HomeMy WebLinkAboutCapriotti's 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: FOOD SERVICE ESTABLISHMENT
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:.
SEAN OLSON, PRESIDENT
Whose place of business is:
OLSON RESTAURANT GROUP MANSFIELD, LLC DBA CAPRIOTTI'S
321A SCHOOL STREET, SUITE 140
PERSON(S) IN CHARGE:
JOHN JULIO, MANAGER
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-71
BOARD OF HEALTH
Nichae(NcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-71
FOOD ESTABLISHMENT PERMIT APPLICATIQN
(Application must be submitted at least 30 days before the planned opening date)
, , ,� j F 1
I&T�S
1) Establishment Name OLSON RESTAURANT GROUP MANSFIELD, LLC DBA CAPE 3:
2) Establishment Address 321A SCHOOL STREET, SUITE 140
3) Establishment Mailing Address (if different) 163-°MAIN-STREET-#2 0 1-06 r
ME-DWAYTMA-02053-- (Y), C
4) Establishment Telephone No (508) 339-0522
5) Applicant Name & Title: SEAN OLSON, PRESIDENT
6) Applicant Address
7) Applicant Telephone No.: (808) 533-3030 24 Hour Emergency No.: (781) 983-2687 SEAN
8) Owners Name & Title SEAN OLSON, PRESIDENT
9) Owner Address (If different from applicant) 6 GOLDENROD DRIVE, MEDWAY, MA 02053
Owner's telephone number 5085333030
10) Establishment Owned By: l
11) If a corporation or partnership, give name, title, and home address of officers
LJ An Association
or partner.
A Corporation
Name Title Address
7 An Individual
C j-, r) c -C
C] A Partnership
' ` ltCt 0 3
LI Other legal Entity_
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: (MATT-GOUGHL-tN
Address: '-163-MAIN-STREET-#2; MEDWAYTMA-03053.-
Telephone No (508) 533-3030 24 Hour Emergency No: (781) 953.2687 SEAN
FAX: 1(508) 533 3010
E-mail: FOXBORO(cDOLSONRG.COM
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
24 Hour Emergency No:
E-mail:. _ __.
Food Establishment Information
14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL TOWN
DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 12
17) DAYS/HOURS: MON-SUN 11:00 AM - 10:00 PM
18) Name of Person In Charge Certified in Food Protection Management: MATTHEW-COUGt11LIN
If more than 3 individuals are certified, complete list is on file. - Lt `',
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: I7 Permanent Location 22) Establishment Type
❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft)
.Mobile End Date:
Mobile Comments:
21) Length of Permit:
n, Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
[�ej 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 $160.00
❑ 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
❑ 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(time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
Check all that apply): I RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing)
❑I Sale of Commercially Pre -Packaged Non-PHFs I [] PHFCooked To Order
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
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
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
to be Prepared by Consumer
Customer Self-Selice
Ice Manufactured and Packaged for
Retail Sale
❑ 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
I_] 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
or Reconditioned Food To be completed by the Board of Health
--_-- ----- -- --- -- - - -- "--"-- Total Permit Fee: $125 00
Payment is due with application El waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply y}��9ith 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain-ec a of 105 CMR 590.000 and the federal Food Code,
24) Signature of Applicant:
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: 46-1566737
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.
I tore of Individual or Corporate Name By: orporate Officer (Mandatory, if Applicable)
1- - / S (irk 7 ., `)
**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.
RAHIthUane's Doc=mts\PERM1T APPLICATIONS\TAX CERTIFICATION FORM.doc