HomeMy WebLinkAboutSarcastic Sweets 5/17/2018Commonwealth 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
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:,
NINA REED, OWNER
Whose place of business is:
SARCASTIC SWEETS - DISTRICT ART SHOW
MANSFIELD SCHOOL COMPLEX - EAST STREET
PERSON(S) IN CHARGE:
NINA REED, OWNER
Permit Expires: May 17, 2018
Food Fee: $25.00
License Number: T-46
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FDate received:
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By:
Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
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1) Establishment Name
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2) Establishment Address
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3) Establishment Mailing Add ess (if different)
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4) Establishment Telephone No
5) Applicant Name & Title:
UvJ Iner
6) Applicant Address r
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7) Applicant Telephone No.:
24 Hour Emergency No.:
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8) Owners Name &Title
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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
D An Association
or partner.
A Corporation
Name Title Address
Cly -ren Individual
_
El A Partnership
Other legal Entity
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Name & Title.
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail: -
Alt E -Mail:
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: °j f L.,v4
15) SEWAGE DISPOSAL: Vt1_a,
DEP Public Water Supply No: (If applicable)
16) No. of Food Employees: VIb'� e
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management: NtvLo_ Reed
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 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): 1
1
220)/ Location: Permanent Location
19Moblie Mobile Start Date:
22) Establishment Type '
Retail ( Sq. Ft)
Caterer $25,00
❑i Milk & Cream $10.00
Mobile End Date:
Food Service up to 100 or
Mobile Food & Consession $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:
E Annual
or up to 25' PHF display $150.00
Food Service up to 201 +
Pushcart $25.00 it of Pushcarts:
El Residential Kitchen $100.00
0 Seasonal
Seasonal Dates:
or 25'+ PHF display $275.00
Retail Food $100.00
Food Service - Institution
E1Retail Snack Food $25.00
Temporary
Temporary Start Data:
( 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 (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
. Sale of Commercially Pre -Packaged Non -PRFs
[] PHFCooked To Order
C] Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Delivery of Packaged PHFs -
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Ti Sale of Raw Animal Foods Intended
to be Prepared by Consumer
-
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Vacuum Packaging /Cook Chill
Customer Self-Servicof Non PHF and Non-
Perishable Foods Only _
❑i Preparation of Non-PHFs --
-
E Customer Self-Servicee
_ Q Ice Manufactured and Package-
Retail Sale
0 Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Other Food Operations
[] Juice Manufactured and Packaged for
Retail Sale
E�] Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
El Offers RTE PHF in Bulk Quantities
01 Retail Sale of Salvage, Out -Of -Date
To be completed by the Board of Health
or Reconditioned Food
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 of 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: � W (,A I"QZv,
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have tiled all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: .�vl
26) Signature of Individual or Corporate Name:
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.
Signature of Individual or Corporate Name
5 5 2U'72,301
"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
The Commonwealth of Massachusetts
UlfDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: S,N-e2,a s
Address: qt- 2 Gtcs,,)�Si.)' 5 k o% d} - '2--A P2Njd-fnw 0-1 9-]rU,
u
City/State/Zip:
Phone #: 1,110 ( - 35 -el _ (� S O V
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a employer with employees (full and/
5. Q'Retail
r part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.9 I am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (incl. 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
4. F] We by
Care
are a non-profit organization, staffed volunteers,
with no employees. [No workers' comp, insurance req.]
12. Q'Other r„ l �- r VJ4A
*Any applicant that checks box 81 must also fill out the section below showing their workers' compensation policy information.
**1f 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 ill.
I ma an e»tployerr that is providing workers' coetpensation instttatice for my eatployees. Below is the policy information.
Insurance Company Name
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. #
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify, wider the pains and penalties of petjrny that the inforatation provided above is trite and correct.
Signature: 1r1 - C. lb fl, Date' S k
Phone #: LI V I 5 61- 9 b-oy
Official ase 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.inass.gov/dia
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Identification
Enter your TIN in the appropriate box. The TIN provided must match the name given online 1 to avoid
W-9
Request for Taxpayer
Give
Form
(Rev. November 2017)
Identification Number and Certification
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
Form to the
requester. Do not
Department
of the Treasury
TIN, later.
send to the IRS.
Internal Revenue Service
► Go to wwwJrs.gov/FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Nina W Reed
2 Business name/disregarded entity name, if different from above
Sarcastic Sweets
m3
Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
4 Exemptions (codes apply only to
M
following seven boxes.
certain entities, not individuals; see
a
o
❑ Individuallsole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
instructions on page 3):
single -member LLC
Exempt payee code (if any)
a o
❑Limited liability company. Enter the fax classification (C=C corporation, S=S corporation, P=Partnership)►
c
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
Exemption from FATCA reporting
y
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
code ( if any)
a.
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
.�
v
❑ Other (see instructions) 0- independent contractor
(applies ro accovntsmairtianWouoide ina U.S.)
N
5 Address (number, street, and apt. or suite no.) See instructions.
Requester's name and address (optional)
in
2 Glasgow St., Apt 2A
6 City, state, and ZIP code
Providence, RI 02908
7 List account numbers) here (optional)
4 20[2F9
Identification
Enter your TIN in the appropriate box. The TIN provided must match the name given online 1 to avoid
Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
❑
4
-0 2- ❑ ❑ 4
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter. 14 ( ( - 2 0 ❑ 211119
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
blgnSignature of %w60,
Here U.S. person►
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099 -INT (interest earned or paid)
Date 10- 0 1OFL2OC8
• Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 11-2017)