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Home My WebLink AboutSimply Cannnoli 4/22/2018Commonwealth 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: TEMPORARY FOOD PERMIT - NEFFA 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:. MARK BLAIN & DEBRA BLAIN Whose place of business is: SIMPLY CANNOLI - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: MARK BLAIN, OWNER Permit Expires: April 22, 2018 Food Fee: $75.00 License Number: NEFFA-8 BOARD OF HEALTH .Michael .McClean, Chairman M FOR BOARD OF HEALTH USE ONLY Permit # Issued NEFFA-8 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address SIMPLY CANNOLI - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET 3) Establishment Mailing Address (if different) 112 MAPLE STREET DOUGLAS, MA 01516 i 4) Establishment Telephone No (508) 341-7097 5) Applicant Name & Title: MARK BLAIN & DEBRA BLAIN 6) Applicant Address 112 MAPLE STREET, DOUGLAS, MA 01516 7) Applicant Telephone No.: (608) 341-7097 24 Hour Emergency No 8) Owners Name & Title 9) Owner Address (If different from applicant) MARK BLAIN & DEBRA BLAIN 112 MAPLE STREET, DOUGLAS, MA 01516 Owner's telephone number 5083417097 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ! IJ A Corporation Name Title Address CJ An Individual 1 A Partnership _Other legal Entity.. 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (MARK BLAIN, OWNER Address: 1112 MAPLE STREET, DOUGLAS, MA 01516 Telephone No: 1(508) 341-7097 24 Hour Emergency No: I FAX: — - — - ---------- E-mail: SIMPLYCANNOLI(&GMA1L.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title Address: - - Telephone No: 24 Hour Emergency No: FAX: i I E-mail: Food Establishment Information 14) WATER SOURCE: ON SITE �15) SEWAGE DISPOSAL ON SITE DEP Public Water Supply No: (If applicable) i 16) No. of Food Employees: 1 j 17) DAYSIHOURS: FRI 7-11 SAT 10-11 SUN 10.5 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: ❑ Permanent Location - 22) Establishment Type I I Mobile Mobile Start Date: [] Retail ( Sq. Ft) Mobile End Dale: I I Food Service up to 100 or Mobile Comments: up to 10' PHF display $126.00 r 21) Length of Permit: ❑ Food Service up to 101 -200 _j Annual or up to 25' PHF display $160.00 Seasonal ❑ Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: Ll Temporary ❑ Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Date: AJrTl"f Temporary Time: 6:00PM-11:3013M, 9:00 MARK W. BLAIN ❑ Caterer $25.00 ❑ Milk & Cream $10.00 '_,i'Mobile Food & Consession $75.00 Lj 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 Rain Date: --- --____ _.-__-.- 23) Food Operations I Definitions PHF- Potentially hazardous loud(tlme/temperalure controls required) Non-PHFs - non -potentially hazardous lood(no Ilme/lemperature controls required) ((Check a0 that apply): RTE - ready to-eal loods (Ex. sandwiches, salads, muffins which need no hurler processing) ,! I Sale of Commercially Pre -Packaged Non-PHFs 7=� PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held I [1 Sale of Commercially Pre Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service --- - _ _ ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ._ _.._ _. .--.-- - ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility --- - -- -- ----- --- l �_] Reheating of Commercially- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer - "------- [] Vacuum Packaging 1 Cook Chill Processed Foods for Service Within 4 Hours _ I; l Customer Self -Service of Non PHF and Non- - - ----- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only --- --- ❑ Ice Manufactured and Packaged for contact alternative, time as a public health ❑Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _ _ __ _ MOBILE UNIT - CANNOLI, COFFEE -""--------" .. " ❑ - -"- — -"-._ ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date --- --- ---- --11 or Reconditioned Food - ETobecompleted by the Board of Health rmit Fee: $75.00 t 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 110055 CMR 590,000 and the federal Food Code. 24) Signature of Applicant: ®d/.LAifk,6GGt2!'Z' 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: 043-275753 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. ,6�&W-aj Signature of Individual or Corporate Name By: Corporate Offic ( andatory, if Applicable) 0 � 16 7.5 3 *Social Security No. (voluntary) or Federal identf cation 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. RQ-IcalthVm&s Docu ents\PERMTC APPLICATIONS\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents i Congress Street, Suite100 Boston, MA 02114-2017 wwm mass.gov/dfa Workers' Compensation Insurance Affidavit: General Businesses. TO BE FMIM, WITH THE PRRAMTING AUTHORITY. nnlicant Information _I PI Business/Organization Address: 11A Are you an employer? Check the apotopriate box: I. [] I am a employer with employees (full and/ or part-time).* 2:0 lam a sole proprietor or partnership and have no empl ees working forme in any capacity. o workers' comp. insurance required] 3 We are a corporation and its officers have exercised their right of exemption per e. 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 Tell.) i 7�j97 Business Type (required): 5. EJ-Ketail 6. DRestaurantBmfBating Establishment ?. 0 Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9, 0 Entertainment I0.0 Manufacturing ] L ❑ Health Care 12. Other *Any applicant that checks box #I must also fill out the section below showing their workers' mmpcnsadon policy information. *°If the corporate officers have cxewpl�d themsdves, but the corporagou bas utha traployces, a workers' compensation policy is required and such an organization should check box Nl. I am an employer that is providing workers' compensation insurance far my employees. Below is the pollcy information. Insurer's City/State/zip: Policy If or Seif--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. Too the pains Official use only. Do not write in this area, to he completed by city or town official. correct City or Town: Permit/License # Issuing Authority(circle one): 1. Board of health 2. Building Deparfraent 3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office 6.Other Contact Person w .mass,gov/dia Phone#: CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name 4RnnpwSn CemB. tee mba:-ell Dnfcof Co pleeion � Date oMyl lion vteee o "am � mna �l ly lRnr ��„n, n� .+yltincawdm n3wcil�`r�ay. mu..or.cm+r9oGms ceu svaaorys1011 J. nm...d..�,=ro.m�na.;.,:., 9bircvfm+.villftmlle�r/%rvlfl)+✓�+f+oc JuafrvmN Je .6Rw15d�a1W LaA! d, 51A VIP1 "w Sw n�Rrnew p