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Home My WebLink AboutTanya's Cakes & More 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. TATIANA SALCUTAN Whose place of business is: TANYA'S CAKES & MORE 101 NORTH MAIN STREET, UNIT A102 PERSON(S) IN CHARGE: TATIANA SALCUTAN, OWNER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RK-07 BOARD OF HEALTH MichaeC-%1cCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued RKRK07 - - _ _ — FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address TANYA'S CAKES & MORE 101 NORTH MAIN STREET, UNIT A102 NOV 2 9 '1011 3) Establishment Mailing Address (if different) 101 NORTH MAIN STREET, UNIT A102 ,'11,r. r_ud MANSFIELD, MA 02048 4) Establishment Telephone No (401) 536-0272 5) Applicant Name & Title: TATIANA SALCUTAN 6) Applicant Address 101 NORTH MAIN STREET, UNIT A102, MANSFIELD, MA 02048 7) Applicant Telephone No.: (401) 536-0272 24 Hour Emergency No.: (401) 536.0272 8) Owners Name & Title TATIANA SALCUTAN 9) Owner Address (If different from applicant) 101 NORTH MAIN STREET, UNIT A102, MANSFIELD, MA Owner's telephone number 4015360272 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1 j An Association or partner. _' A Corporation Name Title Address r An Individual r A Partnership - C Other legal Entity -_- -- _-_- - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: TATIANA SALCUTAN, OWNER Address: 101 NORTH MAIN STREET, UNIT A102, MANSFIELD, MA Telephone No: (401) 536-0272 24 Hour Emergency No: (401) 536-0272 FAX: - --�- E-mail: TSALCUTAN(a)GMAIL.COM Alt E-Mail: TANYASCAKESANDMORE(a)GMAIL.COM - - - - — - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: _ E-mail Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: SUN-MON 10:00 AM - 5 PM 18) Name of Person In Charge Certified in Food Protection Management: 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) I J 20) Location: iV, Permanent Location [ I Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: r'I Annual [_ Seasonal 22) Establishment Type ] Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $125.00 [__' Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates Temporary -----__--- _ !.]Food Service - Institution _ Temporary Start Date: ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: j-- -- ❑ Caterer $25.00 ❑ Milk & Cream $10.00 Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer [] Pushcart $25.00 # of Pushcarts: 0 I ] Residential Kitchen $100.00 ❑ Retail Food $100.00 I_ J Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (timalempemture controls required) 23) Food Operations 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 rurtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ]-Sale of Commercially Pre Packaged PHFs Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours [_I Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations CUPCAKES, COOKIES, SCONES SPECIALTY CAKES I, the undersigned, attest to the accuracy of the inb establishment operation will comply with 105 CMR board of health on how to obtain copies of 105 CM} 24) Signature of Applicant: ill PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ------- -- i Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service [] PHF and RTE Foods Prepared For Highly I Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill -------- ------- ❑ Use of Process Requiring A Variance I ! Customer Self -Service and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative, time as a public health _ Retail Sale control) Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in -Bulk Quantities C1 Prepares Food/Single Meals for Catered Events or Institutional Food Service i.] 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 - ali rovided in this application and affirm that the food ). and all other applicable law. I have been instructed by the .000 and the federal Food Code. Pursuant to MGL Ch.62C, sec. 49A, I certify ung9r the penalties of perjury t at 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: 035-74-5205 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. Signature of Indivigl'ual or Corporate Name By: Corporate Officer (Mandatory, i(Applicable) 635- 74 -S-,ob" "Social Security No. (Voluntary) or Federal Identification Number *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;\Hn1thVan&s Doou eats\PERMIT APPLICATIONS\TAX 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 PERMCTTING AUTHORITY. Applicant Information Please Print Le0bly Business/Organization a Address: /O/ Vor A Main. 3t uinl`� 410a Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail �,( or part-time).* 6. �Restaurant(Bar/Bating Establishment 2:Id1 lam a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (inch real estate, auto, etc.) /� employees wonting forme in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 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. [to workers' comp. insurance req.] 12, Other *Any applicant that checks box #1 must also fill out the section below showing theirworkers' compensation policy information. sap the corporate of5eew have exempted themselves, but the corpom6on has other employees, a workers' eompensafion policy is required and such an organization should check box M. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon. Insurance Company Insurer's 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 imprisonmient, 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 c"erage verification. f do hereby certify, under the pains arldd1fienaldes of perjury that the information provided above is true and correct Phone #• r 461— s34 - 0 a 7 a 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 Elealth 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person www.mass.gov/ma Phone #: