HomeMy WebLinkAboutAttleboro Del's & Ice Cream - 6/1/2010Commonwealth 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: MOBILE
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:.
PAUL PIATELLI
Whose place of business is:
ATTLEBORO DEL'S AND ICE CREAM
226 PLEASANT STREET
PERSON(S) IN CHARGE
PAUL PIATELLI
Permit Expires: June 01, 2010
License Number: P-93
Food Fee: $25.00
BOARD OF HEALTH
Dr, Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application mus a su mi e a eas
1) Establishment Name: t
ays a ore e p anne opening a e
e e—✓�� Ga
2) Establishment Address
(ec j,�
r A. O z 703
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
C) ?
5) Applicant Name & Title:
C) C
(
6) Applicant Address
—
.f-
0-�A—{e 1Q7a
7) Applicant Telephone No.:
45 aL2_6
Li z 2
24 Hour Emergency No.: 5:,o � S
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
An Association
VRIA_Corporation
H An Individual
Ll A Partnership
Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
r
—
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
G- C
Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:—_--
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS: `` /,- 6 el-11
18) Name of Person In Charge Certified in Food Protection Management
If more than 3 individuals are certified, complete list is on file.
as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Lo ation: Q Permanent Location 22) Establishment Type
lie Mobile Start Date: [2 Retail ( Sq. Ft)
Mobile End Date: Food Service up to 100 or
Mobile Comments: up to 10' PHF display $75
21) Length of Permit:
L.ITAnnual
E] Seasonal
Seasonal Dates:
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Service up to 101 -200
or up to 25' PHF display $100
Food Service up to 201 +
or 25'+ PHF display $125
Food Service - Institution
Meals/Day)
❑_-4 Bakery $25
Caterer $25
Food Delivery $25
0 Milk & Cream $2
Mobile Food & Consession $50
Mobile Food Temporary $25
Manufacture Frozen Desserts/Ice Cream
�$5/freezer
' U Pushcart $25 # of Pushcarts:
0 Residential Kitchen $25
Retail Food $50
Retail Snack Food $10
0 Tobacco Products No Fee
23) Food Operations
(Check all that apply):
Definitions. PHF Potentially hazardous food(timertemperature controls required)
Non-PHFs - non -potentially hazardous (ood(no fime/temperafure controls required)
RTE- ready-toeat foods (Ex. sandwiches, salads, muffins which need no further processing)
I[3 Sale of Commercially Pre -Packaged Non-PHFs
i] PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivey ageof Packaged PHFs
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
Processed Foods for Service Within 4 Hours
] Vacuum Packaging / Cook Chill
U Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
0 Customer Self -Service of Non PHF and Non-
Perishable Foods Only
] Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
n Preoaration of Non-PHFs
Other Food Operations Juice Manufactured and Packaged for I (E Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
�D�� l; rp Z�,'1 h�=/4•�6 Ne, d �? Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date _
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will corryp(y with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obta' c pies of 105 CM"90.000and-the Aeral Food Code.
24) Signature of
Pursuant to MGL Ch.62C, stsc. 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. 6�;/ / C`i(' / `{Y
25) Social Security Number or Federal ID: J�/) 0 7 V
26) Signature of Individual or Corporate Name:
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
��
Signature of Individual or
Corporate Name (Mandatory)
9
B . Corporate Officer
(Mandatory, if applicable)
65 4197ZIl 8'
** Social Security Number (Voluntary) or
Federal Identification Number
* 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
U1V
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: �� NP /-o De e- UecP k,-
Address: 2,`;___/7/0M S +_
o 27d� Phone#: S '-s,2-3—S M
Aree you an employer? Check the appropriate box:
Business Type (required):
1. E 1 am a employer with employees (full and/
5. etail
or part-time).*
6. ❑ RestauramtBar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (met. 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
10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
urance with no employees. [No workers' comp. insreq.]
12.0Other
*Any applicant that checks box #I 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
m ganization should check box #1.
I toe an employer that is providing workers' compensation insurance for my employees. Below is tyre policy information.
Insurance Company Name: �_ j �� /N` ✓U a C 6✓'o ✓ (O
Insurer's Address: �'- i - lS a 1k- C) 0 p (7) Do06V^ 10 i i- O
City/State/Zip:
Policy # or Self -ins. Lic. # W G R - 3 t_,V 3 S 57 5S"_- D t 8' Expiration Date: % /0 `1-. Aq
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 cey*, under the pAns and penaltos ofperjury that the information provided above is true and correct
Phone #: 5O&- S 9,3 -- 5 7 P(
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 Person: Phone #:
www.mass.gov/dia