The URL can be used to link to this page

Home My WebLink AboutMansfield Council on Aging - 12/31/2019j-)" 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 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 Whose place of business is: MANSFIELD COUNCIL ON AGING 255 HOPE STREET PERSON(S) IN CHARGE: JOSEPHINE MADRAZO, ACTING DIRECTOR Permit Expires: December 31, 2019 Food Fee: License Number: FS-45 LOMME BOARD OF HEALTH Milk & Cream MchaeCAeatey, Chairman 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: MOBILE FOOD 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 Whose place of business is: MANSFIELD COUNCIL ON AGING 255 HOPE STREET PERSON(S) IN CHARGE: JOSEPHINE MADRAZO, ACTING DIRECTOR Permit Expires: December31,2019 Food Fee: License Number: MF-1 BOARD OF HEALTH MichaeCNeaCey, Chairman WAIVED Milk & Cream 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 Council on Aging Establishment Address: 255 Hope Street, Mansfield MA 02048 Establishment Mailing Address(if different): Establishment Telephone No.: 508-261-7368 Applicant Name & Title: Josephine Madrazo, Acting Director Applicant Address: -�-766 4vr,1- t owj4- !V , 41,- ciyc q S✓ Applicant Telephone No.: 508-261-7368 24 Hour Emergency No.: 508-261-7368 Applicant E-mail: jmadrazo@mansfieldma.com Owner Name & Title (If different from applicant): Town of Mansfield, 6 Park Row, Mansfield MA 02048 Owner Address: Town of Mansfield, 6 Park Row, Mansfield MA 02048 Owner Telephone No.: 506-261-73 /J Owner E-mail: t�11iaxtwze?Ld~*Uyy)a,,Lbly� Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. Ell A Corporation Name Title Address F1 An Individual _ A Partnership H Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 255 Hope Street Mansfield MA 02048 Address: 255 Hope Street Mansfield MA 02048 Telephone No: 508-261-7368 24 Hour Emergency No: 508-933-4181 FAX: 508-339-4886 E-mail: jmadrazo@mansfieldma.com Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Kevin Dumas, Town Manager Address: 6 Park Row, Mansfield MA Telephone No:508-261-7466 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 3 DAYS/HOURS: Mon. - Fri. 8:00 am - 3:30 pm Name of Person In Charge Certified in Food Protection Management Josephine Madrazo If more than 3 individuals are certified, complete list is on file. Marueen Killgallon Phyllis Butler Kate Allen I� Person Trained in Anti -Choking Procedures (If 25 Seats or more): l Location: �❑Permanent Location Establishment Type 0 Caterer $35.00 L]Moblie Mobile Start Date: [] Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Fill] Food Service up to 100 INCLUDING Q Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit I] Manufacture Frozen Desserts/Ice Cream 0 Food Service up to 101 -200 $250.00 $25.00/freezer ❑I• Annual Food Service up to 201 + $300.00 (] Pushcart $50.00 # of Pushcarts: 0 Residential Kitchen $100.00 -- 0 Seasonal Seasonal Dates: l� Supermarkets $400 El Retail Food $125.00 Retail Snack Food $50.00 0 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: -- Food Operations Definitions: PHF - Potentially hazardous food(time/temperdture controls required) Non-PHFs - non -potentially hazardous food(no thme/temperature controls required) (Check all that apply): RTE-ready-to-eat foods (Ex. sandwiches, salads, mufns which need no further processing) T] Sale of Commercially Pre -Packaged Non-PHFs (] PHFCooked To Order !€i 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 Q Delivery of Packaged PHFs — Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility Q Reheating of Commercially to be Prepared by Consumer 0 Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours E] Customer Self -Service of Non PHF and Non- -- 0 Use of Process Requiring A Variance 0 Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations 1'1 Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _ ❑i Offers RTE PHF in Bulk Quantities repares Food/Single Meals for 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 othe pplIcable law. I have been instructed by the board of health on how to obtain copi5 CMR 59 .0 an a ral Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certi u der 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. Signature of Individual or Corporate Name: Social Security Number or Federal ID: 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. %6h7Y1 0�{1�i�WlS2l� ��/IGtI 6t7 rU Josw�/,ke Oad razo Signatur y Individual or Coro ate Name By: Corporate 0ificer (Mandatory, if Applicable) "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\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization City/State/Zip: cS' Phone #: 6-0F - rZ le ) — 73 6p Are you an employer? Check the appropriate box: Business Type (required): 1. EJ i am a employer with i'D 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 (met. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ 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.] 12.aOther oG 16UY S.a fylCIS (AUniG*Pe,,j *Any applicant that checks box #I 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 ape an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. Expiration 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 certify, under the pains and penalties ofperjury that the information provided above is true and correct i I I 7—qI2-o( 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 Person: Phone #: www.mass.gov/dia Mansfield Board of Health Request for Fee Waiver for Food Permit Date ! `I q I pvvy We, 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: �7 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, Sign ure Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: ct 2 � \ � q 2 \ S > � \ � 7 / \ Imm «?B \ ) § (J ] ) : . b e \� \� ? / � R q } \){ �\\ \ 9b e)a/ /=\4 22 t _ /\7 ; >/j2 ()/0 e/>\ bo ) /\\2 oaG ±§§ / . ; \ $ \ ■ \ / r . � . _- � 0 u E \�� z \ } 4-4 � $ � \ \� 9 < z\ � q o . PA § � ) ) / } Q \� \ § Ica § [ P. \2\ Z Cd *w; / Q:a f/\j 2§au {/3z ( \ / \ §Ao y(\a }\\\ / Cd >1 /9) 2C\ \ / ; \ � � \ % t \ \ � \} 4 «� e / ^~ / � 0 / / q c . ■ \ \ «