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Home My WebLink AboutDel's Lemonade 9/30/2018Commonwealth 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: 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:. RYAN SUKASKAS Whose place of business is: RM SUKASKAS INC. DBA DEL'S LEMONADE @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE. RYAN SUKASKAS, OWNER Permit Expires: September 30, 2018 Food Fee: $100.00 License Number: XRF-25 BOARD OF HEALTH .Michael McCCean, Chairman 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:. RYAN SUKASKAS Whose place of business is: RM SUKASKAS INC. DBA DEL'S LEMONADE @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: RYAN SUKASKAS, OWNER Permit Expires: September 30, 2018 Food Fee: $25.00 License Number: XP-14 BOARD OF HEALTH MichaeCMCCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XRF-25 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name RM SUKASKAS INC.DBA DEL'S LEMONADE @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 446 CENTRAL AVNEUE PAWTUCKET, RI 4) Establishment Telephone No (401) 413-5494 5) Applicant Name & Title: RYAN SUKASKAS, OWNER 6) Applicant Address SCAFursc, 7) Applicant Telephone No.: (401)413-5494 24 Hour Emergency No.: (401) 413-5494 8) Owners Name & Title RYAN SUKASKAS 9) Owner Address (If different from applicant) Owner's telephone number 4014136494 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1 An Association or partner I A Corporation Name Title Address An Individual �� S 4L�SWaS' Mice QtYStcip,' q3t Gf—,ee \veftf (lu" 1 A Partnership I Other legal Entity_- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (RYAN SUKASKAS, OWNER Address: �34A STONE TRAIL, NORTH PROVIDENCE, RI Telephone No: I(401) 413-5494 -- - -- FAX: I E-mail: RYANSUKASKAS(ZDGMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title i Address: Telephone No: FAX: E-mail: - - _. 24 Hour Emergency No: (401) 493-5494 -- I 24 Hour Emergency No: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 1 17) DAYS/HOURS: EVENTS 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 [ ] Mobile Mobile Start Date: Mobile End Date: 'Mobile Comments: j 21) Length of Permit: I Annual jl Seasonal Seasonal Dates: I Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) [,] Food Service up to 100 or up to 10' PHF display $126.00 ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 [] Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution Meals/Day) LI Caterer $25.00 [..Jj Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/ice Cream $25.00/freezer [.] Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 EV] Retail Food $100.00 I_ ] Retail Snack Food $25.00 j Tobacco Products $25.00 23)Food Operations Definitions:PHF - Potentially hazardous food (time/tempemture controls required) Non-PHFs non -potentially hazardous food(no time/temperature controls required) j(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs !.. Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations Le'-' �Qrw t [] PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer _ J Customer Self -Service ,I Ice Manufactured and Packaged for Retail Sale [J Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill ] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) El Juice Manufactured and Packaged for I...I Offers Raw Or Undercooked Food Of Retail Sale I Animal Origin in Bulk Quantities U Prepares Food/Single Meals for Catered Events or Institutional Food Sil{ Q l._ J Retail Sale of Salvage Out -Of -Date ----- _ or Reconditioned Food To be completed by the Board of Health __-- Total Permit Fee: $0 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 690.000 and the federal Food Code. 24) Signature of Applicant: S' 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: 46-26405433 1' 26) Signature of Individual or Corporate Name: 1 _� S��S K-41 S, Trx L 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. ! :'kcakAs 1�1L Signature of Individual or Corporate Name y6 - a(;4()Sq 3 **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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. RMimIthVa e's Doc=eats\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 u,p www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNIITTING AUTEORM. Applicant Information PIease Print Legibly Business/Organization Name: 2M SU-kr-S L(rC rG 1),e l 1S` L ,N�Vir\-oj- Address: LNG Ce4\%�( (-ay>- City/State/Zip: Ptr+l.JiyC'..U--4-)R-E QDS61 Phone#: CIO1-LI(3 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2: I am a sole proprietor or partnership and have no employees working for mein 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.] that checks box #1 must also fill out the scetion below Business Type (required): 5. kRetail 6. Restaurant/Bar/EatingEstablishment 7. [J Office and/or Sales (inc1, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10, ❑ Manufacturing 11, ❑ Health Care 12.❑ Other policy information. o<gthe corporate officers have cxcmplcd thcroseNcs, but the corporation has otber emptoyces, aworxem compeasanon pohry is rcquueo ana suca as organization should check box'M. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's 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. [do hereby certify, und,/err the pains nd penalties of perjury that the information provided above is true and correct ,Cianature: 1 ' \ — ...Date: J / 3 / "ZO 1 LS - LI13-Suq Official. use only, Do not mite 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