HomeMy WebLinkAboutSt. Mary's Catholic School - 12/31/2020VaWlid: «.V41
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)0,9
I Establishment Name fit. M6wl5 cx'- wtr/ Sck001
Establishment Address �,bo Qrak-Y 6)fft4� MMhb�le(pl MR 0��g
Establishment Mailing Address (if different)
Establishment Telephone No S0%, °u3�y,4$00
Applicant Name & Title: ( W- WONAwf.( 1-, Kc,"V"' 5
Applicant Address ^�30 e(Kit )it(" K1QA- (1 t(A V\k 0 0 l$
Applicant Telephone No.: 50g . b51AS"o 24 Hour Emergency No.:
Applicant Email
rOwner
Name & Title (If different from applicant) 5} m'&V13'5 CwIrt o t i a �)„w�
Owner Address v
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
171 An Association
partner.
O A Corporation
Name Title Address
11 An Individual
A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: lk0'kir".tW Ih • 7uvvt
MA 01,0 �rS
Address: 'j30 nrN4 6 roA Mr^ n54t t lob
Telephone No: tm • 33ci, too 24 Hour Emergency No:
(I
FAX: 609.225-11 , 20 b3
E-mail: Mt 0"@ 5k
AItE_Mail:----�diycA. S t o OLA51SrLioa�.0 Qaµlh� i Tinc t/ „
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E mail:
9
tiiA ,
Food Establishment information
WATER SOURCE: (esdW
SEWAGE DISPOSAL: j a�vh
,(
--Employees'..
--_ —_ ---- —._
No. of
DEP Public Water Supply No: (if applicable)
—
DAYS/HOURS: KOAAay
Name of Person(s) In Charge Certified in Food Protection Management: cky-"t,
Name of Person(s) In Charge Certified in Allergen Awareness Training WAk/ car" U
Name of pest control company routinely inspecting the premises for evidence of pests
If there is seating for 25 pe_pple or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. Yes wt kt< l ryN
---------- ---------------------------------- --
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
(VAnnual
171 Retail Food $125.00 Q Mobile Food Consession
Q Temporary
Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 Ej Manufacture Frozen Desserts)Ice Cream
Temporary Start Date:
Q,f Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
t[r� Food Service up to 201 + $300.00 ITT] Pushcart $50.00 # of Pushcarts:
Temporary Time:
Q Supermarkets $400 E] Residential Kitchen $100.00
Rain Date:
.Milk & Cream $10.00 Q Caterer $35.00
Food Operations: Definitions: PHF- Poton sally hazardous food (6moRemponuvm controls require.)
Non-PHFs. non -potentially hazardous food(no thneltempealure controls required)
(Cheek all that apply): RTE -ready-fo-eat foods (Ex. sandwiches, salads, mumns which need no lurtherprocassing)
Q Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held
ii"Sato of Commercially Pre -Packaged PHFs Ia Preparation of PHFs For Hot And for More Than a Single Meal Service
�[ Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly
IMI Delivery of Packaged PHFs t
Sale Raw Animal Foods Intended Susceptible Population Facility
-Q'' of
eQ. Reheating of Commercially to be Prepared by Consumer El Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours andlor HACCP Plan (including bare hand
Q Customer Self -Service of Non PHF and Non - Q Customer Self-service contact alternative, time as a public health
Perishable Foods Only Q Ice Manufactured and Packaged for control)
Preparation of Non-PHFs Retail Sale Q Offers Raw Or Undercooked Food Of
�❑-' Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale E] Vacuum Packaging ) Cook Chill
Offers RTE PHF In Bulk Quantities Q Prepares Food/Single Meals for
Q Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
1, 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 copies of 105 CMR 690.000 and the federal Food Code.
Signature of Applicant:�n%��
Pursuant to MGL Ch.62C, sec. 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.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: `/
TAX CERTIFICATION FORM
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 Indi)9dual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this 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 Massachusetts General Law
Chapter 62C, section 49A.
C:\UsasWcitn\DesIaop\Scoft's Documents\Food Esmbtishments-Tamp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: fit' s Ca-K,o l c, 66Vt ool
Address:
Sao Prurt'k
r\&4t1(d V -)-00F
City/State/Zip: hone #:_
5'o8. ?52,q, too
Are you an employer? Check the appropriate box: Business Type (required):
l.❑ 1 am a employer with employees (full and/ 5. Q Retail
or part-time).* 6. n Restaurant/Bar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (inc). real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8- Q Non-profit
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.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I I.L] Health Care
4.n We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurareq.J 12.0 Other
nce
*Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information. .
**If the corporate officershave exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ain an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic.
Expiration
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, under the pains andpenalties ofperjury that the information provided above is true and correct
signature:
{{�^1Date: (t' �� • V
phnna#• 'l'�Q •�J"l. "I�QQ
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
www.mass.gov(dia
Phone
CERTIFICATE OF LIABILITY INSURANCE
1...�-'1
DATE(MMMD/YYYYJ
03/3112019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pottcy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CO ACT
NAME:
Massachusetts Catholic Self Insurance Group
66 Brooks Drive
PHONE , 617-746.5742 uc Not! 61 7-779-4572
ADDRESS; losscontrol@masscatholic,org
INSURERSAFFORDINGCOVERAGE NAICO
INSURERA: Massachusetts Catholic Self Insurance Group
Braintree MA 02164
INSURED
_
INSURERS:
INSURERC:
Diocese of Fall River, MA
INSURER D
Office of The Chancery
INSURER E:
450 Highland Avenue
INSURER F:
Fall River MA 02722
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS
LIRTYPE
OF INSURANCE
A
RPOLICYEFP
POLICY NUMBER
MIOC,
LIC EXP
MMM
LIMITS
COMMERCIALGENERALLIABILITY
CLANS -MADE ❑ OCCUR
EACH OCCURRENCE $
DAMAGPREMISES EaEocounenco 3
MED EXP (My one Person)S
PERSONAL S ADV INJURY S_
GENL AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JEo- LOC
OTHER:
GENERAL AGGREGATE $
PRODUCTS-COMP/OP AGO S
S
AUTOMOBILE
LIABILITY
ANYAUTO
OWNED 5CHEOULED
HIRAUTOS ONLY AUTOS
AUTOS ONLY AUTOS ONLNON-OWNEY
COMBtlINE INGLE S
Ea acdent
BODILY INJURY (Per person) $
BODILY INJURY (Per aocitlenl) 5
Pe amidenOAMAGE y
$
UMBRELIAUAB
EXCESS LIAR
OCCUR
CLAIMS-MAOE
EACH OCCURRENCE $
AGGREGATE $
DEO I inE(ENIIONS
$
A
WORKERS COMPENSATION
AND EMPLOYERS'LIABaITY YIN
ANYPROPRIETOR/PARTNER/EXECUTIVE O
OFFICERRAEMBEREXCLUDE04
(Mandatory In Hill
If yes, deacdbe under
DESCRIPTION OF OPERATIONS below
NIA
Certificate of Approval
Commonwealth of
Massachusetts
3000001012019
03!31/19
03/31/20
X STA 4/TE ERH
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE -EA EMPLOYEE $ 1,000,000
EL DISEASE -POLICY LIMIT $ 1,000,060
i
7
DESCRIPTION OF OPERATIONS/ LOCATIONS/VEHICLES (ACORD 101, AOdleonal Ramada Schedule, troy be aNechad N more space is required)
Re:046-0 / 046-3 St Mary's Padsh & School 330 Pratt Street Mansfield, MA 02048
Evidence of Workers Compensation Insurance
Town of Mansfield, MA
6 Park Row
Mansfield, MA 02048
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Mansfield Board of
"kequestfor for Food
Date (0.94,b .t°1
We, °�" sC( 0° (restaurant/ organization )
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization.
Please list the organization:
We are not charging a fee for food/drink being served.
We are a religious organization,
❑ Other:
Thank you,
Signature, p
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date:
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