Alt E Mail: 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No. FAX: E-mail: 24 Hour Emergency No: (508) 254-0134 OR (508) 339.2362 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) v) No. of Food Employees: 17) DAYS/HOURS: TUES - SATURDAY 0:00 AM - 2:00 PM 18) Name of Person In Charge Certified in Food Protection Management: ARLENE PATRICIA COCCIA If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate �) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑ 20) Location: ❑./ Permanent Location 22) Establishment Type ❑ Caterer $25.00 [ 1 Moblie Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments up to 10' PHF display $125.00 El Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: ❑ Food Service up to 101 -200 $25.00/freezer Annual or up to 25' PHF display $150.OD ❑ Food Service up to 201 + ❑ Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 ❑ Seasonal Seasonal Dates: or 254 PHF display $275.00 ❑Retail Food $100.00 ❑ Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Temporary Start Date: ( Meals/Day) [] Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: I 23) Food Operations Definitions: PHF- Potentially hazardous food (timeAemperature controls required) Non-PHFs non -potentially hazardous food(no timeRemperature controls required) Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no Nrtherprocessing) ❑I Sale of Commercially Pre Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held --- -- -- ---- - -- ----- -- --- -- for More Than a Single Meal Service Sale of Commercially Pre Packaged PHFs ❑Preparation of PHFs For Hot And _-. _, ._,..- ---- --- ------------- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly --1 Delivery of Packaged PHFs _ __--_ _ Susceptible Population Facility _ Reheating of Commercially to be Prepared by Consumer El Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _ - -- - i 1 Use of Process Requiring A Variance _i Customer Self Service of Non PHF and Non ❑ Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only --- - - -- Ice Manufactured and Packaged for contact alternative, time as a public health LI Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health - --_-- Total Permit Fee: $100.00 Payment is due with application ❑ waived I, 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 board of health on how to obtain copies of105CZAR 590.0000 and the federal Food Code. I 24) Signature of Applicant: �/y�-('•f.��L[ - ( TIc' . CL. 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 tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 47-452-3304 26) Signature of Individual or Corporate Name: TAX CERTIFICATION FORM 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. C�C.t,�eyt-C- U �r •c.et. Signature of Individual or Corporate Name g7 5y � 334 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. R:\Hm1thVane's Documents\PERMIT APPLICATIONSUAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Address: � 0 S'�Ea fn5 fT V c City/State/Zip; M"S<4 CAd 1 Allq Phone#: Are you an employer? Check the appropriate box: Business Type (required): I. ❑ 1 am a employer with employees (full and/ S. ❑ Retail orpart-time).* 6. F1RestaurantBar/EatingEstablishment 2: K I am a sole proprietor or partnership and have no ?, Q Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp, insurance required] 3, ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.l 12. ❑ Other *Any applicant that checks box #1 must also filI out the section below showing their workers' compensation policy information. **If the corpoate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an ' organization should check box #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance insurer's City/State/Zip: Policy # or Self -ins, Lic, #- Expiration Data: 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 anal penalties ofperjury that the information provided above is true and correct. Phone #: S� 9— a) S 7 — 1 % 3 3 / Official use only. Do not write in this area, to be completed by city or town offictaL 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 www.macs.gowma Phone #: