HomeMy WebLinkAboutApplication and WC r
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: . . �FOR�BOA�tD OF�HEALT�i USE ONLY . .�
� •I?ate Received .-� � .Date Inspected -. • � Approved By. • . � - Pennit#Issued..::,:::,s.,;;.,::`,
. . � � . .� . . ,�:� =.�.
. .. . ����_��'�;:r
' .THE COMMONWEALTH OF MASSACHUSETTS
_ . . NOV 2 � 2016
TOWN oR CfTY oF e
HEAI_Ts-I f��;��- f
Food Es�a�lishment Permit Application r�� �� � `� `
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(App liccrtion �nust-be su b�nitte d at least 3 0 days be fore t he p la.nrie d opening d� �����
. _ .. . .:,k.:x; .
� � B o .�-t-� �a 33�
1. Establishment.Name: ��t. �G� � �� C �� '! s 4
2. E'stablishment Address: �d � � � � O (,
3. EstablistunenG Mailin�Address(if differentj:
. . a
4. Establishment Telephone•No: ` �� q � � �
� Z��7«$
� 5. Applicant Name�Tide: �.
6. Applicant Address '� � 3� �� Email Address •
.
.. . :. ... . • s es�i . �
`��� 7. Ap�Iicant TeTephone.No. • L 24 Hour EmerQenc No: � �
. s 3. - ox b� � = y : ) 3 Wd 30
8. Owner Name&Ttle(if different from applicant): . � •
' 9. Owner Address{if different from applicant):
10. Establishment Owned By: I1. If a Corporarion or Paitnership,�ve name,tide,and home address of
� , � officers or partner. - ,
❑An Association ,. Na�ne ' Tide ' � Home Address
❑A Corporation � •
❑An Indi�7dua1 .. • � .
: ❑A Partnership . . . . . .
�Other Legal Enury�C..
. �
. �i
. -. ._ �
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12. Person Direcdy Responsible�For Daily Operations(Owner,Person in Charge,�Supervisor,Manaaer, etc.) �
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• i
�Name&-Title:-..... . ---...---- �. • ____ . ._.. . _._... _..----�----�...--�------- ------- -- � - - �
I
Address r
� � ` � � So���, � a '
Telephone No: + � • ;
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Emerjency TeIephone No;-•-- - -��, 3G " �'�. .� .._. _..: � .. ...._. .. Fax_-- -�+�J,..�-t�_'`.� ..: :V:_....._ ;
-1�._. _
13. District or Regional Supervisor(if applicableJ
Name&Title: ` ' ( 1
Address: Y �3 SO � 1
Te]ephone No: S�� � 3 yL��L X� � Fax: ,
_
. . . '. . . . ' . . . :y. . . .
.. � . . . �� ... � ,... ,',T.. . �. '
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� - � -- � . �oad-�s��ablish�ent�Ir�foramation : .�.�. :
. . . . , .1." :t� ..:£ - '��: -:'rt'=` '.'f•^ �F". -- . .
� � 14. Water Source: � ' l�. Sewage DisposaL•
DEP Public Water Supply i�1o.:(if crpPlicabfej � -.:. . ..... .. < . : .. .. .....: . . . .... ..f�..:.. , . .... ..: -
16: Days and Hours of Operation: '� r 'i.. 17. No.of Food Employees: 3
_ " � • •�l7
18. Name of Persan [n Charge Certified in Food Protection Managem nt
Requirrd nr nj!U/1!•'0�!in nccnrdnirce�rirh!05 C1dR 590.003{A)Plraae annc6 cupr ojrrrr.finrrr.
19: Person Trai ned in Anti-Choking Proce�ures.(if 25 seats or more): ;�Yes.,;,0 NR•-. '.,•, :::. :,�,� ,;� �
20:Location . . .. ... ; Z; =Establis�ment Type(check aIl tha[apply) �Caterer
(chec�c�n.ej . . '�
�Permanznt Structure . ❑Retail ( Sq.Ft.) � ❑Food Delivery
0 Mobile �Food Service-( Seau) � Residential Kitchen for Retail Sale �
� ❑ Food Service-Takeout ❑Residential kitchen for Bed and Breakf�st
•�Food�Service-Institution Hon�e
21. LenQth Of Per•mit: . � Meals/Day) Q Residentiai-Kitcfien for Bed and$reakfast
' � , (check nr�e); . � Establishments
Annual - , . Other(Describe} . ❑Frozen Dessert ivfanufacturer .
❑Szasonal/Dates: - - ,
❑Temporary/Dates(I'ime: � �
?3. Food Operations`. De�fnition.s: PHF-porenriull}�hazardous food.(tim_e/temperature corztrols required) �
(dieck�al(that ap�1y): � Non-PHF's-.non potentiglly hc�;,ardoccs food(no time/temperature controls required) �
. RT E-ready-to-eat foods(Ex sandwiches,snlads,:nu,fi`"zns which need rio fu�-tFter pracessing}
❑Sale of Commercially Pre- • ❑PHF Cooked To Order �IiotPHF Gooked'and.Cooled or Hot Held
Packaeed I�ton-PHF's for More Than a Sinele Meal Service.
❑Sale of Commercially Pre- ❑Preparation Of PHFs For Hot And �PHF and RTE Foods Prepared Fot Highly
Packaged�F�'s � Cold Holdin;For Single Mea1 Service Susceptible�opulation Facility .
DeIivery of Packa�ed PH1ts Q Sale of Raw Animal Foods Intended . ❑Vacaum Packa�inJCook Chill � , .
� • to be Pre ared t+ Cons�mer. • �
Reheating o�CommercialIy " �Customer Self-Service 0 Use Of Process Requiring A.Variance And/Or '
Processed Foods For Service . � HA�CP Pl'an(induding bare hand contact
wrhin 4 Hours. � alternauve,time as a ublic healtli cont�ol) � ;
�
❑Customer Self-Senice Of Non-. ❑ Ice Manufactured and Packa�ed for ❑Offers Raw Or Undercooked Food Oi Animal•
PHF and;Non-Perishabfe Foods Retail Sale Ori?in.
Onlv.
QPreparatian Of Non-PHF's � ❑Juice Manufactured and Packaged Q Prepares FoodlSinale Meals for Catered
for Retail Sale � Events or Institu[ional Foad Service ;
� ❑Offers RTE PHF in Butk Quantities To be completed by the Board of Aealth ',
❑Retaii Sale of SalvaQe,Out of Date Total Permit�ee: ��7 — '
� or Reconditioned Food . Payment is.dtte ii-ith application !
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I,the undersi;ned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation � �
will comply with 105 GMR 590.000 and all other applicable law.I have been ins cted by the Board of Health on ho�v to obtain copies of '
105 GMR 590.OU0 and the Federal Food Cod i
24. Sia ature of Applicant l
Pursuant to MGL Ch. 62C,sec. 9A,I c under the penalties of perjury that I,to my best l:nawledge and belief,have :
filed all state tax returns and paid state taxes required under law. . , ' ' .
25. Social Security NurnberorFederal�ID: � . �
- .� . .`
26. 3igna[ure of Individual or Corporate Name: � �S OI � �0 1,