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Home My WebLink AboutGerry's Catering - 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: 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:. GERALD DOHERTY Whose place of business is: GERRY'S CATERING 157 CHESTNUT STREET PERSON(S) IN CHARGE: GERALD DOHERTY Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-31 BOARD OF HEALTH AichaeCHeatey, Chairman Milk & Cream rr FOR BOARD OF HEALTH USE ONLY Permit# Issued ES-32„ MFOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name GERRY'S CATERING Establishment Address 157 CHESTNUT STREET Establishment Mailing Address (if different) 157 CHESTNUT STREET FOXBOROUGH, MA 02035 Establishment Telephone No (774) 254-0200 Applicant Name & Title: GERALD DOHERTY, OWNER/OPERATOR Applicant Address 157 CHESTNUT STREET, FOXBOROUGH, MA 02035 Applicant Telephone No.: (774) 254-0200 24 Hour Emergency No.: (508) 930-7766 Applicant Email Owner Name & Title (If different from applicant) GERALD DOHERTY Owner Address Owner telephone number (774) 254-0200 Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. A Corporation Name Title Address An Individual � --- - - - A Partnership i- _ - Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: GERALD DOHERTY Address: 157 CHESTNUT STREET, FOXBOROUGH, MA 02035 Telephone No: (774) 254-0200 24 Hour Emergency No: (508) 930-7766 FAX: E-mail: SFD2003@HOTMAIL.COM Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: N/ MOBILE e) o P Public Water Supply No: (ifNo. f Food Employees 1 DAYS/HOURS: M-F 5 AM - 5 PM - Name of Person In Charge Certified in Food Protection Management: GERARD F. DOHERTY 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 11 Mobile Mobile Start Date: Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: Food Service up to 100 INCLUDING Mobile Food Consession Mobile Comments: MOBILE CANTEEN FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 1 Manufacture Frozen Desserts/Ice Cream Length of Permit: Food Service up to 101 -200 $250.00 $25.00/freezer 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 Temporary Retail Snack Food $50.00 '.. Temporary Start Date: Date: Tobacco Products $150 00 Temporary End - -� Temporary Time: Rain Date: Food Operations DefimflonsrNon-PHFs Potentiallyhazardous food controls required) oimeltemperature ous rod(no timers mperatu polenhallly hazardus controls required) (Check all that apply) RTE - ready -to -eat foods (Ex sandwiches salads, muffins which need no furtherprcnCooled Sale of Commercially Pre Packaged Non-PHFs PHFCooked To Order Hot PHF Cookedandor Hot Held _.-. .____ ..___— -- -----— ----- --- -- I for More Than a Single Meal Service -_. Sale of Commercially Pre -Packaged PHFs I Preparation of PHFs For Hot And _-__ __-_ --__—. ____— -- --- --- Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs _..-__------- ----- --� Susceptible Population Facility Sale of Raw Animal Foods Intended - Reheating of Commercially to be Prepared by Consumer Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours ---- ---- --- --- -- _ Use of Process Requiring A Variance Customer Seif-Service of Non PHF and Non- Customer SelfService 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 i-- control) - ------------- ------ - Other Food Operations Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities Prepares 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: $175.00 !, 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 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: 021-38-9627 Signature of Individual or Corporate Name: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information // Please Print Legibly Business/OrganizationNamre: e PA&K,�, yQi7t� x/f Address: ..0 -7 e .274- 6— S /, ' Phone #: �774 6 c�e�C Are you an employer? Check the appropriate box: Business Type (required): I. ❑ 1 am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. � a sole proprietor or partnership and have no y, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp, insurance required] 8• ❑Noma -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 I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. El Health Care with no employees. [No workers' comp. insurance req.] 12.Other ❑ *Any applicant that checks box # 1 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 lire 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, certify, rmd�3' the pains and penalties of p Jyury that the information provided above is true and correct. 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,inms.gov/dia 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 **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. 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