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HomeMy WebLinkAboutOur Daily Bread Food Pantry - 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:. CONGREGATIONAL CHURCH Whose place of business is: OUR DAILY BREAD - MANSFIELD'S COMMUNITY FOOD PANTRY 15 WEST STREET PERSON(S) IN CHARGE: RICHARD KELSAY, DISTRIBUTION COORDINATOR Permit Expires: December 31, 2019 Food Fee: License Number: FS -62 BOARD OF HEALTH MichaeCHeatey, Chairman WAIVED Milk & Cream I EIVE FOR BOARD OF HEALTH USE ONLY Perm sued QCT 2 4 2018 FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at I©asf' 30 days before the planner}ening dale) Establishment Name: "'.. ,FOL,tCA. Establishment Address. T Establishment Mailing, Address(if different): Establishment Telephone No.: t>� Applicant Name & Title: `-,c- Applicant Address: -ApplicantAddress: tVvu •e.-'a`"�. 'moi', v , 1`e"�c•._. ate,- < i`�1P-`�C:;`'S} Applicant Telephone No.: `°{ % - �} .` r 24 Hour Emergency No.: Applicant E mail: l: �—:s-iliC.,+ �? L..�iCY\�."yS�.-•�`'� "' Y � `6e.4� c i Owner Name & Title (If different from applicant):Czc Owner Address: Owner Telephone No.: sic,,2 ,3.3`7 ``'E' f!1 Owner E-mail Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or FI An Association partner. F1 A Corporation'.. Name Title Address 71 An Individual 1 A Partnership _ M" ther legal Entity Person Directly Responsible For Daily (Operations (owner}., person in charge, supervisor, manager etc.) Name & Title: t,\ Address: Telephone No 05 24 P /our Emergency No: FAX: t E-mail: �4s� e. t I.t,`,.. '.. Alt E -Mail: District Or Regional Supervisor (if atyp(�plicable) Name & Title: Address: ;.��.t r '., Telephone No: so" . �J w��9 �-."'S�' l 24 Hour Emergency No: PAX: E-mail: Food Establishment Information WATT t: SOU{:(;[ —� f l`"'1 SI VVAGI Dh8,I'0f,'AI DEP Public Water Supply No (If applicable) I No. of Food Employees'. 1�* vy.-��� DAYS/I rOUf„S. r 3V Name of Person In Charge Certified in Food Protection Management 11 Illoil, Than 3 inrllvulnals arc "til r,ontlrlete li r it oil file. Person fromcd in At Choking Pro kidwes (if 25 Scots or moi c): I:] 'N, I i_ocakon. ❑ 1'cnnancut Location I sial pinshmr nl Typo Mnbke sonic Date: ❑ Re ani ( Scl Ft) j nVlobinc Fsd Dote: kid Service up to 100 INCLUDING nVlobfie Comments, FOOD PRI K i 5175 00 t cluj it of P(ifntit L Aniwal ❑ f' -..-.. ,ca.,onal Seasonal Dates: ❑ Temporary Temporary Staii Date: -fomporary Full Dace: T nifoofary Troo: i„un IJate: Food Operations Ochntlione PI -Il Non -1 (Check all that apply): i a* RTE Sale of Commercially Pie -Packaged Idon-Pi-IFs ❑ Solo of C omrnuei rlll ['to Packaged I'l if ❑ Dolivc ry of F act ogod f I IF:, ❑ Rohesimg or Commercially - Poicoilstid Foods of solvice Nhihrn't I foul„ ❑ C.usforncr c II crvii,c of Non R IF and Non - I csish.,bir I nods Only Ll Preparation or Non Pt F -s.. ----. Other Food Opefafions ❑ Food Seprice up to 10'1 -200 $25o.o0 I ] Food Service, up to 20'1 + $300 00 ❑ Supennarkeis ,n4o0 t I Calc rery r, 00 [d'M i I Ii lf,< in am 010 o ❑ Monte I nod Consc ssion NO PI II PPUP.41.i D ON SITE 5100.00 ❑ M inufactilic Flo/en Dc redsliceCream $25.00/freezer ❑ Pu hcari $50.00 £1 of Pushcarts: I] Residentiol Kitchen $100.00 ❑ Retail Food tf12fi 00 Retail Snacic 1-ood $60.00 Nr.,. ii. '>w. c7j r'olenGrlly harnrrlous (ood(Iunc/temperature conhols rcyulmd) IF's- non-polen0ally hazardous foodrno flme/fempe2ture controls mqulmtlJ eady-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Pf FCooked Fo Order r LJ Plot PIII Cooked and Cooled or I lot I Ield [] Preparation of in 11 S I orI lot And Io' Ionic I ban a Single Moat Service Cold I Iolarnc For Single Mc il ;'c ivee ❑ PI IF and RI F Foods I rcpared For Highly ❑ ,ate of I aw;Wrloal oodkl Inik n l Sus epbble I opul abon Facility ility to be Prepared p ared by Consumer � ❑ Vacuum Podlogino / Coe'< Chill El Customu .;elf Service ❑ Use ur f rocs s Regnnng di1�ananeo j bole ❑ Ice Mnnufar.Pnred and "ncknged fir r council akr rlaiivc time lass arpublic hcallh Retmi Talo corbel I ❑ Joinki Manufactured and Packaged for �❑ Offers Raw Or Undercooked Food Of ❑ Orders RTF PI -IF it, Ruth Ounutificc ❑ Prepares hood/Single Meals for Or ❑or Rei onrhtioned Food To im rri pliisi Its n tutioo:t k ood Scrnrice Relhil ilc of .-valvar e Out Of -D at< — - r 1 otal 1 cumt t ee: Payment r one write appkcabon ❑ waived I, the undkir8lgnod, attest to the accuracy of the information provided in this application and artful flur the food - c inbirsnumni oporation will c oulply " nth 105 CMR ,90 000 and II other applir able law. I have boon instructed by the board of he olil r on how o of iwncopic of 1 rU CM¢2 590 Opo and rhy focq ,� \I kind Pace, 6rgnnbne of Applic.ani 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 nd paid f rte iter, fegnned under law, Atk Signature of Individual or Corporsie, Name: Social Security Number or Federal ID: TAX (1WFIFICATION FORM I certify underthe penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all stale taxes required under law. i C SignaWICol Inti ivi dun l or Corpora le Name By: Corporate Officer(Mandnlol l/ ilAppi I/ I" ""rSocial Security No. (Voluulnry) or Federal Iden ticoliorr Number *This license will not be issued runless 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 niet 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 Mas 9achusett5 General Law Chapter 62C, section 99A. ( \Us r�AslciidDcsl<iupAScmrc DucunwnieAFood lAX l I1R'II PK'A I ION PMRNrdor 4 lvca gi, OWE; sM us e d f &040-0560 LU 1 am o clilviteycl WiLh _culployccs (lull Mid,/ 01 jimi Klcv)� 2.1 !mut 0 sm, plop, 4qu, 01 Immims1hil) and have no cllploycos "valmig ;01 inc ill any Capacity. [No workers' comp, insurance required] I W a are a sol potation " W i N 0 JA in m h " a a a a sed (kcu right olflacinjilmn pan 151 §1(4),sud Nvlmve o employees. [No workers' comp. insurance required] A. arc P non pi of it ol P'o I ni all t ioll, s! 0 (Ind by Vo "U'"m s, cn i h no clnployrcs, PAO wommy colmi. insurance Mac cm I 6 7 I I Qfhce mKim SoRs (incl - a estate, mdv ac.) HLI j lvianufacay lot' I IT -1 TTCq1t11 Cars I A j cmta, *Any applicant nkat checks box #1 nimt also hum the section below silowing (heir workers' compensation policy infouniniou. "lftllc l otpolot" othms hilvo, exculph"I Hh, olsd,c, bill ill, 10 ....... eloo has othc,c q ryvcs,e "lalm" co ... pul,a;ntlnai polis y la wrl"mcd alcjsm I wo organizntl ion AMU "ka Nm M, Insurance Coninpolly 1\1eme hisimn's Address: (Awsmozy: Policy HorSelf ins. 10, lophydon AMU z yupy G Cue ..el Wens' vaingandma l4ky Vor"No" pnv (NummE aw noovy "ammov n"d arphyffut, 0010. Failure to secure cot iningin as lmwimd undim inion 25A of m 152 can Raid to On imposition orcrimmai penalties ora Ile up to $Ial)100 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to iiJ_50.o0 a day against the violator, t;r advised Inat a copy oh [hi., .,iatehnent may be 1olwardrd to the Otfire oP I do h emmb certify, mile{ Mepahp, ar(dpenaldes, I jedray Mai Me irfj�wwiaiioki jill;—vided aljove is five ajid coreea. -0 City or Town: Permit/License tmukg AW mm NY ( bwk ow): L Bomarl of Health 2. Builiffiag Depm1menit 3. lCky./Tomm Mat 6. Licensing Hoord 5, Seledmen's OHM, 6. Otber Comind persom %""v.mass.gov/dia phone //e Mansfield Board of Health Request for Fee Waiver for Food Permit Date `U \$ 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. * Please list the organization: We are not charging a fee for food/drink being served. We are a religious organization. /❑ Other: Thank you, 0 N\ e Signature Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Date: 01��1 1 kg