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Home My WebLink AboutMansfield School Lunch Qualters Middle - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 'YV\A' .S �o lc� �)1 i@ ��►—� r , � Establishment Address Establishment Mailing Address (if different) _ Establishment Telephone No ejp�. a\,�.-l�3ci X a1J 10� Applicant Name & Title:'b %N,"vv" Applicant Address a0j0 E . , (`t`yMS ala YVW Off` % Applicant Telephone No.: j;0%, @4k. A A024 Hour Emergency No.: r:j& Applicant Email 4_.-I k vv, C� 6 .�. Owner Name &Title (If different from applic t) M LL� S��t _64 `� Owner Address a Qo r �+ tf JvJ �°�^ ` v. kcs Owner telephone number f�p�, a�a� -IrjOO 1 Owner email: /AW�� ,� rw W".N, S `a S �e \S , Gn Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ® An Association partner. IN A Corporation Name Title Address ® An Individual ❑O A Partnership Other legal Entity Person Directly Responsible For Dail Operations (owner, person in charge, supervisor, manager etc.) Name &Title:�jrtM1 �ae� �cHvvt� yg� Address:ay0 Ck�.11S1.,V Telephone No: a Lot (�3p x��lo$ 24HourEmergencyNo: .dj��, —� FAX:1 5rR•2�\1�1�t3 E-mail: \or�nco Alt E -Mail: District Or Regional Supervisor (if applicable) Name& Title:`\Lrr,� Yv\, Address: o1rJ O € �� . � C� Telephone No: 13046 , � 24 Hour Emergency No: IES FAX:ID0 . a E-mail:G.r-- Food Establishment Information WATER SOURCE: 1 u v_� SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) N0. of Food Employees: S DAYS/HOURS: VVk — tp'. l'S- -t Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Certified in Allergen Awareness Training Charge cr s� l -A r vv� %R "_ n Name of pest control company routinely inspecting the premises for evidence of pestsL 15� tit If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being preparei::17-1014es Does this establishment require a FOG permit? q L5 If yes, please attach the FOG permit application. S` Length of Permit: Establishment Type: Annual IN Retail Food $125.00 Mobile Food Concession ® Temporary ® Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ® Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Q Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 ®Pushcart $50.00 # of Pushcarts: Temporary Time: ® Supermarkets $400 ®Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 ®Caterer $35.00 Food Operations: Definifions:PHF - Potentially hazardous food (timeltemperature controls required) (Check all that apply): Non-PHF's-non-potenh'ally hazardous tood(no fima4emperature controls required) RTE -ready-to-eaf foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Nan-PHFs'�X PHFCooked To Order 'M Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service ® Delivery of Packaged PHFs Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly Susceptible Population Facility IN Sale of Raw Animal Foods Intended `CJ Reheating of Commercially to be Prepared by Consumer ® Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand 'fd Customer Self -Service Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ® Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale 0 Offers Raw Or Undercooked Food Of ❑® Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ® Vacuum Packaging /Cook Chill ❑® Offers RTE PHF in Bulk Quantities � Prepares Food/Single Meals for ® Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 colas of 105 CMR 590.000 and Ithe federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties and paid state taxes required under law. Social Security Number or Federal to: � Y �o3l a'Dq Signature of Individual or Corporate Name: _ F�^..w�`7 that I, to my best knowledge and belief, have filed all state lax returns 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 Individual o Corporate Name oq�p — 00 I . "Social Security No. (Voluntan)) or Federal Identification Number By: Corporate Officer (Mandator4Aplicable) *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. CAUsers\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Mansfield Board of Health Request for Fee Waiver for Food Permit Date We (�cA1 (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: ScA-01A ��o. • - ❑ 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, Signaat^ure 1 C o0c) Title *Please provide proof of valid 501(c)(3) status BOH Use Only — Approved Denied Reason: Signature: Date: Mansfield Food Service List of Staff ServSafe Certified School Year 2019-2020 Dawn M. Langtry—Food Service Director Mansfield High School Carol D'Ambra — Food Service Manager Krissy Schleicher - Senior Cook Deb Harney Deb Cosgrove Bethany Macintosh Qualters Middle School Brenda Cormier— Food Service Manager Anne Murphy—Senior Cook Geraldine Curtin Jordan Jackson Carol Otto — Interim Food Service Manager Thea Pesce —Senior Cook Charlotte Bliss AmyJohnson Robinson Barbara Palie — Food Service Manager Marcie Jones - Senior Cook Liz Lynch Patricia McLoughlin O a� o �N s y,�0-1 m t4 s o av N fD Q Cr N m T rn n CL 3 m N D o eat 'T rDa o m Z3 ii Z p 3 N 3 O o '0 S h Q d rNr r N°' " on cx f D N O m o N r+ 01 �CD� n N Ln, �, _ r+ o a rD Q (D rt QrD =�'Q L — r+ o n ( (D m MC. r1 N N rt a (D fD ofD [7 r v a =$ (DCL D rDD ti m e =; v nD' N r+ Ln rD (D"Q O � C N rt O m m m N D n rt Z iL A " n o e e R'17.