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HomeMy WebLinkAboutMansfield School Lunches - 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:, TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL 250 EAST STREET PERSON(S) IN CHARGE: CAROL D'AMBRA, FOOD SERVICE MANAGER Permit Expires: December 31, 2019 Food Fee: License Number: FS -50 BOARD OF HEALTH MichaeCHeaCey, Chairman WAIVED Milk & Cream FOR BOARD OF HEALTH USE ONLY Ennn ECTAQl re6.lnnGI0T Pr=KNIT APPI I(-.ATIO (Application must be submitted at least 30 days before the planned oM"g date) 1) Establishment Name ' Y l9,/1h S•�� b� ��o' � �� � -_ _—��. _ 2) Establishment Address�O � �} , ��S•��' � � o 21`� 14� —� 3) Establishment Mailing Address (if different) 4) Establishment Telephone No v::,0A6 • o -w 1k'2- 5) Applicant Name & Title: 6) Applicant Address acSc> rj}• y 6&- 7) Applicant Telephone No.: 24 Hour Emergency No.: �� 33� • 3a� ) 8) Owners Name & TitleatiS��oonn� 9) Owner Address (If different from applicant) a -�1'c,,�..1L 1 �_*-s. ',a.lcy ✓� O 9-o 14 $ Owner's telephone number 50 6 • 94I_- 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association A Corporation or partner. Name Title Address An Individual ------ ----- — ____--- ------.___-__ A Partnership -- ------ OtherJegal Entity ---..__...---. 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: i �,ra\ �� �,y )b rte { oo a c�rn„i�. Yv)vv-•. I Address: �(� 4�� S� .� inn g �e 1 8 VM 0 2-0 4 Cd _ 24 Hour Emergency No: Telephone No: cjs% • ab l - X �3 l `� S ' 1 FAX: 2)4 `P 13 I 1 i E-mail: Cb-Wl .�' �\,,"1 M � VV\ Alt E -Mail: 13) District Or Regional Supervisor (if applicable) — Name & Title: Address: a50 � i¢ �d 1 v UA Telephone No: r, a$ , 24 Hour Emergency No: st3l - - 7Cj1 ail: FAX: - 1�� • ave dui 1 3 E-mal�'- � . T @ wiAAnst �l� sc�vool9 Food Establishment Information 14) WATER SOURCE: ,�� 15) SEWAGE DISPOSAL _.__.. DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 1'�A— r j.7jf) 1:�)D 18) Name of Person In Charge Certified in Food Protection Management: Cp,,�i If more than 3 individuals are certified, complete list is on file.` 1 Required as of 1011/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate-- j 19)Person Trained In Antl-Choking Procedures (If 25 Seals or more): -� ------------ 20) Location: `f�. Permanent Location 22) Establishment Type Mobile Mobile Start Date: Mobile End Dale: Mobile Comments: 21) Length of Permit: Annual [ J Seasonal i Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: ❑ Retail ( Sq, Ft) Q Food Service up to 100 or up to 1(Y PHF display $125.00 (] Food Service up to 101 -200 or up to 25' PHF display $150.00 10 Food Service up to 201 + or 25'+ PHF display $275.00 b Food Service - Institution ( '3qp Meals/Day) U Caterer $25.00 �] Milk & Cream $10.00 Q Mobile Food & Consesslon $75.00 n Manufacture Frozen Desserts)ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: F-1 Residential Kitchen $100.00 0 Retail Food $100.00 Retail Snack Food $25.00 P Tobacco Products $25.00 Rain Date: 23 Foad Oerations Definf ions: PHF-Potentially hazardous food (lime/femperaturs controls required) P Nan-PHF's - non -potentially hazardous rood(no timaRemperature controls required) '(Check all that apply): RTE- ready -lo -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ! Sale of Commercially Pre -Packaged PHFs J` -I Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours eI Customer Self -Service of Non PHF and Non- Perishable Foods Only Preparation of Non-PHFs Other Food Operations PHFCooked To Order 'reparation of PHFs For Hol And ;old Holding For Single Meal Service Tale of Raw Animal Foods Intended to be Prepared by Consumer ier Self -Service nufactured and Sale (g Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Hlghlt Susceptible Population Facility n Vacuum Packaging i Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health (_ Juice Manufactured and Packaged for I [j Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ------------ ---� — --_-- Prepares Food/Single Meals for Offers RTE PHF In Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Ouf-Of-Date _ of Reconditioned Food To be completed by the Board of Health -- I Total Permit Fee: Payment is due with application 0 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 obtain copies of 105 CMR 590,000 and thefederal Food Code. 24) Signature of Applicant: — /� - ' N • r Pursuant to MGL Ch.62C, sec. 49A. I certify under the penalties of Al and paid state taxes required under law. ®' I 25) Social Security Number or Federal ID: 'Y \ T"� 26) Signature of Individual or Corporate Name: that --D- I, to my 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. l 6w�n 51, vin�.>r,s-i •� �,� 3 Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal identification Number By: Corporate Off cer (Man tory, '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. R:\Iin th\J ne's Docomeuts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc 4 • Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON 255 EAST STREET PERSON(S) IN CHARGE: DIANE PENNELLATORE, FOOD SERVICE MANAGER Permit Expires: December 31, 2019 Food Fee: License Number: FS -52 WAIVED BOARD OF HEALTH Milk & Cream MichaeCHeaCey, Chairman I FOR BOARD OF HEALTH USE ONLY Permit # Iss � DEC 0 6 Ealy FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name�- 2) Establishment Address ' V`AA O !)—A 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 'S ` 1 S aS y (4,41 6) Applicant Name & Titl . y 6) Applicant Address aS� a�St L p 7) Applicant Telephone No.: 24 Hour Emergency No.: 3 3�, 3�7 0 C 0-0 X3blay 8) Owners Name & Title 9) Owner Address (If different from applicant) a ,k. (2,w Y -Y ,M , kj, yyA aa, t Owner's telephone number t -D cxc, 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers 1 An Association or partner. A Corporation Name Title Address An Individual A Partnership Other-leglEntity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Lan c j�12�1 g�a re I ooh 1A^ r ct v, ; Address: Telephone No: 441 4 Hour Emergency No: 58i . 3 S 9 3 S 1 O FAX: r� ��d �Xn • rl`i �"� _ E-mail: il� Alt E -Mail: I 13) District Or Regional Supervisor (if applicable) Name & Title I� � kA I c t I—t"'µ "soap Address: Telephone No: ir:>b% . Zia ! .77,AQ, YESi 24 Hour Emergency No: CD -0,6 t, FAX' 506' ��s�' 7�\ E-mail: �w, 1 v.S .� �Qn�S. Yak � ^� e - �_l� ems__. 14) WATER SOURCE: Food Establishment Information 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) I 16) No, of Food Employees: I 17) DAYS/HOURS: Wt 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as o/ 10/1/2001 In accordance q1th 105 CMR 590.003(A) Please attach copy f certificate 19) Person Trained In Anti -Choking Procedures (If 26 Seats or mere): 20) Location: Permanent Location 22) Establishment Type Mobile Mobile Start Date: E] Retail ( Sq. Ft) Mobile End Data: [_1 Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: [] Food Service up to 101 -200 11,4, Annual or up to 25' PHF display $150.00 _[JSeasonal Food Service up to 201 + or 25'+ PHF display $275.00 I Seasonal Dates; j '1_1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Service - Institution ( L/2'< Meals/Day) Caterer $25.00 Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Lj Pushcart $25.00 # of Pushcarts: D Residential Kitchen $100.00 0 Retail Food $100.00 I] Retail Snack Food $25.00 Tobacco Products $25.00 23) Food Operations Delinidons:PHF - Potentially hazardous food((lme/lemperature controls required) Non-PHFs - non -potentially hazardous loodtno tlmaltemperature controls required) '.(Check all that apply): - RTE - ready-to-eal foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) "F�Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs IJ Delivery of Packaged PHFs Processed Foods for Service Within 4 Hours Perishable Foods Only j Preparation of Non-PHFs Other Food Operations PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Hol PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health 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 obtaio_coales of 105 CMR 590,000 and the federal Food Code. 24) Signature of 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. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: 1 'N'�j U y �0iM9�4-� c� l�C•h*eot �_ Retail Sale control)______ Juice Manufactured and Packaged for Retail Sale L� Offers RTE PHF In Bulk Quantities Offers Raw Or Undercooked Food Of Animal Origin 41 Prepares Food/Single Meals for Catered Events or Institutional Food Service Lj Retail Sale of Salvage, Out -Of -Date or Reconditioned Food --- _ Po be completed by the Board of Health Total Permit Fee: Payment Is due with application 0 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 obtaio_coales of 105 CMR 590,000 and the federal Food Code. 24) Signature of 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. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: 1 'N'�j U y �0iM9�4-� c� l�C•h*eot �_ 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 o alP- oot . 2a q "Social Security No. (Muntary) or Federal Identification Number By: Corporate Officer (Man tory, 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. R:\HnIthVa .'s DocummtsVERMIT APPLICATIOWTAX CERTIFICATION FORM.doo Mansfield Board of Health Request for Fee Waiver for Food Permit Date t ti % ) 18 i'1n,� �� iJ ao1 , 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: `jc.V.o-1 ❑ 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 e n Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: 0 0 Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ QUALTERS MIDDLE SCHOOL 240 EAST STREET PERSON(S) IN CHARGE: BRENDA CORMIER, FOOD SERVICE MANAGER Permit Expires: December 31, 2019 Food Fee: License Number: FS -53 WAIVED BOARD OF HEALTH Milk & Cream MichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY Permit# I FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned �c 1) Establishment Name 2) Establishment Address sAi I A 3) Establishment Mailing Address (if different) i 4) Establishment Telephone No tl�,O% 5) Applicant Name & Title; �V\A `1S3o ka'�lo�b 0 3-o k4 1� 6) Applicant Address ago �� S}• {�/��, �� �e l� Yy�/j QEj o qQ ---.._. 7) Applicant Telephone No.: 24 Hour Emergency No.: r,O civ.\• '1`10o x SblD-4So% 33a llut 8) Owners Name & Title e f,ti 9) Owner Address (If different from applicant) %L la " o 9-0 L4 1� Owner's telephone number 50C� • Zap t • 150(3 1 D) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers .-i An Association or partner. A Corporation Name Title Address An Individual— A Partnership OtherleegaL-Eirltity - - - ----- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: `j,Yvv��y y oen r c� Yy/\ . Address; Telephone No: 5 a�oi 1530 X2�1�24 Hour Emergency No: GJ(DC6 FAX: _1�+) E-mail: Cvv-v" v @ . _ ____-...._..--------- Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: gso n/VA O2-©`4$ 24 Hour Emergency No: Spy. T, (I • y S l 961�_ E-mail: 1��ol 14) WATER SOURCE: �h Food Establishment Information 15) SEWAGE DISPOSAL: 1* DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: wA — I w'• 15 — t :30 1 S) Name of Person In Charge Certified In Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 1011/2001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate -- i 19) Person Trained In Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location 22) Establishment Type Mobile Mobile Start Date: �[] Retail ( Sq. Ft) Mobile End Date: 1 Mobile Comments: 21) Length of Permit: ;y Annual seasonal Seasonal Dates: ] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 71 Food Service up to 100 or up to 10' PHF display $125.00 [ Food Service up to 101 -200 or up to 25' PHF display $150.00 '[I Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution ( 3 orr3 MealslDay) Caterer $25.00 Milk & Cream $10.00 Mobile Food & Consession $75.00 [) Manufacture Frozen Desserts/ice Cream $25.00/freezer Pushcart $25.00 If of Pushcarts: [� Residential Kitchen $100.00 Q Retail Food $100.00 N Retail Snack Food $25.00 I] Tobacco Products $25.00 Food Operations 0eunitlons: PHF- Potentially hazardous food (tirneRempe(ature controls required) 23 p Non-PHFs - non -potentially hazardous roodfno tlmeBemperature controls required) '(Check all that apply): I RTE - ready -to -oaf foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs [i Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours I Customer Self -Service of Non PHF and Non - Perishable Foods Only I Preparation of Non-PHFs Other Food Operations PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer S Ice Manufactured and Packaged for Retail Sale (g Hot PHF Cooked and Cooled or Hol Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility vacuum Packaolno / Cook Chill I Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health F] Juice Manufactured and Packaged for l Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ------------'---- -- - Prepares Food/Single Meals for Ofiers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Dale — or Reconditioned Food — I To be completed by the Board of Health Total Permit Fee: Payment is due with application I__j 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 obtain copies of 105 CMR 590,000 and thqifederal Food Code, 24) Signature of Applicant: ' ' N Pursuant to MGL C11.62C, sec. 49A, 1 certify under the penalties of p u that I, to my best knowledge and belief, have filed all stale tax returns and paid state taxes required under law. 6q 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: 7"M1-10 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 o�-c�oi • `Zclq "Social Security No. (Voluntary) or Federal Identification Number $y; Corporate Off cer (Man tory, Applicable) *This license will not be issued unless this certification clause is signed by the applicant, ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. R:\Health\Jme's Docu cnts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc Mansfield Board of Health Request for Fee Waiver for Food Permit Date i ti %) 1$ We, I a ......_.... rant/ 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: ':SC"4 r ❑ 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, Signnature Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: 11 0 Commonwealth 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 ESTABLISLHMENT 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ ROBINSON SCHOOL 245 EAST STREET PERSON(S) IN CHARGE: BARBARA PALIE, FOOD SERVICE MANAGER Permit Expires: December31,2019 Food Fee: License Number: FS -51 WAIVED BOARD OF HEALTH Milk & Cream AichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY Permit #lssd :L ------ FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned 1) Establishment Name 2) Establishment Address QA< VVA 3) Establishment Mailing Address (if different) .. ..... — --------- --- ----- 4) Establishment Telephone No 50% - ;L\p 6) Applicant Name & Title: --------------- 6) Applicant Address QLc5c, yv\%mrTold Yv� Oa o qj ... . .. .. . ..... . 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title o r.r W\ W. S 9) Owner Address (If different from applicant) D, -Q&, L P/ -A 0 9-0 Lt % Owner's telephone number 6 oc6 - t-4 1 --1 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual A Partnership �;O1h_QrJ_egw1Entity Name & Title: i Address:CLro Vf-� s.V',6 W`iA Telephone No: hcf% K_G-jbjj 24 Hour Emergency No., FAX: E-mail: vv, Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: i rv\ 9so MA 24 Hour Emergency No: Sod' E-mail: G 5 33 14) WATER SOURCE: r>, DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: vim_ r — x'.'60 18) Name of Person In Charge Certified In Food Protection Management: If more than 3 individuals are certified, complete list Is on file. 1 Required as of 10/1/2001 in accordance with 105 CMR 590.003(1 Please attach copy of i certificate Food Establishment Information 15) SEWAGE DISPOSAL: 16) No. of Food Employees: 119) Person Trained In Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location ii Moble Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: y Annual seasonal Seasonal Dates: j i__I Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Delinitfons: PHF- Polentially hazardous food plma4emperature controls required) Non-PHFs - non -potentially hazardous leonine limeRemperature controls required) '(Check all that apply): RTE - ready -lo -eat foods (Ex, sandwiches, salads, muffin which need no further processing) 22) Establishment Type IJ Retail ( Sq. Ft) I] Food Service up to 100 or up to 10' PHF display $125.00 (] Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution Meals/Day) U Caterer $25.00 [�] Milk & Cream $10.00 E] Mobile Food & Consession $75.00 n Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: L1 Residential Kitchen $100.00 Q Retail Food $100.00 M Retail Snack Food $25.00 Q Tobacco Products $25.00 I&I Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs { Reheating of Commercially Processed Foods for Service Within 4 Hours I Customer Self -Service of Non PHF and Non - Perishable Foods Only _I Preparation of Non-PHFs Other Food Operations PHFCooked To Order 'reparation of PHFs For Hot And 'old Holding For Single Meal Service Tale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Retail Sale 'g Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Hight) Susceptible Population Facility I n Vacuum Packaging / Cook Chill I [] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand for contact alternative, time as a public health LI Juice Manufactured and Packaged Retail Sale F1 Offers RTE PHF In Bulk Quantities L Retail Sale of Salvage, Out -Of -Dat or Reconditioned Food Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health I 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 obtain copies of 105 CMR 590,000 and thq federal Food Code, 24) Signature of Applicant: 4 J . r \ • Pursuant to MGL Ch.62C, sec, 49A, I certify under the penalties of I d d I that I, to my best knowledge and belief, have filed all stale tax returns and paid stale taxes requ re on er aw. ((�� s� 25) Social Security Number or Federal ID: \ r � I I 26) Signature of Individual or Corporate Name:e: 7V_,,1) � Id b L--�\13- 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. L 6L VA w s h o 5LL�.k i4. Signature of Individual or Corporate Name **Social Security No. (Voluntary) or Federal Identification Number �tV1• By: Corporate Officer (Man tory, 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. R:\HmWiVa e's Docu eats\PEPMIT APPLICATIONSWAX CERTIFICATION FORM.doc 11 • Mansfield Board of Health Request for Fee Waiver for Food Permit Date 12 % ) 18 _ YYtg� �/ 1 t We, t 6'""^ 6-b� � � ! (restaurant/ 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:t . ❑ 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 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 2018-2019 Dawn M. Langtry — Food Service Director Mansfield High School Carol D'Ambra — Food Service Manager Krissy Schleicher - Senior Cook Deb Harney Carol Otto Deb Cosgrove Bethany Macintosh Qualters Middle School Brenda Cormier— Food Service Manager Anne Murphy—Senior Cook Charlotte Bliss Geraldine Curtin Jordan Jackson Diane Pennellatore — Food Service Manager Thea Pesce —Senior Cook Robin Nunes AmyJohnson Mary Peirce Mary Rogers -Zion Robinson Barbara Palle — Food Service Manager Marcie Jones - Senior Cook Liz Lynch Patricia McLoughlin Mansfield Food Service List of Staff Allergen Training 10/5/2018 Dawn M. Langtry — Food Service Director Mansfield High School Carol D'Ambra — Food Service Manager Deb Harney Carol Otto Krissy Schleicher - Senior Cook Deb Cosgrove Qualters Middle School Brenda Cormier — Food Service Manager Anne Murphy—Senior Cook Geraldine Curtin Jordan Jackson Diane Pennellatore — Food Service Manager Thea Pesce — Senior Cook Robin Nunes Robinson Barbara Palie — Food Service Manager Marcie Jones- Senior Cook Patricia McLoughlin Mansfield Board of Health Request for Fee Waiver for Food Permit Date 0- % I i g We, 61 �'�-S et ; 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: ❑ 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. 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