Loading...
HomeMy WebLinkAboutMansfield Youth Football & Cheer - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. MANSFIELD YOUTH FOOTBALL AND CHEER Whose place of business is: MANSFIELD YOUTH FOOTBALL AND CHEER 250 EAST STREET PERSON(S) IN CHARGE: GLENDA SMITH, CONCESSIONS MANAGER Permit Expires: December 31, 2019 Food Fee. License Number: FS -56 WAIVED BOARD OF HEALTH MichaeCHeatey, Chairman - _- 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) Establishment Name: Mansfield Youth Football and Cheer Establishment Address: 250 East street Establishment Mailing Address (if different): PO Box 92 Mansfield, MA 02048 Establishment Telephone No: 781-389-9259 77 5FLI "' C i? v 15 2093 Applicant Name & Title: Scott smith, President Applicant Add reSS: 7 Martha's Way Mansfield, MA 02048 Applicant Telephone No.: 781-389-9259 24 Hour Emergency No.: 781-389-9259 Applicant Email: glenda.smith@comcast.net Owner Name & Title (if different from applicant): Mansfield Youth Football and Cheer Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. 64 A Corporation Name Title Address El An Individual ---- O A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Glenda Smith, Concessions Manager Address: 7 Martha's Way Mansfield, MA 02048 Telephone No: 781-389-9259 24 Hour Emergency No: 781-389-9259 FAX: E-mail: glenda.smith@comcast.net Alt E -Mail: MansfieldYouthFootballandCheer@gmail.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town __:TSEWAGE DISPOSAL: Septic DEP Public Water Supply No: (If applicable) No. of Food Employees: 6-6 DAYS/HOURS: Sat & Sun 7am-9pm Name of Person In Charge Certified in Food Protection Management: Glenda smith If more than 3 individuals are certified, complete list is on file. Person Trained in AntiChoking Procedures (If 25 Seats or more): Location: Q Permanent Location Establishment Type: ❑ Caterer $35.00 Mobile Mobile Start Date: ❑ Retail -NO FOOD PREP ( Sq. Ft) $125 V Milk & Cream $10.00 Moblie End Date: ❑�!. Food Service up to 100 seats ❑Mobile Food Consession Mobile Comments: INCLUDING FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 ❑ Manufacture Frozen Desserts/Ice Cream Length Of Permit: Food Service for 101 -200 seats $250.00 $25.00/1reezer ❑ Annual ❑ Food Service for 207+ seats $300.00 E] Pushcart $50.00 # of Pushcarts: E3 Residential Kitchen $100.00 ❑ Seasonal Seasonal Dates: El Supermarkets $400 E] Tobacco Products $150.00 ❑ Retail Snack Food $50.00 ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions:PHF- Potentially hazardous food(timaAamperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs lV PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs E]Preparation of PHFs For Hot And Cold Holding For Single Meal Service E]PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs — ------ ----- ------- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Susceptible Population Facility Reheating of Commercially ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours _..__.. _....___.....___ ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non- -------------- ❑ Customer Self Service Perishable Foods Only _ contact alternative, time as a public health Ice Manufactured and Packaged for ❑ g ❑ Preparation of Non-PHFs Retail Sale control) - _ ❑ Offers Raw Or Undercooked Food Of Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Animal Origin ❑ Prepares Food/Single Meals for Offers SITE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date ---------- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ❑ waived 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 9ptain copies of 105 C,�R 590.000 and the federal Food Code. Signature of Applicant: 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. Mansfield Youth Football and Cheer Signature of Individual or Corporate Name 043-227-070 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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 DoeumentsWood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 www.moss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Mansfield Youth Football and cheer Address: Po Box 92 City/State/Zip: Mansfield, MA 02048 Phone #: 781-389-9259 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ® Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑Health Care 4. © We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121-1 Other *Any applicant that checks box NI must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is lite policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: 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 cfr1ify, under the pros and penalties of perjury that the information provided above is true and correct. June 3, 2019 781-389-9259 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone #: & I r-4 R I I 2 ƒ / 1`0 \ ! § £ § 5 \ \ ( )k\\ ± ° B 73� 2 / \ / 2 ƒ / 1`0 \ƒrs�\ \ )k\\ ± )7% f go . zz: ( ��\ }R 2 ƒ / 1`0 \ƒrs�\ \ )k\\ ± )7% f zz: al 2 Mansfield Board of Health Request for Fee Waiver for Food Permit Date July 15, 2019 We, Mansfield Youth Football and Cheer (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: K 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 Concessions Manager Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: