HomeMy WebLinkAboutMansfield School Lunch Jordan/Jackson - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued
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(Application must be submitted at least 30 days before the planned opening date) V
Establishment Name V\S,,\A 5�`
Establishment Address aSS �5} �en^St`R�d �yi o'L�%4%
Establishment Mailing Address (if different) —
Establishment Telephone No SoC6• ;L)4 \ • `7 b -LS x a 1
Applicant Name &Title: 7V4wn \"V\. �p t oo'� SQwue���e �✓
Applicant Address Aso Z,y y �A., VY t mr, t_ VV) A
Applicant Telephone No.: r. -A .a1e1 • � � )C 3� t � 24 Hour Emergency No.:
Applicant Email 6-44h L @ ffi-W4•-kL1aS�K JI uir,
Owner Name & Title (If different from appl cant) j61,� 4\. (A W S��o t k - S Lk
Owner Address a wl "- J , V\rb Wj�lLdl 0)i D -Z %4
Owner telephone number 5c>% . -L 0t 1500
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Owner emailWl�va`noC�1J�i° yy�(1.MST�aL�SCI�.�o�S.WI-
Establishment Owned By:
If a c poration or partnership, give name, title, and home adc
• An Association
partner.
• A Corporation
WO An Individual
Name Title Addres
Lon
AN A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner. person in charge, supervisor, manager etc.)
Name & Title: l_ D_vbI CO}� TAY hoop SCNv,LsL-
Address: Q13S c w4 Sk., rnt✓v S� �t � c� rM o'tby ('
Telephone No: Sp� , a to \ .1 F&aS X y_M'jd124 Hour Emergency No: CJ04� • �`� ,4S1
FAX: Go% a� � •� Vi13 \ (
E-mail: � rye , �� e VVY@.MS�� �cSC��oI`J . La__
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Alt E -Mail: J
District Or Regional Supervisor (if applicable)
Name & Title:�y Wv� ,
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Address: arp0 LLS��.t1AS� f1 �a WA �1C�y�
TelephoneNo:I pCQ,)(b'1J)al24HourEmergencyNo: rJ 0�� "� )Z
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FAX: �0�6
E-mail: 1, \ 1
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Food Establishment Information
WATER SOURCE: ty+ti�
SEWAGE DISPOSAL: ► �"1 _
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS: Ml - C" :
Namen of Person(s) In Charge Certified in Food Protection Management:
NameofIn Charge Certified in Allergen Awareness Training
_Person(s)
l�.pl, ) C)4.
Name of pest control company routinely inspecting the premises for evidence of pests A y" l'QJ C t
If there is seating for 2apeople or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. _PJ Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
N Retail Food $125.00 N Mobile Food Consession
N 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:
® 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 N Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 ®Caterer $35.00
Food Operations: Definitions:PHF-Potentially hazardous food (fimeltemperature controls required)
(Check all that apply): Nan-PHFs-non-potentially hazardous lood(no timeAemperature controls required)
RTE- ready -to -eat loads (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFsPHFCooked To Order] Hol PHF Cooked and Cooled or Hot Held
❑Q Sale of Commercially Pre -Packaged PRFs ® 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
NSale of Raw Animal Foods Intended Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer ® Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours fiW and/or HACCP Plan (including bare hand
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 Retail Sale
p ®Offers Raw Or Undercooked Food Of
of Non-PHFs
® Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
FMI Vacuum Packaging f Cook Chill
❑� Offers RTE PHF in Bulk Quantities '�'* Prepares Food/Single Meals for
N 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 obtakLaQuiies of 105 CMR 500.000 andlthe federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties Yperjuly 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: ► YVW� V �'M- J f OAra
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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 A pli ble)
O 4 to - no 1 a_t)
"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:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date t.1 1-8119
s Iyuti+9�� �- Jc� ao� l
We, �, � (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: _:Sc -o4 b4_4
❑ 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 C
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date:
7G1
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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
Amy Johnson
Robinson
Barbara Palie — Food Service Manager
Marcie Jones - Senior Cook
Liz Lynch
Patricia McLoughlin
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