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HomeMy WebLinkAboutMansfield School Lunch High School - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issuec_, t7, r:nr)n 9:QTAQ1 IQWKACAIT DCMAIT ADDI 1(`ATInKl (Application must be submitted at least 30 days before the planned opening date) Establishment Name �•. � \\ " `� S Establishment Address VYA 0 "`{y Establishment Mailing Address (if different) — Establishment TelephoneNo5flrc • alp �• �1�{0� x h31y a Applicant Name & Title: tV a^" \J\A • �--�^ r Applicant Address �}rj0 t e.+ S� , nr\.N 3�VVA TL --64 q Applicant Telephone No..C�!A • �'�yC� X b 0 24 Hour Emergency No.: Applicant Email a-r� Owner Name & Title (If different from applicant) '•-V '�'i ' ,C"b r" Owner Address ( , V'�'t_ V p Zpq'V O Owner telephone number O�6 a �p \ . Soo Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or IN An Association partner. O A Corporation Name Title Address [] An Individual O A Partnership Other legal Entity Person Responsible For Daily Operations (owner, person supervisor, manager etc.) _in -charge, --t>'Directly/r�1 Name & Title: LOz t tvYv�a"ort, I � o.s P V V� 0 Ste✓ Address: ado ! Y aask j t '4 A VVO a ?la A ol' Telephone No: -604 . "\ . -T10 �j�jl 5 24 Hour Emergency No: .1(j9jq FAX: Lt) og . a -Lk \ - -1413 I E-mail: C_4. � •�I Ni b rti @ Alt E -Mail: District Or Regional Supervisor (if ap licable) Y)/" Name & Title7-L)a.- �a 017-0 ca Address: 3'S04za-k_ •� "" "^,IC' Telephone No: 430-4 .;N .'1 00 A 33)r'1�i 24 Hour Emergency No: q�ol? 41S' 1 -2— FAX: FAX: 5dc . a W . -1 E-mail: Food Establishment Information WATER SOURCE: JM` SEWAGE DISPOSAL: T_5__ No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: {/k — f — & — 2 Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pestsA If there is seating for 25yeople or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. V Yes Does this establishment require a FOG permit? 25 if yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual ® Retail Food $125.00 [W Mobile Food Consession Q Temporary - ® Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 ® Manufacture Frozen Desserts/Ice Cream Temporary Stan Date: ❑® Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up l0 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: Definitions:PHF - Potentially hazardous food (timeRemperature controls required) (Check all that apply): Non-PHFs- non-potenfially hazardous food(no fimeRempemture controls required) RTE -ready-foeat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of commercially Pre -Packaged Non-PHFs�x PHFCooked To Order 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 ❑11 Delivery of Packaged PHFs Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly Susceptible Population Facility ®Sale of Raw Animal Foods Intended Reheating of Commercially to Prepared Consumer Q Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (Including bare hand customer Self er -Service YJ 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 nE Vacuum Packaging /Cook Chill ® Offers RTE PHF in Bulk Quantities \4 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 aR�plicable law. I have been Instructed by the board of health on how to obtain copi=c nr+ne CAR 590.000 andithe federAl, Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury I and paid slate taxes required under law. 1 1 Social Security Number or Federal ID: Signature of Individual or Corporate Name: I, tollay best knowledge and belief, have filed all state tax 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 or Corporate Name �Dy.Iq.. o o I . -.�.q "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandato if Ap licable) *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\De ktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe Mansfield Board of Health Request for Fee Waiver for Food Permit Date 17-k I ) t— We, sw� nt/ 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: Scrod w� ❑ 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 `Ooo�cx *Please provide proof of valid 501(c)(3) status BOH Use Only — Approved Denied Reason: Signature: Date: LJ r�c • ) til p( \ nom{ /§& 0 otl rD \// g ~_" 2 m /7Ln 7R � � o; n \° � 7 n � \ \ \)k \ r+ a °2 0 / 2 m ��§ 7Ln 0 % ƒ(n I:b2 c /\(rD & @ « D / m m \ ƒ \ E. � r mio § / ( £ ]E R 7 //§ o . 2{= $ A \Qo e m 7 // c 7 \ orD! \ � � 4 !klQ ° UL.», !. ! E ) } 0 . | [ � k { Cd )\§ C6 u4� M /!� } 2 � < @_ � E)\ - icy ) 2\2 U/� $ 4�E / 2tA \\\ ƒ Ln � q$ y -. c.4)p� 2 o § Q - / 2 QJ L-\bN = /\ 2 Q \\ O m I .� ���m \ ƒ\ 7® m �� L \ -Cy \ 2§/ \ V 0 § ` &2 0 m § ®n 45 �\ L � \>_ `§zbJD \ q \§ ° )2 }®U { \§d e aUm 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 June 19, 2019 Dawn Langry Director of Food Services Mansfield Public Schools Mansfield MA 02048 RE: FOG pre-treatment maintenance program Dear Ms. Langtry, Town of Mansfield 6 Park Row, Mansfreg Massachusetts 02048 Health Department Amy Donovan -Palmer, MPH, RS Health Agent Based on my observations during routine grease trap pumping on June 19, 2019, Mansfield School Food Services has been approved to follow an alternative grease trap pumping schedule than the one stated in the Mansfield FOG regulations. All pumping must be done by a professional drain cleaner, licensed plumber or Permitted Offal/Septage Hauler. Regular grease trap pumping must occur at least semi-annually, with no more than five months of school operations between pumping sessions. All pumping records must be sent to the BOH office, noting the percentage of solids and grease that are removed within one week of pumping. If at any point the percent solids removed exceed 20% of the total volume of the grease trap, monthly pumping may be required. Please let me know if I can be of any other assistance. U r_� I-�AW� Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)269-7366 Fax (508)261-7425 Emalladpalmer@manseldma.com Drain Remedy PO Box 674 Stoughton, MA 02072 Bill To (866) 937-2467 Mansfield Public Schools 250 East Street Mansfield, Ma. 02048 Attn: Building & Grounds Terms Due Date P.O. Na Net 30 7/19/2019 Job Site See Description Invoice Date Invoice # 6/19/2019 50937 Technician Technician ATR PJA 's-..c-r� } n2r�3-a c r "c„ 5�13"`3�7`-'.-- `�. f�_i4kea+� irk Boom Sim PM Yearly Preventative Maintenance. Pumped out grease trap and 1,212.00 1,212.00 disposed of grease, also power snaked line leaving high school. Relocated to Middle School and pumped out grease trap and disposed of grease. Relocated to Jordan Jackson School and pumped out grease trap and disposed of grease, also power snaked outgoing line. Relocated to Robinson School and pumped out grease trap and disposed of grease, also power snaked line leaving. t t J f E Total $1,212.00 2 3 2019 Payments/Credits $0.00 ��JUL Balance Due $1,212.00