HomeMy WebLinkAboutSmoke & Squeal 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:
XFINITY 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:.
r-ITITTIT,
Whose place of business is:
SMOKE AND SQUEAL BBQ, LLC
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
ADAM BATCHELDER
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: XFS-30
BOARD OF HEALTH
wlichae(McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received:Date Inspected: Approved By: 4 Permit # Issued
rvVu Lb I At31_15HMENT PERMIT APPLICATION
pp Hca ion mus esu mi e a eas ays a ore
e p anne opernng a e
1) Establishment Name
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2) Establishment Address
✓ 24 Hour Emergency No:
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3) Establishment Mailing Address (if different)
4) Establishment Telephone No
Name & Title:
5) Applicant Name & Title:
Address:
Telephone No:
6) Applicant Address
FAX:
7) Applicant Telephone No.: 24 Hour Emergency No.:
E-mail:
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8) Owners Name & Title y'j�GIY PI
9) Owner Address (if different from applicant)
Owner's telephone number
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10) Establishment Owned By:
11) If a corporation or partnership, give -(name, title, and home address of officers
EJ An Association
or partner.
Z A Corporation
Name Title
Address
O An Individual���¢��
11 A Partnership����
Other legal Entity
ick rci sun un ecuy rtesponsiule For uaiiv uoeranons (owner. nerson in charm- sunpmisnr mannnpr ote
Name &Title:
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Address:
Telephone No:
✓ 24 Hour Emergency No:
.FAX:
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E-mail:=Alt
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
M=
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 Char Certified in Food Protection Management: A'K� doof -Lf,vlC.t`7- —
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 mare)
20) Location: El Permanent Location
22) Establishment Type
[A Caterer $25.00
V Moblie Mobile Start Date:r/Wy `o18f
Retail ( Sq. Ft)
H Milk & Cream $10.00
Mobile End Date: &W at( jT
Food Service up to 100 or
Mobile Food & Consesston $75.00
Mobile Comments:
up to 10' PHF display $125.00
I Food service up to 101 -200
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
21) Length of Permit:
Annual
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
Food Service - Institution
Pushcart $25.00 # of Pushcarts:
Residential Kitchen $100.00
El Retail Food $100.00
0 Retail Snack Food $25.00
E] Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
( Meals/Day)
EJ Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date: —
---
---
23) Food Operations
(Check all that apply):
Definitions: PHF- Potentially hazardous food (time4emperature controls required)
Non-PHFs - non -potentially hazardous food(no time4emperature contmis required)
RTE -ready -to -eat foods (Ex. sandwiches, salads, mums which need no furtherpmcessing)
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
Q Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
E] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs —
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
Processed Foods for Service Within 4 Hours
EJ Vacuum Packaging / Cook Chill
Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Customer Self -Service of Non PHF and Non-
Perishable Foods Only _
El Customer Self -Service
O — -r - g
Ice Manufactured and Packaged for
Retail Sale
Preparation of Non-PHFs
Other Food Operations
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2.V66�� � GC. -L___
Juice Manufactured and Packaged for
Retail Sale
EE Offers Raw Or Undercooked Food Of
Animal Origin
Q Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Q Offers RTE in Bulk
f S
Retail Sale of Salvage, Out -Of -Date
Out -Of -Dale
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 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies off D.'± R 59q the fe�ood Code.
24) Signature of Applicant: /-4,••f
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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: LX/
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.
F
Signature of Individual or Corporate Name
D19y- 7t�-- 8%22
*"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.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
lne utimmonweatrn ojmassacnuserts
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 Leeibiv
Business/Organization Name:
Address: I o . rt ,o : 02&;22 -
Are you an employer? Check the appropriate box:
L ❑ I am a employer with employees (full and/
or part-time).*
2. M I am a sole proprietor or partnership and have no
employees working for me in 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.]
Phone #: 617 – Sr-% 5 76 f�
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.'o Other �/ 6Z
*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
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coveraee verification.
I do hereby certify, under the pains
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
above is true and correct.
-/G4 Z2e � �—
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone #:
tit,
q,[trr cF Commonwealth of Massachusetts Letter ID: L0995201280
Department of Revenue Notice Date: July 17, 2017
Michael J. Heffernan, Commissioner
P Account ID: MLS -18471960-003
rE�7 pFe mass.gov/dor
SALES TAX ON MEALS AND BEVERAGES REGISTRATION CERTIFICATE
SMOKE & SQUEAL BBQ, LLC
SMOKE & SQUEAL BBQ
1005 MAIN ST STE 7060
PAWTUCKETRi 02860
Attached below is your Sales Tax on Meals and Beverages Registration Certificate (Form MT -1). Cut
along the dotted line and display at your place of business. You must report any change of name or
address to us so that a correct MT -I can be issued.
At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and
re -print a copy of this certificate.
DETACH HERE
�rs�FT� MASSACHUSETTS DEPARTMENT OF REVENUE Form MT -1
` 'ill Sales Tax on Meals and Beverages Registration Certificate
'�r c$' This registration must be posted and visible at all times.
�EVi pf"
SMOKE & SQUEAL BBQ, LLC
1005 MAIN ST STE 7060
PAWTUCKET RI 02860
Account ID: MLS -18471960-003
Certificate Number: 875548672
This certifies that the taxpayer named above is registered under Chapters 62C and 64H of the
Massachusetts General Laws to sell meals and beverages at the address shown above. This registration
is non -transferable and may be suspended or revoked for failure to comply with state laws and
regulations.
Effective Date: August 4, 2017
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Health & SIfety
instituter
We Make Protecting dnd Savin Lives Easyn'
Adam Batchelder
50 Constitution Blvd
Franklin, MA 02038
i
re: OSHA 10 Hour Gene{al Industry Course
Adam Batchelder
Congratulations on your
10 Hour General Indust
which should be kept in
continued success in y<
Sincerely,
Scott Wallace
OSHA Program Coor
Summit Training Sou
ASHI, MEDIC First Aide, 24-7
recent successful completion of Summit's OSHA
Course. Enclosed you will find your OSHA card
asafe Iocation.You have our best wishes for
r safety efforts.
Inc.
Fire, EMP Canada, and Summit Ttainmg source are members of the HSI family of brands.
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: -M —H -DER
Certificate Number: nz 381
Date of Completion: vzar2ot3
Date of Expiration:
Die above-named person it hereby issued this certfti ate
for completing an allergen awareness training program
recognized by the Nlesrarhusetts Department of Public Health
in accordance with 105 CMR 590.009(G)(3)(a).
15 is certificate will be valid forfrue (5) years fi'on: date of ompletion.
Issued By.
MHH
NATIONAL i
RESTAURANT
ASSOCIATION,
Massachusetts Rcmaaant Association
800.765.2122
333 Turnpike Road, Suite 102
a ..tcstauraneorg
Southbomugh,MA 01772
508-303-9905
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