HomeMy WebLinkAboutBlondie's Cakes 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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:.
JESSICA GAUDETTE
Whose place of business is:
JESSICA GAUDETTE - BLONDIE'S CAKES
7 MAYFLOWER DRIVE
PERSON(S) IN CHARGE:
JESSICA GAUDETTE
Permit Expires: December 31, 2018
Food Fee: $100.00
License Number: RK-09
BOARD OF HEALTH
9%4ichaeC.McCCean, Chairman
(1'-t.CC_k_ 41- 10 C1 q
FOR BOARD OF HEALTH USE ONLY
[Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
�App1lca 1o�t_be submitted at leastdays betore the planned opening date)
1) Establishment Name _
2) Establishment Address M VU 2 i�GCY1.S T 1 dd
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title: , ASS\CIl l7Gl tJ CA2T1�
6) Applicant Address � � 01 J C S I�r� d� �GtV1 S� l2�� IA 60649
7) Applicant Telephone No.: 24 Hour Emergency No.:
5N-qq3-
8) Owners Name & Title -ye SS 1C-
9) Owner Address (If different from applicant)
Owner's telephone number_ Ll
10) Establishment Owned By:
1-1 An Association
El A Corporation
[KAn Individual
A Partnership
El Other legal Entity
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:
SesS �CC),_
Address:
I ►ti 1si o
Telephone No:
4�N- 1)q 9L _ (0C)' 61 24 Hour Emergency No:
K
-NA-N
L
FAX:
---
E-mail:
Alt E-Mail:
f� n
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE: _fowr 16) SEWAGE DISPOSAL: 'T6ln)n
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
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 10/l/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
I-
1g) Person Trained in Anti -Choking Procedures (If 25 Seats or more): Q
20) Location: 1;9 Permanent Location
22) Establishment Type
❑ Caterer $25.00
El Mobile Mobile Start Date:
Retail ( Sq. Ft)
%,Milk & Cream $10.00
Mobile End Date:
I] Food Service up to 100 or
❑ Mobile Food Consession
Mobile Comments:
up to 10' PHF display INCLUDING
NO PHF PREPARED ON SITE $75.00
_
21) Length of Permit:
FOOD TRUCKS $125.00
❑ Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200
$25.00/freezer
Annual
or up to 25' PHF display $150.00
Q Food Service up to 201 +
El Pushcart $25.00 # of Pushcarts:
Seasonal
or 25'+ PHF display $275.00
-] Residential Kitchen $100.00
Seasonal Dates:
❑ Food Service - Institution
❑Retail Food $100.00
❑Retail Snack Food $25.00
_
Temporary
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Definitions:PHF - Potentially hazardous food (lime/tempemture controls requiter)
Non-PHFs - non -potentially hazardous food(no time/tempemture controls required)
(Check all that apply):
RTE - ready -to -eat foods (Ex. sandwiches, salads, mulflns which need no /urtherprocessing)
Q 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
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
Delivery of Packaged PHFs
--
Susceptible Population Facility
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
i] Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
❑ Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
control) _
0 Ice Manufactured and Packaged for
Retail Sale
_
Preparation of Non-PHFs
Other Food Operations
❑ Juice Manufactured and Packaged for
Q Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
❑ Prepares Food/Single Meals for
Offers RTE PHF in Bulk Quantities
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:
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 690.000 and all other applicable law. I have been instructed by the
board of health on how to obtain oopioo of 105 QvIR 59D,000 and the federal Food Code.
24) Signature of
Pursuant to MGL Ch.62C, sec. 4`M, 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, y/0�
25) Social Security Number or Federal ID: Qa�
26) Signature of Individual or Corporate Name: Ak
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.
Signs re of (Individual or Corporate Name By: Corporate Officer (Mandatory, if 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.
C:\Users\sleite\Desktop\Scotts DocumentArood Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization
Address: r7
City/State/Zip:
Phone #: 90�- q q a - (o 01 C)
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑
I am a employer with employees (full and/
5. Retail
`,�,
2. NJ
or part-time).*
1 am a sole proprietor or partnership and have no
6. ❑ Restaurant/Bar/Eating Establishment
TTT
y, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ 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. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct.
v
Phone#: go— (Opm
Of 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 #:
www.mass.gov/dia