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HomeMy WebLinkAboutMansfield Park & Recreation - 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 Whose place of business is: TOWN OF MANSFIELD PARK RECREATION DEPARTMENT PERSON(S) IN CHARGE: SHERRI GURNON, RECREATION DIRECTOR Permit Expires: December 31, 2019 Food Fee: License Number: FS-79 WAIVED BOARD OF HEALTH MichaeCHeatey, Chairman i FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS91 --- - FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the plann&d opening date) Establishment Name TOWN OF MANSFIELD PARK RECREATION DEPARTMENT Establishment Address 6 PARK ROW Establishment Mailing Address (if different) 6 PARK ROW MANSFIELD, MA 02048 Establishment Telephone No (508) 851-6458 Applicant Name & Title: SHERRI GURNON Applicant Address 6 PARK ROW, MANSFIELD, MA 02048 Applicant Telephone No.: (508) 851-6458 24 Hour Emergency No.: (508) 802-3951 Applicant Email Owner Name & Title (If different from applicant) TOWN OF MANSFIELD Owner Address 6 PARK ROW, MANSFIELD, MA 02048 Owner telephone number Owner email: SGURNON(a)MANSFIELDMA.COM stablishment Owned By: An Association A Corporation An Individual A Partnership Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: SHERRI GURNON, RECREATION DIRECTOR Address: HOPE STREET, MANSFIELD, MA 02048 Telephone No: (508) 851-6458 24 Hour Emergency No: (508) 802-3951 FAX: E-mail: RECREATION@MANSFIELDMA.COM Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: ALAN WEITRAUB, CAMP DIRECTOR Address: 6 PARK ROW, MANSFIELD, MA 02048 Telephone No: (508) 261-7383 24 Hour Emergency No: FAX: (508) 261-7425 G-mail: Food Establishment Information WATER SOURCE: TOWN SEWAGE DISPOSAL: TOWN No. of Food Employees: 5 DEP Public Water Supply No: (If applicable) DAYS/HOURS: MON-FRI 8 AM-4 PM JUNE 15 - AUGUST 24*, 2018 Name of Person In Charge Certified in Food Protection Management: COURTNEY GURNON If more than 3 individuals are certified, complete list is on file. —� Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: Permanent Location Establishment Type: Caterer $35.00 Moblie Moblie Start Date: Retail ( Sq. Ft) Milk & Cream $10.00 Moblie End Date: Food Service up to 100 INCLUDING Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: Annual Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: 0 - — ---- — Seasonal Residential Kitchen $100.00 Seasonal Dates: Supermarkets $400 Retail Food $125.00 Retail Snack Food $50.00 _ Temporary Temporary Start Date: Tobacco Products $150.00 Temporary End Date: i emporary time: Rain Date: Food Operations: I(Check all that apply): Definitions: PHF - Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat roods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer - Reheating of Commercially Processed Foods for Service Within 4 Hours - Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health confrop Customer Self -Service of Non PHF and Non- Perishable Foods Only Customer Self -Service Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations NO PHFS Juice Manufactured and Packaged for Retail Sale I Offers RTE PHF in Bulk Quantities I Retail Sale of Salvage, 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 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 the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I c 1 and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 04-6001209 ST-2 MAS ACHUSETTS DEPARTMENT OF REVENUE CERTIFICATE OF EXEMP.TION Cortificatlon Is hereby made that the organization herein named Is an exempt purchaser under General Lawd, Chapter 64H, Sections B(d) and (4 All purchases of tangible personal property by this organization are exempt from taxation under said chapter to the extent that such property Is used In the conduct of the business Of the purchaser. Any abuse Or misuse of this certificate by any tax-exempt organization or any unaunc�rized use of this certificate by any Individual constitutes a serious violation and will lead to revocation. .. WIWI misuse of this CertIflosts of Exemption Is $*a to ahn{nsl caerctiosm of up to 1 year In pdson'sM $10,660 (MAWl07 corpomtlons) in fins. (See reverse side). EXEMPTION NUMBER E TOWN OF MANSFIELD 046-00 1-209 ISSUE DATE SIX PARK ROW 0 1089 MANSFIELD, MA 02048 CE FI TE EXPIRES ON NONE NOT 'ASSIGNABLE OR TRANSFERABLE COMMISSIONER OF REVENUE 1. $TBTR9j4,W. KIDDER Date We, Mansfield Board of Health Request for Fee Waiver for Food Permit rant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: © This is a request from a town department. rz Please list the department: ❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, &JUL-- Signature Y DiY-ej 66 Mansi� �� �Vra+i�7 Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: yr F r s Ii vr' r,' Z O , ` a X W yn C W d" O 'a- N w O Q a o0 a 141 4 X . / \ \ R)2,� �U/'2t`°` gym)§$ [ );± \ a§}a [ ®®® \ ilk \ ® !\{7 ® « 4,1\ \ \ \ / w�)m �%\ ƒ � /