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HomeMy WebLinkAboutDave & Jerry's - 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: FOOD SERVICE -TEMPORARY 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. 98 HARTFORD STREET PERSON(S) IN CHARGE: JOYCE DENTE Permit Expires: April 26, 2009 License Number: FS-1 T Food Fee: $75.00 BOARD OF HEALTH 0- Dr. Raymond Martin, Chairman 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) Establishment Name: ©Ll t/-e- + L . 2) Establishment Address: •qi 61 S4 , c `j 1 ill p 17& O 3) Establishment Mailing Address (if dill ent): 4) Establishment Telephone No: /-7 — �/Z , 2(O G 5) Applicant Name & Title: " ro 6) Applicant Address: �� 2 6ct C1c � '-nitYvl-- 01'7(o O 7) Applicant Telephone No: -7r9 s" 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: m An association m cor ora ion m n individual • Apartnership m Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address � ur,e DPrl�"e. eare�c- Q�/ /rec4VeAf .236(U OWA) 0 -, W et1 i Lk 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc. Name & Title: Address: �n MN— 017(oO Telephone No: &/-7— Lj// —`/�4q( Fax: cy )-09`S3 — P9j— Emer enc Telephone No: (0l7 Tl Z — 66 q 13 District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: 59Dapplication6-2.doc /c Food Establishment Information 14) Water Source: "Tows✓ 15) Sewage disposal: DEP Public Water Supply No: ( If applicable) `To wr-+ 16) Days and Hours of Operation: _ y/dr _ ell?e, ti1d tl 17) No. of Food Employees: 16) Name of Person In Charge Certified in Food Protection Management: Q o, rn Required as of 101112001in accordance with 105 CMR 590.003(A) r��,.naaa�n nronn�w. ( j• ulAix�r:>3" 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes ®No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Permanent Structure ❑ Food Service — ( Seats) o Residential Kitchen for Retail Sale Mobile ❑ Food Service —Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ FoodService— Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) Lemon + W a-+er melon ❑ Frozen Dessert Manufacturer _-rfd ta_, zZcr 21) Length Of Permit: (check one) Fr-2Ac-A r-ri wJ ❑ ❑ Annual 11 Seasonal/Dates y/�y/4lal`�y44- ode"F Hot boys w�t soda fan 'm+Mh/ Cb,/�eyOnvoNf/ 7omatfocf ❑ Temporary/Dates/Time: Definitions: PHF- potentially hazardous hwd(time/temperature controls required) 23) Food Operations: Non-PHFs - non -potentially hazardous food (no time/temperatum controls required) check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Cl Sale of Commercially Pre- PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service. E9 Sale of Commercially Pre Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs T, 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 Service And/Or HACCP Plan (including bare hand Within 4 Hours. contact 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 ofHealth ❑ Retail Sale of Salvage, Out -of Date Total Permit Fee: or Reconditioned Food 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 1,05 CZAR 590.000 and the federal Food Code. n� 24) Signature of Applicant: v/ p dl Pursuant to MGL Ch. 62C, se . 4 A, 1 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: 6 t13a 7?�'� B 291 Ainnahira of Individual or Cnrnnrate Mama: 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. 2�C,0— Ca"� Signature of lWdividufWor Corporate Name By: Corporate Officer (Mandatory, if Applicable) C3 (-/ BP- -Z ° 10- a - "Social Security No. (Voluntary) or Federal Identification Number *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. CADocuments mid Settuigs\Own"Tocal SettingsMaTorary Internet Files\Content.IE5WCO663LATAX CERTIFICATION FORMPI.doc The Commompealth ofMtissachusetts Department of Inditsitial Accidents Office of Investigations Of 600 Washington Street Boston, MA 02111 ivirminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Legibly Business/OrrganizaatiionNaName:__ Address: `$ 1&1t� ot_al S7� City/State/Zip: '�fA`t A A ,0�Phone #: R—(053 — l i n Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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] g• ❑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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, rat l� with no employees. (No workers' comp. incuranee req.] 12.f Other 1 f O "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 #L Ian: an employer that is providing workers' compeensation insurancefor my employees. Below is the policy information. Insurance Company Name: �1�t �ftnkv+no r d Insurer's Address: qY f"{ctrl -Port . S+� City/State/Zip: M Y4' OI'I(e Policy # or Self -ins. Lic. # 0 g G)e C T/V t➢ 5-17gi Expiration Date: kl f /a 9 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, under the pains and penaties ofperjury that the -t//7--9(0(-// Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # true and correct Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone www.mass.gov/dia ?4 (Policy Provisions: WC 00 00 00 A) 65 JN INFORMATION PAGE WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115 NCCI Company Number: 10456 Company Code: 6 POLICY NUMBER: 108 WEC JN6574 Previous Policy Number: 08 WEC JN6574 HOUSING CODE: SB 1. Named Insured and Mailing Address: DAVE & JERRY' S WORLD FAMOUS, INC. (No., Street, Town, State, Zip Code) 0 N 0 98 HARTFORD SI FEIN Number: 043219482 NATICK, MA 01760 State Identification Number(s): UIN: The Named Insured is: CORPORATION Business of Named Insured: RETAIL ICE CREAM Other workplaces not shown above: 98 HARTFORD ST NATICK MA 01760 2. Policy Period: From 08/29/08 To 08/29/09 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: SCIARRATTA & DOUCETTE INS AGCY INC Suffix LARS RENEWAL 09 PO BOX 367 NEEDHAM, MA 02494 Producer's Code: 080956 Issuing Office: THE HARTFORD 4401 MIDDLE SETTLEMENT RD. NEW HARTFORD NY 13413 (800) 962-6170 Total Estimated Annual Premium: $866 Deposit Premium: Policy Minimum Premium: $270 MA (INCLUDES INCREASED LIMIT MIN. PREM. ) Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. n / Countersigned by Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 07/19/08 Page 1 (Continued on next page) Policy Expiration Date: 08/29/09 ORIGINAL 0 Z m n m X N W n a 1 m z O Ln V 0�