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P.IVA In caso di Societ: denominazione o ragione sociale ___________________________________________________________________________ con sede legale ovvero [ ] amministrativa nel Comune di_______________________________________ (prov. ______ ) via/p.za/loc. ________________________________________________________________ n. _______ CAP __________ tel. ________________________ Fax ___________________________ E-mail __________________________@_________________________ [ ] barrare se certificata Iscritta al Registro Imprese della C.C.I.A.A. di __________________________________ al n. _________________________ Iscrizione al Tribunale di ______________________________ al n. ___________ (se previsto) In caso di cittadino straniero: % di essere in possesso di permesso di soggiorno per ___________________ __________________________________ (specificare il motivo del rilascio) n ______ rilasciato da __________________________ il _____________ con validit fino al _____; % di essere in possesso di carta di soggiorno n ____ per ______________ ________________________ (specificare il motivo del rilascio) n _____ rilasciato da _________________________________ il _________ con validit fino al _____________. VISTO l  HYPERLINK "http://comune.manciano.gr.it/index.php?option=com_docman&task=doc_download&gid=89&Itemid="avviso pubblico con cui viene resa nota la disponibilit di un requisito quantitativo per l avvio di un esercizio di somministrazione di alimenti e bevande nella Sottozona  Zona T.L. , della Zona  1 di Manciano, PRESO ATTO del contenuto di detto avviso, che dichiara di accettare integralmente, Consapevole che le dichiarazioni false, la falsit negli atti e l uso di atti falsi comportano l applicazione delle sanzioni penali previste dall art. 76 del DPR 445/2000 e la decadenza dai benefici conseguenti DICHIARA % di iniziare l'attivit di somministrazione di alimenti e bevande, indicativamente volta ( ai soli fini statistici ) ad esercitare l attivit di : % BAR % RISTORANTE % BAR/ RISTORANTE % ALTRO______________________________________________ nel locale posto in via/piazza/loc. ________________________________________________________________n. ________ % di avviare effettivamente l attivit dalla data: % di registrazione al protocollo generale della presente dichiarazione; % che sar successivamente comunicata tramite l apposito modello, entro i termini previsti dal comma 2, dell articolo 107, della L.R. 28/05 e succ. modificazioni. % che l esercizio: % in possesso % sar in possesso, prima dell avvio effettivo dell attivit, dei requisiti per l assegnazione dei seguenti indicatori di qualit: % 1 Sedia ( Obbligatorio ), % 2 Sedie, avendo raggiunto il punteggio complessivo di prima ipotesi di 16 punti, o di seconda ipotesi di 18 punti, % 3 Sedie, avendo raggiunto il punteggio complessivo di prima ipotesi di 18 punti, o di seconda ipotesi di 20 punti. ------------------------------ l---------------------------------- --------------------------------------------------- (Firma) DICHIARA di essere a conoscenza di quanto previsto dalla vigente normativa in materia di attivit di somministrazione di alimenti e bevande ( L. R. dello 07.02.2005 n. 28 e succ. mod. ); di essere a conoscenza delle disposizioni in materia di igiene dei prodotti alimentari e dei relativi procedimenti da attivare e che l avvio effettivo dell attivit subordinato all acquisizione di validit della DIA ai fini igienico .- sanitari ai sensi del Regolamento CE n 852/2004 del 29 aprile 2004 e al D.P.G.R. 01.08.2006 n 40/R; di essere in possesso dei requisiti di onorabilit e professionali, rispettivamente previsti dagli articoli 13 e 14 della L.R. 28/05 e succ. modificazioni [ Allegati 1) e 2) ]; DICHIARA, inoltre che i locali possiedono i requisiti urbanistico  edilizi, igienico-sanitari, di sicurezza e di destinazione d uso prescritti dalle vigenti disposizioni di legge e dai regolamenti comunali in materia; che vengono rispettate, ai fini della prevenzione dell inquinamento acustico, le norme previste dal piano Piano Comunale di Classificazione Acustica; che i locali sono sorvegliabili ai sensi del D.M. 564/92, come da certificazione rilasciata da tecnico abilitato; che gli impianti installati (elettrico, idraulico, gas, riscaldamento, ecc.) sono conformi alle normative vigenti nelle rispettive materie; che la disponibilit dei locali a titolo di: % propriet % affitto % comodato % Altro ___________________________ DICHIARA, altres ( solo in caso di Societ ) % di designare quale persona preposta all attivit, il Sig& & & & & & & & & & & & & & & & & & & & & & & & & & & .. nato a& & & & & & & & & & & . il& & & & & & & & & .., C.F& & & & & & & & & & & .., che accetta l incarico e si sottoscrive. ( Firma del preposto per accettazione ) & & & & & & & & & & & & & & & & & & & & & .. ALLEGA % Copia documento di riconoscimento di tutti i soggetti tenuti a presentarlo % Autocertificazioni dei soggetti tenuti a presentarle, concernenti il possesso dei requisiti di onorabilit e professionali [ allegati 2) e 3) ] % Permesso di soggiorno ( solo per cittadino extracomunitario ) % Dichiarazione di sorvegliabilit dei locali (D.M. 564/92) % Schede tecniche relative ai requisiti di qualit posseduti [ allegati 1) e 2) ] % Altro (specificare ) & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ------------------------------ l---------------------------------- --------------------------------------------------- (Firma) Allegato 1) REQUISITI QUALITATIVI - PUNTEGGIO DICHIARATO (barrare il riquadro corrispondente al requisito posseduto) Tabella A  Requisiti strutturali Punteggio dichiarato ( 1 punto per ciascun requisito) 1. Superficie del locale di somministrazione, di almeno 45 mq.  2. Superficie aperta al pubblico adiacente o pertinente al locale, appositamente attrezzata per la somministrazione in modo tale da proteggere il consumatore dagli effetti nocivi derivanti dal traffico, dal calpestio del suolo, e similari.  3. Parcheggi in numero minimo di uno ogni 8 posti tavola, su area di propriet privata, adiacente o distante dal locale di somministrazione non pi di ml. 50  4. Almeno un parcheggio su area di propriet privata e/o su suolo pubblico, adiacente o distante dal locale di somministrazione non pi di ml. 50, ad esclusivo servizio di persone disabili, ed idoneo percorso di collegamento fino alla struttura  5. Almeno un servizio igienico a disposizione dei clienti, aggiuntivo al numero minimo obbligatorio previsto dalla normativa  6. Individuazione di idonei spazi all interno del locale o in aree private, per lo stoccaggio di materiale da riciclare ( lattine, bottiglie, cartoni, etc.)  7. Utilizzo esclusivo di lampade e apparecchiature a basso consumo energetico (attestato da schede tecniche)  8. Adozione, anche parziale, di sistemi per il risparmio idrico (attestata da schede tecniche o certificata da installatore)  9. Impianti funzionanti ad energia prodotta da fonti rinnovabili (attestata da schede tecniche o certificata da installatore)  10. Climatizzazione del locale di somministrazione  11. Esercizio ubicato in edificio di interesse storico, culturale, architettonico o di altro particolare interesse ( attestato dall Ufficio Urbanistica del Comune )  12. Sala distinta per fumatori  13. Insonorizzazione dei locali (documentata da Tecnico abilitato)  14. Apposito spazio per capi di abbigliamento  15. Almeno uno spazio d intrattenimento attrezzato all interno dell esercizio ( sala ricreativa, sala TV, sala di intrattenimento per bambini, ecc. )  16. Almeno uno spazio di svago attrezzato all esterno dell esercizio ( spazio giochi per bambini, dog parking, gioco bocce, ecc. )  Requisiti Tabella A: Totale Punti: & & & .. Allegato 2) Tabella B - Requisiti di offerta Punteggio dichiarato (1 punto per ciascun requisito) 1. Adesione a disciplinari di qualit, anche relativi alla qualificazione professionale dell esercente (specificare quali )  2. Adesione ad iniziative e/o a circuiti regionali e/o provinciali di promozione dei prodotti tipici toscani ( specificare quali )  3. Adesione ad iniziative e/o a circuiti regionali e/o provinciali di promozione del territorio ( specificare quali )  4. Adesione ad iniziative organizzate o patrocinate formalmente dall Amministrazione Comunale di promozione e valorizzazione del territorio, es. centro commerciale naturale ( specificare quali )  5. Produzione propria dei prodotti di panificazione e/o di pasta fresca e/o di pasticceria  6. Men o offerta esplicita di prodotti tipici toscani ( * )  7. Men o offerta esplicita di prodotti tipici locali  8. Men per celiaci e/o diabetici  9. Men o offerta esplicita di prodotti provenienti da agricoltura biologica  10. Caratterizzazione della prima colazione con prodotti tipici locali freschi e/o conservati, o con prodotti di produzione propria  11. Caratterizzazione dell aperitivo con prodotti tipici locali freschi e/o conservati, o con prodotti di produzione propria  12. Carta dei vini con almeno 6 prodotti di aziende locali  13. Carta degli oli, con almeno 2 prodotti di aziende locali  14. Carta dei formaggi, con almeno 3 prodotti di aziende locali  15. Carta della birra, con almeno 5 prodotti  16. Eliminazione dal men della voce  coperto e/o servizio  17. Divise per il personale  18. Apertura di almeno 300 giorni/anno  19. Apertura giornaliera di almeno 16 ore  20. Conoscenza di almeno una lingua straniera (attestata da titoli di studio o da corsi di specializzazione da parte del titolare, preposto, soci, dipendenti)  21. Men tradotto in almeno due lingue ( specificare quali )  22. Accettazione di tutti i principali mezzi di pagamento  Requisiti Tabella B: Totale Punti: & & & .. ( * ) Per l individuazione dei prodotti tipici toscani di cui al punto 6, si fa riferimento ai prodotti tipici della Regione Toscana, riconosciuti nei cataloghi ARSIA, del progetto Vetrina Toscana, Vetrina Toscana a tavola e nelle altre iniziative ufficiali coordinate a livello regionale.  REQUISITI QUALITATIVI - PUNTEGGIO MINIMO OBBLIGATORIO Punteggio di Prima Ipotesi: Requisiti strutturali: 5 Requisiti di offerta: 9 Punteggio di Seconda Ipotesi: 16 REQUISITI QUALITATIVI - RIEPILOGO PUNTEGGIO OTTENUTO Punteggio di Prima Ipotesi Requisiti strutturaliPunteggio ottenuto Punteggio minimo obbligatorio& & & & & & & & ...& & & & .. 5  & & & & & .Requisiti di offerta Punteggio minimo obbligatorio& & & & & & .& & & & & & & 9  & & & & & . Punteggio di Seconda Ipotesi Totale Punteggio ottenuto Punteggio minimo obbligatorio& & & & & & & ..... & & & & ... 16  & & & & & . Il punteggio dei requisiti qualitativi, da raggiungere per l assegnazione di uno, due o tre indicatori di qualit, stabilito come segue: per l assegnazione di un indicatore di qualit ( una sedia ): il punteggio minimo obbligatorio di prima ipotesi per ognuna delle due macrotipologie di requisiti (5 e 9 ), o, qualora non lo si raggiunga, in subordine, il punteggio di seconda ipotesi complessivo per le due macrotipologie di requisiti (16 ); per l assegnazione di due indicatori di qualit ( due sedie ): il punteggio minimo obbligatorio di prima ipotesi per ognuna delle due macrotipologie di requisiti pi due punti complessivi (16 ), o, qualora non lo si raggiunga, in subordine, il punteggio di seconda ipotesi complessivo per le due macrotipologie di requisiti, pi due punti (18 ); per l assegnazione di tre indicatori di qualit ( tre sedie ): il punteggio minimo obbligatorio di prima ipotesi per ognuna delle due macrotipologie di requisiti pi quattro punti complessivi (18 ), o, qualora non lo si raggiunga, in subordine, il punteggio di seconda ipotesi complessivo per le due macrotipologie di requisiti, pi quattro punti (20 ). ----------------- l--------------------- -------------------------------------------------- ( Firma ) La compilazione della dichiarazione dei requisiti di qualit, comporta assunzione di responsabilit anche penale circa la veridicit dei requisiti dichiarati a norma del D.P.R. n. 445/2000. Informativa ai sensi dell art 13 del D. Lgs n. 196 del 30 giugno 2003: Ai sensi dell articolo 13 del citato decreto legislativo recante disposizioni in materia di protezione dei dati personali desideriamo informarla che i dati personali da lei volontariamente forniti per l attivazione dei servizi richiesti saranno trattati, da parte dell Ente ricevente, adottando le misure idonee a garantire la sicurezza e la riservatezza, nel rispetto della normativa sopra richiamata. Allegato 3) AUTOCERTIFICAZIONE ANTIMAFIA E REQUISITI MORALI (D.P.R. 252/1998 Art 2 comma 3) (Art.13 L.R. 28/05 e succ. modificazioni) Cognome ________________________________________ Nome __________________________________________________ C.F. __________________________________________________ Cittadinanza _______________________________________ Data di nascita ____ /____ /____ Luogo di nascita: _______________________________ Provincia ___________________ Residenza: Provincia_________________________________Comune ______________________________________________ Via, piazza, ecc.______________________________________________________ n.__________ CAP___________________ A tal fine, sotto la propria responsabilit e consapevole delle responsabilit penali connesse alla produzione di dichiarazioni false, punite ai sensi dell'art. 495 c.p., dell'art. 76 del D.P.R. 445/2000, dell'art. 11, comma 3, D.P.R. n. 403/1998, e della decadenza dai benefici eventualmente conseguenti al provvedimento emanato sulla base della dichiarazione non veritiera DICHIARA % Di essere in possesso dei requisiti di onorabilit previsti dalla normativa vigente per l esercizio dell attivit.( art. 13 L.R. 07.02.2005 , n. 28 ) % Che non sussistono nei propri confronti  cause di divieto, di decadenza o di sospensione di cui all'art. 10 della legge 31 maggio 1965, n. 575 (antimafia). ---------------------- l----------------------- ------------------------------------------ (Firma) ( per soci, in caso di societ ) Cognome ________________________________________ Nome __________________________________________________ C.F. __________________________________________________ Cittadinanza _______________________________________ Data di nascita ____ /____ /____ Luogo di nascita: _______________________________ Provincia ___________________ Residenza: Provincia_________________________________Comune ______________________________________________ Via, piazza, ecc.______________________________________________________ n.__________ CAP___________________ A tal fine, sotto la propria responsabilit e consapevole delle responsabilit penali connesse alla produzione di dichiarazioni false, punite ai sensi dell'art. 495 c.p., dell'art. 76 del D.P.R. 445/2000, dell'art. 11, comma 3, D.P.R. n. 403/1998, e della decadenza dai benefici eventualmente conseguenti al provvedimento emanato sulla base della dichiarazione non veritiera DICHIARA % Di essere in possesso dei requisiti di onorabilit previsti dalla normativa vigente per l esercizio dell attivit.( art. 13 L. R. 07.02.2005 , n. 28 ) % Che non sussistono nei propri confronti  cause di divieto, di decadenza o di sospensione di cui all'art. 10 della legge 31 maggio 1965, n. 575 (antimafia). ---------------------- l----------------------- ------------------------------------------ (Firma) Allegato 4) DICHIARAZIONE DEI REQUISITI PROFESSIONALI (Art.14 L.R. 28/05 e succ. modificazioni) ( da sottoscrivere da parte del titolare, in caso di impresa individuale, o del legale rappresentante o di altra persona specificamente preposta in caso di Societ) Cognome ________________________________________ Nome __________________________________________________ C.F. __________________________________________________ Cittadinanza _______________________________________ Data di nascita ____ /____ /____ Luogo di nascita: _______________________________ Provincia ___________________ Residenza: Provincia_________________________________Comune ______________________________________________ Via, piazza, ecc.______________________________________________________ n.__________ CAP___________________ In qualit di: % titolare % legale rappresentante della Societ ________________________________________ % preposto della Societ ___________________________________________________ sotto la propria responsabilit e consapevole delle responsabilit penali connesse alla produzione di dichiarazioni false, punite ai sensi dell'art. 495 c.p., dell'art. 76 del D.P.R. 445/2000, dell'art. 11, comma 3, D.P.R. n. 403/1998, e della decadenza dai benefici eventualmente conseguenti al provvedimento emanato sulla base della dichiarazione non veritiera DICHIARA di essere in possesso del seguente requisito professionale previsto dall articolo 14 della L.R. 28/05 e successive modificazioni: % avere frequentato con esito positivo un corso di formazione professionale relativo alla somministrazione di alimenti e bevande, come disciplinato dalla vigente normativa delle Regioni e delle Province autonome di Trento e Bolzano (specificare quale e dove e quando stato conseguito)__________________________________________________; % essere in possesso di un diploma di istituto di istruzione secondaria di secondo grado o di laurea aventi un indirizzo attinente alle materia dell alimentazione o della somministrazione (specificare quale e dove e quando stato conseguito)_______________________________________________________________________________________________; % avere esercitato in proprio, per almeno due anni nell ultimo quinquennio, l`attivita` di somministrazione di alimenti e bevande o avere prestato la propria opera, per almeno due anni nell ultimo quinquennio, presso imprese esercenti l`attivita` nel settore della somministrazione di alimenti e bevande, in qualit di dipendente qualificato addetto alla somministrazione, alla preparazione o all amministrazione o in qualit di socio lavoratore di cooperativa o, se trattasi di coniuge, parente o affine, entro il terzo grado dell imprenditore, in qualit di coadiutore familiare, comprovata dall iscrizione all INPS (specificare numero e data di iscrizione)______________________________________; % essere stato iscritto al REC di cui alla L. 426/1971 ed alla L. 287/91, per attivit di somministrazione al pubblico di alimenti e bevande o alla sezione speciale del medesimo registro per la gestione di impresa turistica, salvo cancellazione dal medesimo registro, volontaria o per perdita dei requisiti (specificare numero e data di iscrizione) _________________________________________________________________________________________________________. ---------------------- l----------------------- ------------------------------------------ (Firma) OBBLIGHI Il locale dovr richiamare, nel suo interno, gli elementi tipologici caratteristici della zona. Anche gli arredi dovranno uniformarsi a tale caratterizzazione. E fatto obbligo di esporre all interno dell esercizio la tabella riassuntiva dei criteri di qualit dichiarati, debitamente vistata dal Comune. Deve essere sempre garantito il rispetto dei requisiti dichiarati. I requisiti possono essere modificati con presentazione di apposita nuova dichiarazione al Comune, purch sia rispettato il punteggio minimo previsto per la zona di appartenenza. Il Comune, qualora lo ritenga opportuno, pu, in qualsiasi momento, effettuare controlli per verificare la sussistenza ed il mantenimento dei requisiti dichiarati. Qualora si verifichi il venir meno dei requisiti qualitativi, l Amministrazione proceder ad assegnare all interessato un termine non inferiore a 15 e non superiore a 60 giorni per l adeguamento. Nel caso in cui detti requisiti non siano ripristinabili o qualora il titolare volesse variare i requisiti stessi, potr presentare nuova tabella per il raggiungimento del punteggio minimo previsto per la Zona o Sottozona di appartenenza. In caso di mancata ottemperanza, si applica l articolo 103, comma 2, della L.R. 28/2005 e successive modifiche ed integrazioni. ------------------------------ l---------------------------------- Per presa visione e accettazione: Firma ---------------------------------------------------   COMUNE DI MANCIANODICHIARAZIONE DI INIZIO DI ATTIVIT DI SOMMINISTRAZIONE DI ALIMENTI E BEVANDE IN BASE AI CRITERI QUANTITATIVI E QUALITATIVI   PAGE 11 D&(   < > P R \ ^ ` b d f h j l n p r t v x v[5B*CJmHsH5PJnH^JaJ_HtH\OJQJ/B*CJmHsHPJnH^JaJ_HtHOJQJ5B*CJmHsH5PJnH^JaJ_HtH\OJQJ/B*CJmHsHPJnH^JaJ_HtHOJQJ5B*CJmHsH6PJnH^JaJ_HtH]OJQJ;B*CJmHsH65PJnH^JaJ_HtH]\OJQJ jU#x z | ~ rf 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