HomeMy WebLinkAboutLinda's Cookies 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:.
LINDA FERNANDO
Whose place of business is:
LINDA'S COOKIES/LBFC, INC.
6 CEDAR RIDGE LANE
PERSON(S) IN CHARGE:
LINDA FERNANDO
Permit Expires: December 31, 2018
Food Fee: $100.00
License Number: RK-03
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued RK-03
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name LINDA'S COOKIES/LBFC, INC.
2) Establishment Address 6 CEDAR RIDGE LANE
3) Establishment Mailing Address (if different) 6 CEDAR RIDGE LANE
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 337-9809
5) Applicant Name & Title: LINDA FERNANDO
6) Applicant Address 6 CEDAR RIDGE LANE, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 337-9809 24 Hour Emergency No.: (781) 771-5102
8) Owners Name & Title LINDA FERNANDO
9) Owner Address (If different from applicant) 6 CEDAR RIDGE LANE, MANSFIELD, MA 02048
Owner's telephone number
10) Establishment Owned By:
❑ An Association
I_1 A Corporation
ICI An Individual
L 1 A Partnership
L_ Other legal Entity_
6083379809
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.)
Name & Title:
iLINDA FERNANDO
Address:
6 CEDAR RIDGE LANE, MANSFIELD, MA 02048
Telephone No:
(508) 337-9809 (781) 771-5102 24 Hour Emergency No: (781) 771.5102
FAX.
E-mail:
LINDA(ZDLINDASCOOKIES. NET LBHFERNANDO@HOTMAIL.COM
Alt E-Mail:
LBHFERNANDO@HOTMAIL.COM
13) District Or Regional Supervisor (if applicable)
Food Establishment Information
14) WATER SOURCE: TOWN
15) SEWAGE DISPOSAL: TOWN
I DEP Public Water Supply No: (If applicable)
16) No. of Food Employees: 1
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: EV] Permanent Location
22) Establishment Type
❑ Caterer $25.00
❑ Moblie Moblie Start Date:
❑ Retail ( Sq. Ft)
❑Milk &Cream $10.00
Moblie End Date:-j
Food Service up to 100 or
❑ Mobile Food & Consession $75.00
Moblie Comments:
up to 10' PHF display $125.00
❑ Manufacture Frozen Desserts/Ice Cream
21 Length of Permit:
) 9
El Service up to 101 -200
$25.00/1reezer
IV] Annual
or up to 25' PHF display $150.00
❑ Food Service up to 201 +
❑ Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
❑ Seasonal
Seasonal Dates:
or 25'+ PHF display $275.00
❑ Retail Food $100.00
i--] Temporary
❑ Food Service - Institution
❑ Retail Snack Food $25.00
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date:
---- ------
_.___.
23) Food Operations Definitions: PHF- Potentially hazardous food (thane/temperature controls required)
Non-PHFs - non -potentially hazardous food(no thme/temperature controls required)
;Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches salads, muffins which need no further processing)
[,I Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
--- ---- ------ ---------- —--- for More Than a Single Meal Service
❑J Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
-- - --- Cold Holding For Single Meal Service �._] PHF and RTE Foods Prepared For Highly
i ] Delivery of Packagedd PHFs Susceptible Population Facility
---- - ---- ------ - ❑ Sale of Raw Animal Foods Intended
❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
--- ---- -- ---
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
---------
�l Customer Self -Service
—I 9--
Manufactured and Packa ed for
Retail Sale
❑ Juice Manufactured and Packaged for
Retail Sale
L] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
_ __Ice
Preparation of Non-PHFs
Other Food Operations
-
❑ Offers Raw Or Undercooked Food Of
Animal Origin
El Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Offers RTE PHin Bulk Quantities
I_J 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 state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 46-3072583
26) Signature of Individual or Corporate Name: f k t"u a'�hi
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.
IJ �-L- fib f
Signature 4Individual or Corporate Name By: Corporate Officer (Mandatory, iif Applicable)
"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:\HwIth\J=e's Docu ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of lndushial Accidents
1 Congress Stree4 Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information Please Print Legibl
Business/Organization
Are you an employer? Check the appropriate box:
I, ❑ I am a employer with employees (full and/
or part-time).*
I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. 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 employees. [No workers' comp. insurance req.]
hone #:
Business Type (required):
5. ❑ Retail
6. F1 Restaurant/Bar[Eating Establishment
7. ❑ Office and/or Sales (ind. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
ME] Manufacturing
I LEI Health Care
12,❑ Other
*Any applicant that checks box #1 must also fill out the stodon below showing their workers compensation policy information.
**If the corporate officers have cxcmplcd theursdves, but the corporation ba6 other employees, a workers' compensation policy is required and such an
organization should check box #I.
I am an employer that is providing workers' compensation insurance for my employees. Betow is the policy information.
Insurance Comnanv Name:
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.
I do hereby certify .under the pains anal penalties ofperjury that the information provided above is true and correct
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: Phone