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Home My WebLink AboutNancy Antonucci 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:. NANCY ANTONUCCI, OWNER Whose place of business is: NANCY ANTONUCCI 186 STEARNS AVENUE PERSON(S) IN CHARGE: NANCY ANTONUCCI, OWNER Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: RK-06 BOARD OF HEALTH Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued RK-05 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name NANCY ANTONUCCI 2) Establishment Address 186 STEARNS AVENUE 3) Establishment Mailing Address (if different) 186 STEARNS AVENUE MANSFIELD, MA 02048 4) Establishment Telephone No 858-5691 5) Applicant Name & Title: NANCY ANTONUCCI 6) Applicant Address 186 STEARNS AVENUE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (781)858-5691 24 Hour Emergency No.: 1781)858-5691 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: CI An Association I A Corporation ICI An Individual I _l A Partnership NANCY ANTONUCCI, OWNER 186 STEARNS AVENUE, MANSFIELD, MA 02048 7818585691 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) I Name & Title. r- INANCY ANTONUCCI, OWNER - Address: I186 STEARNS AVENUE, MANSFIELD, MA 02048 Telephone No: 1(781) 858-5691 24 Hour Emergency No: (781) 858-5691 FAX: -— E-mail: NANCY.ANTONUCCI(c@COMCAST.NET Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: N/A Address Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: SEPTIC DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 0 17) DAYS/HOURS: 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) ❑ 20) Location: lyl Permanent Location 1_, 1 Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ICI Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 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 ❑ Food Service - Institution Meals/Day) ❑ 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 0 Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations I Definitions: PHF- Potentially hazardous food (tlme4emperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) ,Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre Packaged Non PHFsP PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held -- --- for More Than a Single Meal Service of Commercially Pre Packaged PHFs Preparation of PHFs For Hot And _Cold Holding For Single Meal Service (] PHF and RTE Foods Prepared For Hight) Delivery of Packaged PHFs -------------- Susceptible Population Facility --------- —— -- ❑Sale of Raw Animal Foods Intended [_] Reheating of Commercially _ - Foods for Service Within 4 Hours to be Prepared by Consumer ❑Vacuum Packaging /Cook Chill Customer Self Service of Non PHF and Non - Perishable Foods Only Non-PHFs Other Food Operations GRANOLA Customer Self -Service [_I Ice Manufactured and Packaged for Retail Sale Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities I ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health L -- — -- Total Permit Fee: $100.00 Payment is due with application [--1 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 of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify ub9er 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: 030-48-6737 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 hUividual or Corporate Name ip-T-N ?I - -�)q f sI q4-- **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. RdHmIthU=6s Doc==ts\PERMTT 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 PERMITTING AUTHORITY. Business/Organization Name: /� LW6,R,h Address: �IO `Sfaan,-\ S A�)L , r Are you an employer? Check the appropriate box: I. ❑ I am a employer with employees (full and/ or part-time).* 2:�A lam a sole proprietor orparmarship and have no employees working for me in any capacity. [No workers' camp. 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 enaDiovees. (No workers' coma. insurance reo.1 Phone. #: —7g11'659- ✓ICJ j Business Type (required): 5. ❑ Retail 6. F1 Restaurant(Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 11. ❑ HealR th Care ` � � i 12,�]Other �lexl �%L *Any applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information. **If the corporate ofEcera have exempted themselves, but the corporation has other employees, a workers compensation policy is required and such an organization should check box #]. 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify /under the pains and p naldes ofperrury that the information provided above is/truu�e and correct �1L1 �.��T7///gsii/, TlatP• ��"T—/ �/ Official use only. Do not write in this area, to be completed by city or town offiei¢L 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: Phone#: svww.mess.gowma