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HomeMy WebLinkAboutGood & Healthy d/b/a Bueno Y Sano - 4/26/2009Commonwealth 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: 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:. ROBERT LOWRY Whose place of business is: GOOD & HEALTHY, INC. dba BUENO Y SANO RESTAURANT 1 BOLTWOOD WALK PERSON(S) IN CHARGE: Permit Expires: April 26, 2009 License Number: FS-7T Food Fee: $75.00 BOARD OF HEALTH Dr. Ravmond Martin. Chairman 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 "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) �r- *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:\DOCUME-1\Owner\LOCALS—I\Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations k1ri 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization o Z/ City/State/Zip: /)/a A,- S %%V 0 one #:5 Z-'Id C) Are y an employer? Check the appropriate box: Business Type (required): 1. ` I am a employer with 2 0 ,p employees (full and/ 5. ❑ Retail e orpart-time).* 6. ORestaurant/Bar/EatingEstablishment 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. 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 Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0Other *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 an, an employer that is providing workers' coinpensation insurance for uty employees. Below is the policy information. Insurance Company k7ei /- ei i /. to e, ie7 /, ch'I Insurer's Address: A/4. e ;, 21 City/State/Zip: G - Nt cx `1-_e, / y:' , � .S / S S Policy # or Self -ins. Lic. # U' ��G��� S7i Z % �/ / 0 r% Expiration Date: K - 0 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; tinder the pains and penalties ofperjury that the information provided above is true and correct 6 Phone #: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone www.mass.gov/dia B 2 ■ $ § w / \ ± \ \ � , � \ \ m \ )\ R Lo ! ; ! | /a 2 z * �0 2 }\ 1 ; 19 !§\ I FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued Y Food Establishment Permit Applicatiri (Application must be submitted at least 30 days before the planne�,gpening date)- 1) Establishment Name: / 71 , 2) Establishment Address: 1 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 5) Applicant Name & Title: ?� ✓,,._ �. �: 6) Applicant Address: 7) Applicant Telephone No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: 11) 1 ® An association office m A partnership m Other legal er MO. /L r XA /1 1. S/ f cb A 0/dfI/ Z r'L4/Y'-�' i''!ll )1l /'.--1 24 Hour Emergency No:"v- f a corporation or partnership, give name, title, and home address of rs or partner. Name Title Home Address ,4 / Fax: 14,E-)o /21/9 017Ze Food Establishment Information 14) Water Source: f eo 15) Sewage disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: //-w W 7 p Cr , p s- 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: J9 Z- Required as of 101112001in accordance with 105 CMR 590.003 A area:a erce�n �a orren�r�ere. '` 6 e 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® 0 No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Pe[��nnanent Structure --• . Fd`©�Servic�y�>>:"ty�' Seats) ❑ Residential Kitchen for Retail Sale ❑ "'171ohilp ❑ Food Service — Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service — Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: ❑ (check one) Annual j U i�i✓ sa~ ❑ Seasonal/Dates: ❑ Temporary/Dates/Time: Definitions: PHF- potentially hazardous food(time/temperature controls required) 23) Food Operations: Non-PHFs - non- potentially hazardous food (no time/temperature controls required) Check all that a 1 RTE- ready -to -eat foods (Ex. sandwiches.. s, muffins which need no further processing) ❑ Sale of Commercially Pre- ❑ PHF Cooked To Order of PHF Cooked and Cooled or Hot Held Packaged Non-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. ❑ 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 And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. I 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. Only. ❑ Preparation Of Non-PHFs ❑ Juice Manufactured and Packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -of Date Total Permit Fee: or Reconditioned Food Payment is due with application 1, 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- 5 CMR 590.000 and the federal Food Code. 24) Signature of Applicant:.-� 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 tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: ' 6-1 �- �'�,(f 6 "` / ;fl.t i "