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HomeMy WebLinkAboutMexican Food Booth - 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: CHRIS RICCIOTTI Whose Place of Business is: NEFFA MEXICAN FOOD BOOTH Permit Good April 25-27, 2008 License Number. FS-161T Food Fee: $25.00 Milk & Cream: NO BOARD OFJIEALTH Dr. (tay and Martin, Chairman 1 04/23/2008 wee 11:10 aAx E002/006 FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) EstablishmentNameI NEFFAI4VV4- /<i / ,1 ivr� (� P 2) Establishment Address: 393 UNION ST FWJ 3) Establishment Mailing Address (if different) 393 UNION ST 4) Establishment Telephone No: Ma — 5) Applicant Name & Title: CHRIS RICCIOTTI 6) Applicant Address: 393 UNION ST., ROCKLAND MA 02370-1729 7) Applicant Telephone No.: 617-852-4042 24 Hour Emergency No.: 617-852-4042 CELL 8) Owner Name & Title (if different from applicant): CHRIS RICCIOTTI 9) Owner Address (if different from applicant): 393 UNION ST ROCKLAND MA 02370-1729 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or oartner. INDIVIDUAL CHRIS RICCIOTTI ❑ An Association ❑ A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal en' y 12) Person Dirpnfly RP.RnnnRihlP. Fnr daily nnerztinnc lnwnee nerenn i.. �i..,...., c—.,...:— nn........... .., A Name & Title: tCC4 _ �/ Q ✓kk Address: Telephone No: Fax: $ _636 Emergency Telephone No:�( Z N112 pot�—toZC3 yr?Y�h jI 04/23/2008 WED 11;11 FAX W003/D06 Food Establishment Information 14.) Water Source: TOWN 15) Sewage Disposal TOWN DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation. 0i( 5 17) No. of Food Employees UP TO 32 � r 18) Name of Person In Charge Certified in Food Protection Management: ®y Required as of 10112001 in accordance with 105 CMR 590.003 A Piease attach Wiw orcertificare 19) Person Trained in Anti -Choking Procedures (if 25 seats or more); I NO 20) Location: 22) Establishment Type: - ❑ Retail ( Sq. Ft) ❑ Caterer MPORARY ❑ Food Service — ( )Seals ❑ Food Delivery ermanent Food Service - Institution ❑ Residential Kitchen for Retail Sale ❑ Mobile (Dates) ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Home Othe Describe) El Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer 21) Length Of Permit: ANNUAL 23) Food Operations: .. a., PHF— Potenthulyhazardous food (tims4emperature controls required) OelinitionRTE— Nan-PHFs— non-potentfairy hazardous food (no 6'meAomparature 0ontruis required) (check all that apply)., roady-to-eat rood& (Ex. sandwiches, salads, muffins which need no further processing) Sale of commercially Pre- ❑ PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Packaged Nan-PHFs for More Than a Single Meal Service ❑ 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 El Delivery of Packaged PHFs Lj Sale of Raw Animal Foods Intended ❑ Vacuum Packaging/Cook Chill to be Prepared by Consumer Reheating of commercially J9 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 El Customer Self -Service of LJ Ice Manufactured and Packaged for Lj Offers Raw Or undercooked Food Of Non PHF and Non- Retail Sale Animal Origin Perishable Foods Onl . Preparation of Nan-PHFs El Juice Manufactured and packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale Events or institutional Food Service ❑ Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Other (Describe). I Ej 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 provi of is plication and I affirm that the food establishment operation will corms I wi M 590';000 I other ap able law. I have been instructed by the board of health on how too aain y s s 0 C J'90 eda Fo d Code. 24) Signature ofApplican . Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalti of perjury that I, to my best knout ledge and belief, have filed all state returns and paid state taxes required under law. �� 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate N 06/23/2908 WED 11:11 PAX 2004/006 '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. or Corporate Name "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. R:1Hea1rhUnnc's DoculnennlPERMiT APPI,ICA'1'IONSITAX CERTIFICATION FORM.doe 06/23/2008 wnn 11ill FAX 0005/006 The Commonwealth of Massachusetts .Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street .Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Pr Business/Organization Name: /�[) Q (l( CQ_ (l ' P ( o y,� f .L Fp Address: 9 t_Q )mT c�t ftE'� 1 e M�©mil #°l Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail 2. ❑ or part-time).* I 6. ❑ Restaurant/Bar/Eating Establishment am a sole proprietor or partnership and have no employees for in 7.Office and/or Sales (final. real estate, auto, etc.) working me any capacity. [No workers' compinsurance required] : B• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 0. ❑ Entertainment their right of exemption per c, 152, § 1(4), and we have lo.❑Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4,k We are a non-profit organization, staffed by Solhhteers, with no employees. (No workers' comp. insurance req.] 120 Other *Any applicant tint ohcoks lox r 1 must also till out the section below showing their workers' compenaudon pol icy information. •"Iftho corporateofficers haJc exempted themselves, but the corporation has other employees, aworkers' oompensmion polioy IS inquired and Buchan organization shoold check box kl. I am an employer that is providing; workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's or 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 ora 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 / do that the information propided a ope is u e and nnta• I oZ<'Z T2.00 Official ave only. Do not write in this area, to be completed by airy or town offtelal. 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,news.gov/dia APR-24-2008 09:51 AM S.R. 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