HomeMy WebLinkAboutThe Ultimate Cookie 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:.
ELLEN BORDEN
Whose place of business is:
THE ULTIMATE COOKIE
23 CAVAN CROSSING
PERSON(S) IN CHARGE:
ELLEN BORDEN
Permit Expires: December 31, 2018
Food Fee: $100.00
License Number: RK-08
BOARD OF HEALTH
MichaeCMcCCean, Chairman
-
FOR BOARD OF HEALTH USE ONLY permit # Issued RK-08
i
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name
2) Establishment Address
THE ULTIMATE COOKIE
23 CAVAN CROSSING
-
3) Establishment Mailing Address (if different) 23 CAVAN CROSSING
MANSFIELD, MA 02048
4) Establishment Telephone No (774) 266-4322
5) Applicant Name & Title: ELLEN BORDEN
6) Applicant Address 23 CAVAN CROSSING, MANSFIELD, MA 02048
7) Applicant Telephone No.: (774) 266-4322 24 Hour Emergency No.: (774) 2664322
8) Owners Name & Title ELLEN BORDEN
9) Owner Address (If different from applicant)
Owner's telephone number 7742664322
10 ) Establishment Owned By 11) If a corporation or partnership, give name, title, and home address of officers
!An Association or partner.
1 A Corporation Name Title Address
r] An Individual
A Partnership-
I
Other legal Entity
-
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: !ELLEN BORDEN
Address: 123 CAVAN CROSSING, MANSFIELD, MA 02048
Telephone No: (774) 266-4322 24 Hour Emergency No: (774) 266-4322
FAX
E-mail: NURSEELLEN(cDCOMCAST.NET
Alt E Mail: -
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: ` E-mail: - - -_
CF (,t _> r
Food Establishment Information
- _--
14) WATER SOURCE: TOWN I 15) SEWAGE DISPOSAL: SEPTIC
DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management:
I If more than 3 individuals are certified, complete list is on file.
i 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
20) Location: U Permanent Location
1 Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
:-4 Annual
Seasonal
Seasonal Dates:
1 Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
Retail ( Sq. Ft)
I ] Food Service up to 100 or
up to 10' PHF display $125.00
-'I Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 254 PHF display $275.00
Food Service - Institution
( Meals/Day)
-) Caterer $25.00
j Milk & Cream $10.00
l _) Mobile Food & Consession $75.00
Manufacture Frozen Desserts/Ice Cream
-' $25.00/freezer
Pushcart $25.00 # of Pushcarts: 0
1 Residential Kitchen $100.00
Retail Food $100.00
Retail Snack Food $25.00
J Tobacco Products $25.00
231 Food Operations Definitions'PHF - Potentially hazardous food (time/temperaturecontrols required)
'.(Check all that apply):
Non-PHFs - non -potentially hazardous foodum time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs
PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
--
Sale of Commercially Pre -Packaged PHFs
--1 ---- -
'I Preparation of PHFs For Hot And i
for More Than a Single Meal Service
-- -
Delivery of Packaged PHFs
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
_
---- ---{
-- -- --- a
j Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially
- to be Prepared by Consumer
I Vacuum Packaging / Cook Chill j
i1�t.,W xxairfz m k#ornkAtm-1491ltri if,KM urm�
I Customer Self -Service of Non PHF and Non -
Perishable Foods Only
-_J Preparation of Non-PHFs
r Self -Service
Ice Manufactured and Packaged for
Retail Sale
[ Use of Process Requiring AVariance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Other Food Operations ❑ Juice Manufactured and Packaged for 1 Offers Raw Or Undercooked Food Of
Retail Sale iAnimal Origin
Off ersRTE 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 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 slate tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 013564920�'` 1 ��
jk 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 Individual or Corporate Name
"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: Hmlth\J nds Doc l ents\PERMrP APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth ofAfassachusetts
Department of Industrial Accidents
I Congress Stree4 Suite 100
Boston, MA 02114-2017
r, www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LeLTibly
Business/Organization Name: � hr,
Address:7;Z:!> C(aq(3K�t Cr-oSS;
KA I\ rAn "1 7I_l. — -si _ .Lt a
Are you an employer? Check the appropriate box:
Business Type (required):
I. ❑ 1 am a employer with employees (full and/
5. ❑ Retail
or part-time).*
V have
6. �Restaurant/Bar/Ba6ng Establishment
2: 1 am a sole proprietor or partnership and no
q, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity,
8. ❑ Non-profit
ENo 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
i o. El Manufacturing
no employees. [No workers' comp. insurance required]*
1 I. [� Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information.
**If the corporate officers have exempted themsdyes, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
1 am an employer that isproriding workers' compensation insurance for my employees. Below is thepolicy informadoh.
insurance
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. #- Expiration Date:
Attach a copy of the workers' compensation policy declaration page (sbowing 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 fire
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.
1 do hereby certify, under the pains anal penaldespofperjury that the information provided above is true and correct.
Simature: �- �JJ IC Y Date: k,�k\ 1-7
Phone #• in
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
Contact Person
www.mass.gowma
Phone
Bank #
Pkta
TOWN OF MANSFIELD
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER
Deparfmonf: IDOARD OF HEALTH I Dafe: r2/21/2017
Schedule: JED122117
ELLEN BORDEN 01512-445000 _ $ 100.00
THE ULTIMATE COOKIE
10000
100.DO
The above is a detailed list of moneys collected by me, amounting in the aggregate to:
$10000 _[for ing 112/21/201{
which I have Daid to the Town Treasurer whose receiot I hold therefor.
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