HomeMy WebLinkAboutJerry's Food Concessions - 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 CONCESSIONS
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:.
JAMES APPEL
Whose place of business is:
JAMES APPEL DBA JERRY'S FOOD CONCESSIONS
16 OLD COLONY WAY
PERSON(S) IN CHARGE:
JAMES APPEL
Permit Expires: December 31, 2019
Food Fee: $100.00
License Number: MF-2
BOARD OF HEALTH
MichaeCHeaCey, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name: .JA CS� / 6'P?rZ Ot.?1-'I?I?Y' �76`7��� yC�7
Establishment Address: )C 0 -D COLOAi% v€ qy
Establishment Mailing Address (if different): 'J ` AV6' 11V,4 i /9 i
8V,Yt1r01V i3tr cl-1 1':Z4
3 3 :/ 73
Establishment Telephone No: 70�.<� �✓--c �795
Applicant Name & Title: A PPI 4 C➢
Applicant Address: 3171 jWllle%sllvA /-/A/Qc s obi? 80 1°1V7_&A1 3,$;40y /-14 33-/,7?,
Applicant Telephone No.: /V `/"7- -0 9 V S1 24 Hour Emergency No.: 7 &'/ ' 77 j--o 7 q k.
Applicant Email
Owner Name & Title (If different from applicant):
Owner Address:
Owner telephone number:
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
19An Individual
❑ A Partnership
❑ Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title: T.6 liQ�li�
Address: ,` /-// /i,,4t16jVA1/4 j,Ajq.5 iDi� 80XI,,/7cFly 3.3-17_3
Telephone No: f 7S C 996 24 Hour Emergency No: 7s/"c77Y-07 r
FAX:
E-mail:,�ttf'L.�s�381�Cf,C('
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
No. of Food Employees: "
DAYS/HOURS: '-�
Name of Person In Charge Certified in Food Protection Management:
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
Mobile Mobile Start Date:
❑ Retail -NO FOOD PREP ( Sq. Ft) $125
P, Milk & Cream $10.00
Mobile End Dale:
Mobile Comments:
Food Service to seals
INCLUDING FOOD
TROD TRUCKS $175.00
❑ Food Service for 101 -200 seals $250.00
❑ Food Service for 201+seats $300.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Manufacture Frozen Dessertslice Cream
❑ $25.00/freezer
El Pushcart $50.00 # of Pushcarts:
Length Permit:
nnual
❑ Seasonal
Seasonal Dates:
❑ Supermarkets $400
❑ Residential Kitchen 0
Tobacco Products $150. 00
❑ 00
❑ Retail Snack Food $50.00
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations:
(Cleek all that apply):
Definitions: PHF-Potentially hazardous food (time/tempemture controls required)
Non-PHFs- non -potentially hazardous rood(no time/temperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
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
ElHF Preparation of Ps 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
di Variance
❑ Use of Process Plan (including
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
❑ 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
❑ Juice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of
Animal Origin
❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Offers RTE PHF in Bulk Quantities
❑ 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 affmn 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 5#.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C.�Wc. 49A, 1 certif/arl°der the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid stale taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: el 8 S'5i2- AC 72 �
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.
S' ature of Indi/y c ral or Corporate Name
d A�
"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.
C:\Users\sleite\Desktop\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf rvwtv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: ,', 1t,,5 A P22Z, p]" ,li�/ ,;i6iul
Address: U Z/ i2®'3VZZ6QA tidy ,i CjV1✓I0e,j 13,ACzl 1'44
City/State/Zip:
Phone #: s � l - q � .S- -o i" 7
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑ I/ am a employer with employees (full and/
5. ❑ Retail
Arrpart-time).*
6.❑RestaurantBar/EatingEstablishment
2. 1 am a sole proprietor or partnership and have no
7. ❑ Office and/or Sales (inct real estate, auto, etc.)
employees working for me in any capacity.
S. ❑ 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
10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.�Other 7 i R It
with no employees. [No workers' comp. insurance req.]
1'0(i VC
*Any applicant that checks box kl must also fit 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 H 1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
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, tinder the pains and penalties of perjury that tine information provided above is true and correct.
mature: Date:
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.nrass.gov/dia
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To whom it may concern,
I, Steve Cerillo, owner of Catman Cafe at 16 Old Colony Way, give
Jerry's Food Concessions DBA James Appel full access to use my
restaurant as his home base.
u,-, d&
Steve Cerillo