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Home My WebLink AboutCibo Matto - 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 Serviee Establishment Type: FOOD 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:. PETER KUPLAST Whose place of business is: CIBO MATTO 254 CHAUNCY STREET PERSON(S) IN CHARGE PETER KUPLAST Permit Expires: June 01, 2010 License Number: FS-56 Food Fee: $75.00 Milk & Cream ❑O BOARD OF HEALTH At - Dr. Raymond Martin, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that., PETER KUPLAST having a place of business at: CIBO MATTO 254 CHAUNCY STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 Licen o.: FS-56 r Scott Leite, yealth Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION pp roa ton mus a su mi e a eas e p anne opening a e1) j�aysoe Establishment Name:2) Establishment Address CL—A C-' 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 5 G 41 5) Applicant Name & Title:�I tLV 6) Applicant Address lR 7) Applicant Telephone No.: Vf9 / 24 Hour Emergency No.: 8) Owners Name & Title 9) Owner Address (If different from applicant): 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers O An Association or partner. Name Address O A Corporation El An Individual + . ``// /�Ti11tl__e oL [!(,, r p ��E El A Partnership �f. o�l✓u�•(? �y (ov�tAi'� ■Other legal Entity LCC - -. L �' (4 r �LAA Name &Title: _ 1 '6NA l G tnl ✓tt i/j'f—$ Address: Telephone No: rP 6 24 Hour Emergency No: FAX E-mail. Alt E-Mail _ 9 st District Or Regional Supervisor (if applicable) Name & Title Address: _ JTelephone 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: fln C7 17) DAYS/HOURS: p, \ I - AAA, t r IS) Name of Person In Charge Certifi d in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in 20) Location: LY] -1 Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21 ength of Permit: Annual 0 Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Dale: (If 25 Seals or more): U Location 22) Establishment Type 0 Retail ( Sq. Ft) �ood Service up to 100 or up to 10' PHF display $75 0 Food Service up to 101 -200 or up to 25' PHF display $100 Food Service up to 201 + or 25'+ PHF display $125 0 Food Service - Institution ( Meals/Day) Bakery $25 (] Caterer $25 Food Delivery $25 F1 Milk & Cream $2 0 Mobile Food & Consession $50 0 Mobile Food Temporary $25 Manufacture Frozen Desserts/Ice Cream $5/freezer 0 Pushcart $25 # of Pushcarts: 0 Residential Kitchen $25 Retail Food $50 F-1 Retail Snack Food $10 0 Tobacco Products No Fee 23 Food O Operations Definitions:PHF - Potentially hazardous food(fimellempemfure controls required) P Non-PHFs - non -potentially hazardous food(no (ime4emperature controls required) (Check all that apply): RTE -ready-fo-eat ods (Ex. sandwiches, salads, muffins which need o further processing) L- Sale of Commercially Pre -Packaged Non-PHFs P FCooked To Order of PHF Cooked and Cooled or Hot Held _ for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs reparation of PHFs For Hot And C Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly f -,I Delivery of Packaged PHFs _ . _ .. Syaceplible Population Facility Foods for Service Within 4 Hours ielf-Service of Non PHF and Non - Foods Only r of Non-PHFs Other Food Operations I] Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged for Retail Sale 0 Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food vacuum Packaging / Cook Chill 0 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contactallernative, time as a public health fifers Raw Or Undercooked Food Of Animal Origin _ Prepares Food/Single Meals for Catered Events or Institutional Food Service I I 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 comply with 105 CMR 590,000 and all other applicable law. I have been instructed by the board of health on how to obtain cgp)eyof 105 CMR 590.030.aad,,the fe�l. Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, se . 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid slate taxes required under law. �� f 25) Social Security Number or Federal ID: d 26) Signature of Individual or Corporate Name: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1 st of each year. NAME OF BUSINESS: C(�o U " `) X + 4-4 ADDRESS: �-.5- ( ctt�" J' TELEPHONE AT LOCATION: S-O J O FAX NUMBER: 56 c( 6 OWNER OF BUSINESS: TELEPHONE OF OWNER: 7 �2 FEDERAL ID/SS NUMBER: Q FEE: $2.00 PERMIT NUMBER: SIGNATURE: _ DATE: r �� O — 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. * SigAature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) o?7oAFIT � - ** 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 Boston, MA 02111 U1V witnv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_ y @ alb "\ U, c Address: a?S 4 C4#90rVd� ,ll City/State/Zip: Phone #: Aree yo an employer? Check the appropriate box: Business Type (required): 1. [9,71 am a employer with L4) employees (full and/ 5. ❑ Retail or part-time).* 6. []( 'rRestaurant/Bar/Eating Establishment 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 [Wo workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. Q Entertainment their right of exemption per c. 152, §I(4), and we have 10.[1 Manufacturing no employees. [No workers' comp. insurance required]* H1 Ej Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.El Other with no employees. [N9 workers' comp, insarance req.] *,any applicant that checks box #1 must also fill" the scahm below showing their workers' eomparsation 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 ant an employer that is providing workers' compensation insurance for my mployem Below is a Policy Information. Insurance Company Name: /yam;=� ') ~�t V� t 9 LtM Insurer's Address: IL guy City/State/Zip: W o k t--f— J. T> A r c t T a. Policy # or Self -ins. Lic. # Rotw 60 Lo 7 S p Expiration Date: 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, /un`der the pains and pen�alliiess of erer"j`ury that the information provided alb�ove ' true /held correct Ciuman,rr• '4 -,- �® ,? Date: / �� / 4' r 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 www.mass.gov/dia Phone Sheet4 _.,. -- 101612009 _ ------------ SCHEDULE ----- OF- DEPARTMENTAL-- TOWN OF MANSFIELD -____ - PAYMENTS TO TREASURERS, Dept; BOARD OF HEALTH - 01512-445006 __—_. FROM WHOM FOR HAT ` .. - -, AMOUNT Ck.#/Memo PETER KUPLAST FOOD AND MILK & CREAM PERMITGASH. — - to ype—fpayment o the Departmental Officer making the payment - —Dept: BOARD OF HEALTH__ _01572-445006 _ R ecei t. oF.�. $77 00 — -- I ir the period ending OCTOSER 8, 2009 — ollections as Per sculehedof this date and filed in -my office_ --__..—____.___—_—_--___ Treasurer TOWIN OF MANSFIELD PAID OCT 08 2009 Page 1 CHECK # `S" AkfT�_�