Loading...
HomeMy WebLinkAboutFood & Friends Kitchen - 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:. FIRST BAPTIST CHURCH Whose place of business is: FOOD & FRIENDS KITCHEN - FIRST BAPTIST CHURCH 52 NORTH MAIN STREET PERSON(S) IN CHARGE: DOROTHY FOWLER Permit Expires: December 31, 2019 Food Fee: License Number: FS-26 WAIVED BOARD OF HEALTH Milk & Cream .MichaeCHeatey, Chairman fov FOR BOARD OF HEALTH USE ONLY Permit# Issued i FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: rc'o a j fy/ei7ds Aiy'ej,.f, Establishment Address:rS%dJ�3T�L/urc�� ✓tea �����5�/ /�l�nS�j/Y��• Establishment Mailing Address(if different): Establishment Telephone No.: `j 0 X —9 j �— '70 Applicant Name & Title: 6 ✓ 6 -thy l . tr'au-;'/e—v- Coo e'll z/�/e'r `FVa��� r p1�{ic Applicant Address: / CF Cl e4 ��^ J i'!�,/9 I2G6/ /%%��• Z CJ d Applicant Telephone No.: mpg 33�n, %U y7 24 Hour Emergency No.: J—U Applicant E-mail: dote 7677 01VZA 6 p , CoYrr Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: O An Association 11 A Corporation El An Individual O A Partnership X 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: 7a Z_ Address: G��✓t s7 />%CGG�S7iP�d lyJif• f 20� Telephone No: J� Q� �� _7c 517 24 HourLlmergencyNo: �©� urn>_ f72� FAX: E-mail: Alt E-Mail: 1. District Or Regional Name & Title: Address: Telephone No: FAX: E-mail: (if applicable) 24 Hour Emergency No: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) '�. NO. Of Food Employees: DAYSMOURS: tuaj ✓ Name of Person In Charge Certifi in Food Protection Managemenf If more than 3 individuals are certified, complete list is on file. PC�Yn —�Y C'_ 1l d Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: Permanent Location Establishment Type D Caterer $35.00 Moblie Moblie Start Date: I] Retail ( Sq. Ft) Milk & Cream $10.00 Moblie End Date: 171 Food Service up to 100 INCLUDING Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: Q Food Service up to 101 -200 $250.00 I Manufacture Frozen Desserts/Ice Cream $25.00/freezer IQ Annual - ---- ---- ----- -- ❑Food Service up to 201 + $300.00 E] Pushcart $50.00 # of Pushcarts: E] Seasonal Residential Kitchen $100.00 Seasonal Dates: ❑ Supermarkets $400 Retail Food $125.00 ❑ Temporary Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: - '�, Food Operations Definitions..PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous rood(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order Q Hot PHF Cooked and Cooled or Hot Held E] Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service Q PHF andRTE 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 E] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours — Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations Self -Service Ice Manufactured and Retail Sale Juice Manufactured and Packaged Retail Sale F-I Offers RTE PHF in Bulk Quantities or Reconditioned Food Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health E] 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 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 CUR 590.000 and the federal Food Code. Signature of Applicant: waived 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. Signature of Individual or Corporate Name: / �r�rJi/,'�/�� (4 r/ Social Security Number or Federal ID: () q 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. 61� C a4onE% Lzle A � � -� C, XF,-,s Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) o � - 3 da 6 a5a-- **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:\Usm\sleite\Desktop\Scott's Documents\Food Establislunents- Teinp\TAX CERTIFICATION FORM.doe The Conintomvealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 r it,minass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: F rs1zj�g�� Address: IV, __:�3 y'_ %O Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 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 (incl. real estate, auto, etc.) employees working for me in any capacity. 8. Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have W ❑ Manufacturing no employees. [No workers' comp. insurance required]* 11. ❑Health Care 4.f We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance real 12.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the cmpomte officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I ant an employer that is providing Ivorkers' compensation insurance for ary employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie, 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofpeljroy that the information provided above is true and correct Sienature: ��C C rl CPir/ Date: Official use only. Do not ivrite in this area, to be completed by city or town official City or Town: Pernrit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone www.mass.gov/dia Mansfield Board of Health Request for Fee Waiver for Food Permit Date \ `1 �$ 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: ❑ 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 Denied Reason: Signature: Date: W .,. 6a _ � 0 w O CJ ,O o_ LO Nco w 8 LO w (D clw� z � z �. � � �A r.#n W4 z � � � � 9 � Rl / U 4).\\$ 0 \ ) z 00 0 » �L)®®) k BillA MI. § & ] � , § ) « «!}e ƒ t{mR »t\/ g \ \\k\ \ r