HomeMy WebLinkAboutTasty Ray's 12/31/2018 (2)FOR BOARD OF HEALTH USE ONLY Permit# Issued C=2
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name TASTY RAY'S LLC
2) Establishment Address 20 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 20 SOUTH MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-1839
5) Applicant Name & Title RAYMOND DEAGRELA, OWNER/MANAGER
6) Applicant Address 50 MAYNARD STREET, APT 128, ATTLEBORO, MA 02703
7) Applicant Telephone No.: (508) 965 7258 24 Hour Emergency No.: (508) 965-7258
8) Owners Name & Title RAYMOND DEAGRELA
9) Owner Address (If different from applicant) 50 MAYNARD STREET, APT 128, ATTLEBORO, MA 02703
Owner's telephone number (508) 965-7258
10) Establishment Owned By: 11) If a corporation or partnership give name, title, and home address of officers
Li An Association or partner.
1 A Corporation Name Title Address
C1 An Individual
1 A Partnership
U Other legal Entity_-
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: '',RAYMOND DEAGRELA, OWNER/MANAGER
Address: 50 MAYNARD STREET, APT 128, ATTLEBORO, MA 02703
Telephone No: ',(508) 965-7258 24 Hour Emergency No: (508) 855-7258
FAX: I(508) 226-3860
E-mail: TASTYRAYS@_YAHOO.COM
Alt E-Mail: r d r, 41m),
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Eme
..... _..... _.
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL:
I
DEP Public Water Supply No: (If applicable) _ .. 16) No. of Food Employees:
17) DAYS/HOURS: TUES-SAT 11-9 SUN 4-9
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
TOWN
X01
RAYMOND DEAGRELA
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): I�
20) Location: i; Permanent Location 22) Establishment Type [J] Caterer $25.00
]j Moblie Moblie Start Date: ] I Retail ( Sq. Ft) L Milk & Cream $10.00
Moblie End Date: r-
j t_ Food Service up to 100 or (❑ Mobile Food & Consession $75.00
Moblie Comments: up to 10' PHF display $125.00 l . _
21) Length of Permit:
[Jl Annual
Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Food Service up to 101 -200
or up to 25' PHF display $150.00
'(-11 Food Service up to 201 +
or 25'+ PHF display $275.00
Food Service - Institution
( Meals/Day)
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
I Pushcart $25.00 # of Pushcarts: 0
] Residential Kitchen $100.00
i Retail Food $100.00
] Retail Snack Food $25.00
] Tobacco Products $25.00
Rain Date:
23) Food Operations Definitions' PHF- Potentially hazardous food (thrialemperature controls required)
Non-PHFs - non -potentially hazardous food(no time4emperature controls required)
Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
_ [ ISale of Commercially Pre -Packaged
d F Non-PHFs
i i Sale of Commercially Pre -Packaged PHFs
( Delivery of Packaged PHFs
[_J Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
fJ PHFCooked To Order
IVi Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Ji Sale of Raw Animal Foods Intended
to be Prepared by Consumer
-1 Customer Self -Service
i Ice Manufactured and Packaged for
Retail Sale
Juice Manufactured and Packaged t
Retail Sale
Offers RTE PHF in Bulk Quantities
1 Retail Sale of Salvage Out -Of -Date
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
J Offers Raw Or Undercooked Food Of
Animal Origin
l� Prepares Food/Single Meals for
Catered Events or Institutional Food Service
or Reconditioned Food To be completed by the Board of Health
"_-- - Total Permit Fee: $25.00
Payment is due with application ❑ waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copie,5 of 105 CMR 590.000 and the federal Food Code.
24) Signature G Applicant: / ��L
Pursuant to MGL Ch.62C, sec. 49 I certify under
penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 46-0546835
26) Signature of Individual or Corporate Name:
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
/ �
Signature of Indi dual or Co
rporate Name
9 6-05-/6Y35
**Social Security No. (Voluntary) or Federal
Identification Number
R A7 me ^ d &OL27"l l
IL4ZN--� �A-
By: Corporate Officer (Mandatory, ifApp irable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
R:\Hn1thUan0s Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORMdoc
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Business/Organization
Address:
Od
�U$ 33`1-07jy
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑ 1 am a employer with employees (full and/
S. Retail
6. EestaurantiBar/Bating Establishment
orpart-time).*
have
2.� i am a sole proprietor or partnership and no
?, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
$• ❑ 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. ElManufacturing
no employees. [No workers' comp. insurance required]*
I1.❑ [iealth Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
/
12.52 Other (2 g4e/' i, r.
*Any applicant that checks box #] must also fill out the section below showing their Workers' compensation policy information.
**lfthe eorporab officers have exempted thcrosclvcs, but the corporation bas other employees, a workcrs' compensation policy is required and such an
organization should check box M.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon.
Insurance Company
Insurer's
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
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby cerdfyy]under rhepains andRanaldes ofperjury that the information provided above is true and correct
. -7 a 6`3
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
Phone
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