HomeMy WebLinkAboutGourmet Bae 8/25/2018Commonwealth 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: RETAIL FOOD -FARMERS MARKET
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:.
BAILEY REYNOLDS, OWNER
Whose place of business is:
GOURMET BAE CATERING - FARMERS MARKET
888 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
BAILEY REYNOLDS, OWNER
Permit Expires: August 25, 2018
Food Fee: $10.00
License Number: RFM-22
BOARD OF HEALTH
Michaet-McCCean, Chairman
FOR BOARD OF HEALTH USE
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title: 'IX
6) Applicant Address
V'f'
7) Applicant Telephone No.: 24 Hour Emergency No,:
8) Owners Name & Title of \'C!
9) Owner Address (if different from applicant)
Owner's telephone number
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
B An Association
or partner.
IM A Corporation
Name Title Address
IR An Individual
H A Partnership
(9 Other legal Entity
iz) verson uirecuy Kesponsiole [-or Uaily ulperations4(owner, person in charge, supervisor, manacier etc.)
Name & Title:
'� ) �
v"
Address:
Telephone No.
24 Hour Emergency No:
FAX:
E-mail:
Aft E-Mail:
A' kv
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:
15) SEWAGE DISPOSAL:
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. i
Required as of 10/l/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seals or more): ❑`-f
20) Location: (--a Permanent Location
22) Establishment Type
.[^a] Caterer $25.00
Q Moblie Mobile Start Date:
Retail ( Sq. FQ
f Milk & Cream $10.00
Moblie End Date:
Food Service up to 100 or
t9 Mobile Food & Consession $75.00
Mobile Comments:
up to 10' PHF display $125.00
� Food Service up to 101 -200
f3 Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
21) Length of Permit:
9
❑—a Annual
or up to 25' PHF display $150.00
i Food Service up to 201 +
or 25'+ PHF display $275.00
L1 Pushcart $25.00 # of Pushcarts:
(- Residential Kitchen $100.00
K'0 Retail Food $100.00
f"3 Seasonal
Seasonal Dates:
Food Service - Institution
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
(Check all that apply):
Definitions:PHF- Potentially hazardous food(h'meltemperature controls required)
Non-PHFs - non -potentially hazardous food(no time4emperature controls required)
RTE-ready-to-eat foods (Ex. sandwiches, salads, mu/fins which need no further processing)
Q Sale of Commercially Pre -Packaged Non-PHFs
❑1 PHFCooked To Order
r1 Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercial/ Pre -Packaged PHFs
® Y 9
r;,
� Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
E`•1 Delivery of Packaged PHFs
trI PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Fa Vacuum Packaging / Cook Chill
❑. Customer Self -Service of Non PHF and Non-
Perishable Foods Only
Customer Self -Service
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
_ control)
Ice Manufactured and Packaged for
Retail Sale
te[:J
•'1 Preparation of Non-PHFs
Other Food Operations
O Juice Manufactured and Packaged for
Retail Sale
L7 Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
0 Offers RTE PHF in Bulk Quantities
!'- Retail Sale of Salvage, Out -Of -Date
by the Board of Health
or Reconditioned Food
[Tompleted
rmit Fee:
is due with application (3 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 cooies.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
26) Signature of Individual or Corporate Name.
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Signature of lgdividual 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.
k� Ill Washington
�'
Boston, 02-111
I I I
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Address
Jr
City/State/Zip: 1,, c(p(Ki` �nct W" U'UPhone#: ` Se; " io2Z _ 5Z `�, 2.
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
I am a employer with employees (full and/
S. ❑ Retail
orpart-time).*
6. EIRestaurant/Bar/EatingEstablishment
2. J4
I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (met. 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.]
1 12.0 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 themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am 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
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
www.mass.gov/dia
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