HomeMy WebLinkAboutRosa's Food/Hardy's Catering 11/19/2009Commonwealth 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 Permit
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:.
ROSA GALENO
Whose place of business is:
ROSA'S FOOD SHOP (HARDY CATERING)
320 WEST CENTER STREET
PERSON(S) IN CHARGE
ROSA GALENO
Permit Expires: November 19, 2009
License Number: FS-6T
Food Fee: $10.00
BOARD OF HEALTH
Dr, Raymond Martin, Chairman
19-N04-:'009 09:25AM F6vti' ;;'L ASSOCIATES INC
+150N7.89 'r' ' T-499 PA02/007 F-981
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
pp ica ton mpust be su nit eft 30 clays EW—re fhe pfanried opening ate)
1) Establishment Name: /�2 OS u S �ovd T A
Hurafy J - -
2) Establishment Address 3 l_
3) Establishment Mailing Address (if different) `N -1-6 !3 d��,N�zf &�' t E't f I<•
4) Establishment Telephone No:
5) Applicant Name & Title:
6) Applicant Address
8' EtisrMR.t� sreEe
7) Applicant Telephone No.:
24 Hour Emergency No.:
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8) Owners Name & Title
9) Owner Address (If different from applicant): � EasiYJla-in S.7/J
1D) Establishment Owned By: 11) If a corporation or partnership, give name, title, and ome address of officers
1l An Association or partner.
9ACorporation Name Title Address Seek, e;4sf,
IJ An Individual
-
❑ A Partnership
CI Other legal Entity - - --
12) Person Directly Responsibl_e__For Daily Operati
Name & Title:
Address:
Telephone No;
FAX:
E-mail;
- Alt E-Mail: _.._.
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
1c i w, it 6 e- 12.+--�-.: ncl fv) j<S h-,FM '
person in charge, supervisor, manager etc,)
24 Hour Emergency No:
24 Hour Emergency No;
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19—NOV•`2009 09:15AM FROM-OALENO.& , " o„IATES INC +15082885028` ..'i*.ti„ct: ,7-488 P.003/007 F-381
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Food Establishment Information
14) WATER SOURCE:
15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
16) No. of Food Employees:
17)DAYS)HOURS:-
18) Name of Person In Charge Certified in Food Protection Management: 114
If more than 3 individuals are certified, complete list is file.
a r% r / r tart rc{ y
on
Hei. rG�/
Required as of IWM001 In accordance whit f o5 CMR 590.Oo9(A) Please attach copy of certificate
19) Person Trained in An[I-Choking Procedures (If 25 Seats or mere); ❑ -
20) location: ❑ Permanent Location
22) Establishment Type
n Bakery $25
❑ Mobile Mobile Start Date:
❑ Retail ( Sq. Ft)
❑ Caterer $25
Mobile End Date;
❑ Food Service up to 100 or
Li Food Delivery $25
Mobile. Comments:
up to 10' PHF display $75
(] Milk & Cream $2
21) Length of Permit.
❑ Food Service up to 101 -200
❑ Mobile Food & Consession $50
Annual
or up to 25' PHF display $100
❑ Mobile Food Temporary $25
I,] Seasonal
(1 Food Service up to 201 *
❑ Manufacture Frozen Dessens/Ice Cream
Seasonal Dates:
or 25'* PHF display $125
$5/freezer
❑ Pushcart $25 # of Pushcarts:
F J Temporary "'-
L Food Service -Institution
LI Residential Kitchen $25
Temporary Start Date:
( Meals/Oay)
❑ Retail Food $50
Temporary End Date:
& Retail Snack Food $10
Temporary Time:
❑. Tobacco Products No Foe
Rain Date;--
._ ...
.... .. — -.
23) Food Operations Definitions:PHF - PorenRady hazardous food idmerrempurafura controls required)
Non.PMF's -non-patendally imamous toodino amenemperaluro cantrdls required)
(Chock all that apply): RTE-roady-to-eerroods rya, sandMchea, sarads rnuf£rns which neadno rudherproeossina)
0 Sale of Commercially Pre -Packages Non-PHFs
LI PI+FC❑eked To Order
U Ho[ PHF Cooked and Cooled or Hot Held
Sale of CommorcAll Pre -Packaged PHFs
n Y 9
-
❑Preparation of PhIFs For Hot And
for Moro Than a Single Meal Service
❑ Dellvory of Packaged PHFs '—
Cold Holding For Single Meal Service
❑ PHF and SITE Foods Prepared For Highly
_
❑ Reheating of Commercially
(1 Sale of Raw Annual Foods Intended
Susceptible Population Facility
_
Processed Foods for Service Within 4 Hours
to be Prepared by Consumer
[� Vacuum Packaging /Cook Chill
'C "-
CJ uslomer Self•Setvlco of Non PHF and Non-
11 Customer Solf-Service
❑ Use of Process Requiring A Variance
Perishable Foods Only
--
and/or HACCP Plan (including bare hand
( 9
U Preparation of Non-PiiFs _
LJ Ice Manufactured and Packaged for
Retail Sale
contact alternative, time as it public health
control) _
F r t1t�Ia �y
U Juice Manufactured and Packaged for
U Offers Raw Or Undercookod Food Of
Retail Sale
Animal Origin
r
❑ Offers RTE PHF in Bulk quoni ties
_
LJ Prepares Food/Single Meals for
/
•p „ ,
C "`{'l- ���
E] Retail sale of Salvage, Out -of -Date
Catered Events or Institutional Food Service
_
S �
rr L( I 1
of Reconditioned Food
7b bd Completed bytlle BoEYd ❑r Health
ct: S'i. vl (aA-r ` �7C�-i(�t/a % - "- Total Permit Fee;
Payment is due with application n waived
1, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
ostablishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on now to obtain copies of 105 CMR 590.000 and the federal Food Code.
24) Signature of Appftcmtl
Pursuant to MGL Ch,62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have had 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: _
C8-NOt/ 26AM FROM-GALENO & ASSOCIATES INC i.': '' +15082385028 T-488 P.OWO .4VI'-381
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 (Mandatory)
0
(Mandatory, if applicable)
* Social Security Number ( oluntary) or
Federal Identification Number
x 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.
u• I9' t:S:009 09:26AM FROM & ASSOCIATES dNC t'!ii!5:S' +16082386023 T-487 x_5t./007 F-361
The Corttmornvealtlt ofMassaebusetts
Department ofIndustrial Accidents
Office dfInvestigations
iUV 600 Wasbington Street
Boston, MA 021 it
wwtv.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A»niieant Information Please Print Legibly
Busilless/Organization
Address: 23 aS % *UUj i
Ci /State/Zi �as (, oa37S
tY R k2 ✓-eh ��h 6 in . Phone #: 60.47 25; cN7 oL lfwy. - yG19 -l�lp S
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
orpan-time)," 6. ❑ Resiaurant/Sat/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (incl. real estate, auto, otc.)
employees working for me in any capacity.
[No workers' comp. insurance roquired] 8• ❑ Non-profit
3 j� We are a corporation and its officers have exercised 9, ❑ Friterrainmunt
their right of exemption per c• 152, §1(4), and we have 10,❑ mnulitcutring
no employees. [No workers' comp. insurance required]•
4. ❑ We are a non-profit organization, staffed by volunteers, I 1 • Health Care
with no employees. [No workers' camp, insurance raq,] 12. Other
*Any applicant that chccks box NI must utso fill out the section below showing fl cirworkers' compensation polity information,
••If die Corporate ottleers have oxempted thOrnselvca, but rho corporation has othor employees, a workers' compensation policy is required and Such an
organization should check box el.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy itJorination.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration Dale:
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, IS2 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 tine
of up to $250.00 a day against the violator. Be: advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance covaraee veriftcalinn.
1 do hereby certify, under the pains and penalties of perjury that the information provided above is true
Signature: Date: ��/..ri✓VG_'.G(C
Phone H:
Official use only. Do not write in tills area, to be completed by city or town ofj7clai
City or Town! Permt/Lieonse #
Issuing Authority (circle one):
1. Board of Health 2, Building Department 3. Chyfrown Clerk 4. Licensing Board S, Selectmen's Office
6. Other
Contact
www,mss.gov/dla
Phone
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