HomeMy WebLinkAboutDave & Jerry's - 4/27/2008TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD, MA 02048
PERMIT TO OPERATE A FOOD SERVICE -TEMP ESTABLISHMENT
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:
LORETTA PRESUTTI/JOYCE DENTE
Whose Place of Business is:
DAVE & JERRY'S INC.
Permit expires April 27. 2008
License Number. FS-155T
Food Fee: $25.00
Milk & Cream: NO
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
BOARD OF HEALTH USE
Date Received Date Inspected Approved By
.Y
Permit # Issued
a-1`}7I
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
DAVE & JERRY'S INC.
2) Establishment Address:
3) Establishment Mailing Address (if different)
98 HARTFORD ST.
4) Establishment Telephone No:
5) Applicant Name & Title:
JOYCE DENTS, TREASURER
6) Applicant Address:
98 HARTFORD ST., NATICK, MA 01760
7) Applicant Telephone No.: 508-653-1895
24 Hour Emergency No.: 617-412.9641
8) Owner Name & Title (if different from applicant):
LORETTA PRESUTTI SO ue- D q nfe
9) Owner Address (if different from applicant):
236 N. MAIN STREET, NATICK, MA 01760
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home
address of officers or partner.
CORPORATION
JOYCE DENTE 98 HARTFORD ST. NATICK, MA 01760
❑ An Association
Wl'A Corporation
An Individual
❑ A Partnership
❑ Other legal entity
i
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Name & Title:
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Address:
ff 01'7&0
Telephone No:
' ? (I Z _ Fax: 508 _ 66 3 ,12q JI
Emergency Telephone No:
, L// Z —%8 3
Name & Title:
Address:
Telephone No:
Fax:
Gnnrl Getahlichmant Infnrmatinn
14.) Water Source: TOWN
15) Sewage Disposal TOWN
DEP Public Water Supply No: (if applicable): �Ia�
16) Days and Hours of Operation: 11:30PM 4/22n1M 0A(5 30PM Y !�
17) No. of Food Employees 2
18) Name of Person In Charge Certified in Food Protection Management: � U ap&� b
Required as of 101112001 in accordance with 105 CMR 590.003 A Please attach co of certificate
19) Person Trained in Anti -Choking Procedures (if 25 seats or more):
20) Location:
22) Establishment Type:
❑ Caterer
TEMPORARY
❑ Retail ( Sq. Ft)
❑ Food Service — ( ) Seats
❑ Food Service - Institution
❑ Food Delivery
❑ Residential Kitchen for Retail Sale
❑ Permanent
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast Home
(Dates)
Mobile Dates
Other (Describe)
❑ Residential Kitchen for Bed & Breakfast
Establishment
El Frozen Dessert Manufacturer
21) Length Of Permit:
TFR_P d1�-41�1.,41���a7
23) Food Operations: Definitions: PHF— Potentially hazardous food (time/temperature controls required)
Non-PHF'— non -potentially hazardous food (no time/temperature controls required)
RTE—
ready -to -eat foods (Ex. Sandwiches, salads, mums which need no further processing)
check all that apply):
❑ Sale of commercially Pre-
PHFCooked To Order
❑ Hort PHF Cooked Cooledor H Held
Packaged Non-PHFs
ore Than a Single l Servt
® Sale of Commercially Pre-
® Preparation Of PHFs For Hot And
❑ PHF and RTE Foods Prepared For Highly
Packaged PHFs
cold Holding For Single Meal
Susceptible Population Facility
Service
❑ Delivery of Packaged PHFs
❑ Sale of Raw Animal Foods Intended
❑ Vacuum Packaging/Cook Chill
to be Prepared by Consumer
❑ Reheating of commercially
❑ Customer Self -Service
❑ Use of Process Requiring A Variance
Processed Foods For
and/or HACCP Plan (including bare hand
Service Within 4 Hours.
contact alternative, time as a public
health control
❑ Customer Self- Service of
❑ Ice
Manufactured and Packaged for
❑ Offers Raw Or undercooked Food Of
Non PHF and Non-
Retail Sale
Animal Origin
Perishable Foods Only.
❑ Preparation of Non-PHFs
❑ Juice Manufactured and packaged
❑ Prepares Food/Single Meals for Catered
for Retail Sale
Events or institutional Food Service
L i Utters R I E PHI- In BUIK QuanuuGs
Other (Describe): To be completed by the Board of Health
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food Total Permit Fee: $25.00
Payment is due with application
I, the undersigned, attest to the accuracy of the information provided in this application and I 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: OA
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 returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 043279482
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26) Signature of Individual or Corporate Name: k)f
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I certify jnder 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.
b -
* Signatur of In vidual or
Corporate Name (Mandatory)
9MLI�'b
B rporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
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 Legibly
Business/Organization Name: 1C)AAIP_ 4-
Address: 9 8
City/State/Zip: tV 7i hone #: 509-66 3 —1 �9% S
Are ou an employer? Check the appropriate box:
Business Type (required):
1.1 am a employer with :Z employees (full and/
5. ❑ Retail
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
6. 0 RestaurantBar/Eating Establishment
employceswarking for me injilly eapalty.
7'• ❑ Office aiid/pr Sales (incl. real estate, auto, etc.)
[No workers' comp. insurance required]
3. ❑ We
8• ❑ Non-profit
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]*
4. ❑ We are a non-profit organization, staffed by volunteers,
I LE! Health Care
with no employees. [No workers' comp, insurance req.]
12. Other M ()b i) , �U O e ri i i` t e
*Any applicant that checks box # I must also fill out the section below showing theirworkers' compensation policy information.
**If the corporate officers have exempted themselves, but the eotpomtion has other employees, a workers' compensation policy is required and such an
organization should check box #1.
-
I ant an employer that is providing workers' compensation insurance for my employees. Below Is the policy information.
Insurance Company Name: :e N A CUl)rd
Insurer's Address: 9$ f4Qr-f -Ard a
City/State/Zip: A)hTi (k— M 14 Q CUP (p 0
Policy # or Self -ins. Lic. # D 9' (PEC T AJ 4) 5qq
Expiration Date: ?',D-q IO g
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, tify, under th ains and penalties ofperjury that the information provided above is true and correct
Signature: Date:/°) S
Phone #: 5O $ ' 03 $ 9 S-
Official use only. Do not write in this area, to be completed by city or town ojfcial
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building is
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #:
wvnv.mass.nov/dia
Thomas M. Menino
Mayor
Owner Establishment/DBA
Dave & Jerry'S World Famous # 1 Dave & Jerry'S World Famous # 1
J. DENTE/L. PRESUTTI DAVE & JERRY'S INC. Citywide
98 Hartford Street Boston Me,
Natick, Ma 01760
HEALTH PERMIT 2008
PERMIT NUMBER PERMIT TYPE PERMIT DESCRIPTION
25904 MF Mobile Food Server
25905
FD
CERTIFIED FOOD MANAGER:
Frozen Desserts
THIS PERMIT EXPIRES: 12/31/2008
This Permit Must Be Posted in a Conspicuous Public Place
Complaints regarding the sanitary condition of this establishment may be
referred to the Health Division at: (617) 635-5326
www.citVofboston.gov/isd/health