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HomeMy WebLinkAboutMansfield School Lunch Robinson - 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) 69fY Establishment Name V\rs,,4jt _U Establishment Address Q415 �u.S� S�•� �nnS{ iLlc+ V\ A -z>4$ Establishment Mailing Address (if different) — Establishment Telephone No 1j0%• a \p 'o l 3 X SI 31 q Applicant Name &Title: _1 WovN VIn. ��nqJ ocL S2wt csL �v Applicant Address ) 50 �G`,� Si •r �MQ+v s tied ►n 1/� O a a 4 Applicant Telephone No.: 5Dc6 • a %i 1 qo 33� a�24 Hour Emergency No.: flC6 , �Ct • l05 33 Applicant Email l_ &n Y) I - j r hrtQA#_ 6 S pal G Owner Name &Title (If different from ppl cant) _n11 6l0 W%%M �L -, 31 tr Owner Address a Pkw\c ( A-.4 %4 Owner telephone number 1;tf6 . a� , II( ( 1 Owner email: Q1Wwvk. 4_ �0 � e YY`tianST i t Last 1100 1 LO Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or IN An Association partner. ❑® A Corporation Name Title Address O An Individual FillA Partnership '* Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: �1 Address: ��5 �0.S} S} , �V�In�Sr�e �i WA o -2- q q Telephone No:I�C>1 ,. �, j5t3 XS131g 24 Hour Emergency No: rJa%,�ryJq FAX: rjDc6 ' O'1�01 •-1 �} l � E-mail: tA�-bcL+-e P0., i� M MnS��e L S,c Loo S Alt E-Mail District Or Regional Supervisor (if applicable)� �;or -I- o,O , Name & Title: }mow . \r),l . L&AN q ' I, , Address: 011;O r F.,� S�,f rr-kA Sv 1' w L " '3 -7-4 q � Telephone No: SflS • a 1p I . ] qOO al 24 Hour Emergency No: FAX: 1 1q 13 E-mail: 1 is ( I Food Establishment Information WATER SOURCE: Lww� SEWAGE DISPOSAL: �y M No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: W\ —f -I V. 3p NameofPerson(s) In Charge Certified in Food Protection Management: 'FSyv-\ Name of Person(s) In Charge Certified in Allergen Awareness Training A f- Lml,Y Name of pest control company routinely inspecting the premises for evidence of pests 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 prepared.-,W Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual W Retail Food $125.00 IN Mobile Food Consession 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: ® $25.00/freezer Food Service up to 101 -200 $250.00 Temporary End Date; Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Q Supermarkets $400 ®Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 ®Caterer $35.00 Food Operations: Definillons: PHF- Potentially hazardous food (time/temperature controls required) (Check all that apply): Non-PHFs -non-potentially hazardous food(no fimedemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑� Sale of Commercially Pre -Packaged PHFs ®Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility ® Sale of Raw Animal Foods Intended Reheating of Commercially � 9 Y 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 'N Customer Self -Service 'W 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 ® 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 copies of 1105 CMR 590 the federal Food Code. � a ' Signature of Applicant: V ` Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties` of and paid state taxes required under law. Social Security Number or Federal ID: ©4--ho2figot 0 0' Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns 1 awl 0Ito �dt s1-% 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 or Corporate Name By: Corporate Officer (Mandatory, if App 'cable ,,�A �. --oo( - 2.)q *"Social Security No. (Voluntary) or Federal fdentification 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:\Users\sleaeTmktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Mansfield Board of Health Request for Fee Waiver for Food Permit Date t l I I We, �- Steel i organization ) request a waiver of the Food Service Permit Fee for the following reason: This is a request from a town department. 1 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, Signaatture Ooo ��w ��ctc3� Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: w q`� � ACE n7R . H«2 /\ /m& 0 rD CL L� § } / \ E \ 0 � R MN r+ 0 / m \ \ 0 ) §\k . � \ / \}/ 2 \ n °k O §{ \ \rD Ln5% �f �'� � { ± D/q k § g ` 2 r+ CL c ~ ® 7 IQL C� § « isr+ & 7 ^ R / k n2® m r A \D m §\7 \ o! rD \ . .... � / . |{\ ° ((E :\P �( 03 � !°¥ ) ( Mansfield Food Service List of Staff ServSafe Certified School Year2019-2020 Dawn M. Langtry —Food Service Director Mansfield High School Carol D'Ambra — Food Service Manager Krissy Schleicher - Senior Cook Deb Harney Deb Cosgrove Bethany Maclntosh 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 Amy Johnson Robinson Barbara Palle — Food Service Manager Marcie Jones - Senior Cook Liz Lynch Patricia McLoughlin O O t7 � o 0 091 N o N rD d Vf � T D O N n -� 3 v Ln s � -I o rD an s �: o o �� 3 o n O lul Q'a raj. n l V Q N ° a. n (D V) 0 v m O s N ti � N r ` r+ v 1-4 (D (D D n o0 0 'S rrD = M Q.. 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