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Home My WebLink AboutA.K. Dincer Turkish Gourmet - 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: ►1NUAR M419 7 Whose Place of Business is: ALI K. DINCER TURKISH GOURMET-NEFFA Permit expires April 27. 2008 License Number. FS-157T Food Fee: $25.00 Milk & Cream: :•_:l • . G ff Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date,2eceived Date Inspected Approved By Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: f l ,j� / ; X , t1 I Tcv �c 15 lJ O c{ y ✓t IE ) 2) Establishment Address: l Y lQ H S �1,IG�p,�p I ,e- G{ I" I j tof I e � c- [4 ov 3) Establishment Mailing Address (if different) Z 2 Tq C IL 5 p r I 6 e I't'i o f t ui V 2 4 7 4) Establishment Telephone No: 6 1 7 _ $ — 5) Applicant Name & Title: I K I N I7 C l Ct' 6) Applicant Address: Z 2 1�c ofd U. wc, 9 f 0 2 J 7 f8 �t 7) Applicant Telephone No.: 6 1 7 _ 4,f_ 5-1/0 24 Hour Emergency No.: �� 8) Owner Name & Title (if different from applicant): saw 9) Owner Address (if different from applicant): 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. ❑ An Association ❑ A corporation ® An Individual ❑ A Partnership ❑ Other legal entity 12 Person Directly Responsible For Daily Operations Owner, person in charge, Supervisor, Manager, etc. Name &Title: /7 It' K ik,, Address: 77 2 2 5cr p Pam' Lctc>a2� 0 Z 47 Telephone No: 617 _ r7 �j Fax: Emergency Telephone No: 13 District Or Regional Su ervisor(if a licable Name & Title: Address: Tele hone No: Fax: BLANK_f00D PERMIT_ APPLICATION Food Establishment Information 14.) Water Source 15) Sewage Disposal DEP Public Water Supply No: (if applicable): To c_�-K C, 16) Days and Hours of Operation: 3 p( 5 N E! Fiq Vim' 17) No. of Food Employees Lr _ S 18) Name of Person In Charge Certified in Food Protection Management: K Required as of 101112001 in accordance with 105 CMR 590.003 A Please attach cc of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): 20) Location: Ma �tS �1 e 14 /LWd le- 22) Establishment Type: ❑ Caterer Jc6v?r Cat'e.te_'ia ❑ Retail ( Sq. Ft) ❑ Food Delivery �ood Service - ( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Perrganent f, 2 7 'zS — El Food Service- Institution ❑ Residential Xitchen for Bed & Breakfast Home /'Mobjle (Dates) T ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) ❑ Annual ❑Seaso4l/ ate- % y'2 2 S` — 7 LvJ Temporary/Dates! Times iVEFFR Fe<t-t�21 ��renG.�le 23) Food Operations: Definitions: PHF--Potentiallyhazardousfood(timeftemperaturecontrelsrequired) (check all that apply): Non-PHFs - 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- ElPHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service ❑ Sale of Commercially Pre- Preparation Of PHFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Holdin For Single Meal Service Susce tible Population Facilit ElDelivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill be Pre ared b Consumer ❑ RQheating of commercially ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service of Non ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Qnl . Prpparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑-Prepares FoodtSingle-Meals-for Catered Retail Sale Other (Describe): ❑ Offers RTE PHF in Bulk Quantities by the Board of Health ❑ Retail Sale of Salvage, Out -Of -Date or =Payment Reconditioned Food th 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: Zg (/ta't Pursuant to MOL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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: D 2 q — Z% — j 74 5 26) Signature of Individual or Corporate Name: �� / �r41-111 BLANK FOOD PERMIT APPLICATION The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �rII II i iPlease Print Leuibly Business/Organization Name: /7 l I , 1 ki C a `7 2- fI P— d Addregc• �C � <0 1-7 Cil(p 78 Phone #:_ 6/7— Are you an employer? Check the appropriate box: Business Type (required): } • ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. 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. [No workers' comp. insurance required] 8• ❑ Non-profit 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *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. lam an employer tliat is providing workers' corupensation insurance far my employees. Below is the policy information. Insurance Company Insurer's Addr 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. I4o hereby certify, uunder I hhe pains and penalties ofperjury that the information provided above is true and correct. Signature: /7`C,i Agin Z2u,, cl�,,— Date: 3 /7/d & r Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): j . Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Person: Phone www.mass.gov/dia I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all State tax retums and paid all Statetaxes required underiaw * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federat-tdentification Number ®2%'-4,y-- G'745- * This license will not be issued unless the certification clause is signed by ffre applicant. ** Your Social Security number will be furnished to the Massachusetts Department of Revenue to'determine whether you `have met fax firing 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 62G, Section49A.