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Home My WebLink AboutCupcake City 12/31/2018I Commonwealth 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: XFINITY RETAIL FOOD PERMIT 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:. KRISTIN CATALDO Whose place of business is: CUPCAKE CITY - THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: KRISTIN CATALDO Permit Expires: December 31, 2018 Food Fee: $100.00 License Number: XRF-4 BOARD OF HEALTH wlichae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XRFA FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name CUPCAKE CITY -THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET —APR 17 2018 3) Establishment Mailing Address (if different) 137 MAIN STREET READING, MA 01867 4) Establishment Telephone No (781) 944-0400 5) Applicant Name & Title: CUPCAKE CITY j 6) Applicant Address 137 MAIN STREET, READING, MA 01867 7) Applicant Telephone No.: (781) 944-0400 24 Hour Emergency No.: (617( 766.6821 OR (617( 612-9108 8) Owners Name & Title KRISTIN CATALDO 9) Owner Address (If different from applicant) 46 SUNSET ROCK LANE, READING, MA _ I Owner's telephone number 7817791052 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual A Partnership _ Other legal Entity _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: !KRISTIN CATALDO Address: 46 SUNSET ROCK LANE, READING, MA Telephone No: (781) 779-1052 24 Hour Emergency No: (617) 755.6821 OR (617) 512.9108 FAX: E-mail: INFO(cDCUPCAKE-CITY.COM Alt E -Mail: KRISTINCATALD016(,)GMAIL.COM 13) District Or Regional Supervisor (if applicable) Name & Title: KARIN DINAPOLI (OWNER) / Address: MA9 �fue�IS1�Cc� �LIU� Telephone No 24 Hour Emergency No: FAX: E-mail: /rh (Gr %1Jr1 /r �Q(�IZIJYI. (te_l— I I� Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6 17)DAYS/HOURS ;1frW ✓4Tf YJ �j0fcf /✓�� o2y 9A41.t. ' LO- g"I" 18) Name of Person In Charge Certified in Food Protection Management: KRISTIN CATALDO If more than 3 individuals are certified, complete list is on file. Required as o1 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of PHFCooked To Order certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): Sale of Commercially Pre -Packaged PHFs 20) Location: !.. I Permanent Location 22) Establishment Typo '. _I Caterer $25.00 Mobile Mobile Start Dale: I Retail ( Sq. Fp i I ; Milk & Cream $10.00 Mobile End Date: Food Service up to too or Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 --, Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: ! Food Service up to 101 -200 $25.00/freezer . Annual or up to 25' PHF display $150.00 Pushcart $25.00 # of Pushcarts: 0 SeasonalFood Service up to 201 + I Residential Kitchen $100.00 Customer Self -Service or 25'+ PHF display $275.00 V: Retail Food $100.00 Seasonal Dates: '.. " Temporary Food Service - Institution '. Retail Snack Food $25.00 Temporary Start Date: 6/23/2010 ( Moals/Day) �•- i Tobacco Products $25.00 Temporary End Date: a{P61" - - - Offers RTE PHF in Bulk Quantities Temporary Time: 'b Rain Date: j.... ' Retail Sale of Salvage, Out -Of -Date " carnations: PHF - Potentially hazardous food (time/Iemperalum controls required) 23) Food Operations p Non-PHPs - nompofenlially hazardous food(no limeltemperalure controls required) i(Check all that apply): RTE - ready-lo"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 for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs 1 Preparation ofPHFs For Hol And I Cold Holding For Single Meal Service I PHF and RTE Foods Prepared For Highly '.. Delivery of Packaged PHFs Susceptible Population Facility I Sala of Animal Foods Intended � -.... Reheating of Commercially to be Prepared by Consumer ! Vacuum Packaging I Cook Chili Processed Foods for Service Within 4 Hours Use of Process Requiring A Variance Customer Self -Service of Non Pl-IF and Non- Customer Self -Service 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 - I-.. Retail Sale... -. _..- control) Other Food Operations Juice Manufactured and Packaged for 1 Offers Raw Or Undercooked Food Of �.[ Retail Sale Animal Origin Y 1SALE OF NPH CUPCAKES - CUPCAKES , BAKED IN RETAIL OVEN IN READING, MA - - - Offers RTE PHF in Bulk Quantities ! Prepares Food/Single Meals for Catered Events or Institutional Food Service ' Retail Sale of Salvage, Out -Of -Date -- - - -- --- i or Reconditioned Food i To be completed by the Board of Health I, the undersigned, attest to the accuracy of the information provided In this establishment operation will comply with 105 CMR 590.000 and all other ap board of health on how to obtain copleVo) 105 CMR 59Q.000 and Maden 24) Signature of Applicant Pursuant to MGL Ch.62C, sec. 49A, I certify oder the penalties and paid stale taxes required under law. ��,,�,,�p 25) Social Security Number or Federal ID: 45.3163BO9/ZR 26) Signature of Individual or Corporate Name: -1//• A Total Permit Fee. $100.00 Payment is due with application - waived Ion and affirm that the food law. I have been instructed by the T 1, to my best knowledge and b6liq, have filed all stale tax returns TAX CERTIFICATION FORM 1 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 imder law. /19LLL — �,I sh D)- Siynatre of In 'vidt a, NY: Corporate Officer (Mandafot,i/, rf Applicable) -A5i31�9oy--- "Social Security No. (Voluntary) or Federal ideutiffealion Ntanber *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. Jbis request is made under i:he authority of Massachusetts General Law Chapter 62C, section 49A. RAHm1diVaae's Dm=eaLc\PERMIT APPLICATIONS\TAX CGR'1'[FICA'1'IoN FORM.doe The Commonwealth of Massachusetts _ Departutent of Industrial Accidents I Congress Street, Suite 100 Boston, MA 0211 4-2 01 7 www nlass.go v/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH TRY PERIvMMG AUTHORITY. nnlicaut Information ___ P' Business/Organization Are you an employer? Check the ppropriate box - 1. la-1 ox:1.la-1 am a employer with _ employees (full and/ or part-time).f 21] 1 run a sole proprietor or partnership and have no employees working for me in any capacity, [No workers' camp. insurance required] 3, ❑ We are a corporation and its officers have exercised their right of exemption pct 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.] Business T e (required): 5, ti 6. estaurant/Barirating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc,) 8. 0 Non-profit 9, ❑ F.nlcnainment 10.0 Manufacturing 11.[] Health Core 12.[] Other_.__--____ _!Any applicant ahot cheeks box #I must also fill out the section below showing dmir workers' compensation policy infonnaaiom f 0]i the empnmae officers have cxcmplcd lbowalves, but the corporation has other employees, a workers' cornpeosalim policy is required And such an organisation should ehech box #1. f out an employer (fiat is providing If�rkers' r-�,Vrpensahon Wurmue for yjtemployees Belory is tire d e policy efyrmadait. r Insurance Company Insurer's City/state/zip: - f-T&I7_'2 _G__ �-- % �/ l� /J_J Policy it or Self -ins, Lic. #�6-Cr L "M, Bxpiration Date:/e/Attach a copy of the workers' compensation policy age (showing the policy number rid c pira/o date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition o 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 ibis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby c gfjy,�sunder tit//�ri��/palms and penalties of perjury (fiat the information provided above/iso true mrd/coorrect. //n / l l �./A A Tlnfn ri"�I' /[7 Of use only, Do not uwite Gt this area, to be completed by city or town off daL 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 34 (Policy Provisions: WC 00 00 00 C) 71 CI INFORMATION PAGE WFC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 20605 Company Code: G POLICY NUMBER: 108 WEC CI7134 Previous Policy Number: 108 WEC C17134 HOUSING CODE: SB 1. Named Insured and Mailing Address: CUPCAKE CITY LLC (No., Street, Town, State, Zip Code) 137 MAIN ST FEIN Number: 001060532 READING, MA 01867 State Identification Number(s): UIN: The Named Insured IS: LIMITED LIABILITY COMPANY Business of Named Insured: BAKERY STORE WITH COOKING Other workplaces not shown above: 137 MAIN ST READING MA 01867 2. Policy Period: From 02/09/18 To 02/09/19 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: GILBERT INSURANCE AGENCY INC 137 MAIN STREET READING, MA 01867 Producer's Code: 087867 Issuing Office: THE HARTFORD THE it HARTFORD Suffix LARS RENEWAL 06 301 WOODS PARK DRIVE CLINTON NY 13323 (800) 962-6170 Total Estimated Annual Premium: $1, 94o Deposit Premium: Policy Minimum Premium: $329 MA (INCLUDES INCREASED LIMIT MIN. PREM.) Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. J r fn L.l�et.[z2 Countersigned by 12/23/17 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 12/23/17 Policy Expiration Date: 02/09/19 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: KRISTIN cAToLoo Certificate Number: 2604758 Date of Completion: 10/5/2016 Date of Expiration: 10/112021 7be above-named person is bereby isnted this eertifirate ,for completing an allergen awareness training program recognized by the Massachusetts Department of Pablie Healtb in aerordauee with 105 CMR 590.009(G)(J)(a). 775 is certificate will be valid for frve (5) years front date of'tompletioit. Issued By: NATIONAL C RESTAURANT ASSOCIATION® Ihiassachusctrs Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 w cosurstaurantorg Southborough,MA 01772 508-303-9905 u ..masestnurantassoc.urg