HomeMy WebLinkAboutMMAS (Fall Fest) - 10/6/2019FOR BOARD OF HEALTH USE ONLY
Date Received Permit Fee Approved By Permit # Issued
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name:
2) Establishment Address: 3 k/d (,2 I h i%UJCt , I W MSf) e a/
0 Zoy
3) Establishment Mailing Address (if different):
4) Establishment Telephone No: JU J ? T _. Z 2 C
5) ApplicantlOwner Name & Title: 4,"v A) _ r t L11� l -t v ,f ;;i.
6) Applicant/Owner Address: JO <zIl'"ti'l i c2 1� { I Vry '7�� MGr-)j- n , /
7) Applicant/Owner Telephone No: s �� '� ._ 16 6' '3
8) Applicant/Owner Email address:
9) Person Directly Responsible For Onsite Operations:
Name & Title: _ �� C tY�C' C' 7
Address: A t_ V(1
Telephone No: Fax:
Emergency Telephone No:
10) Event Attending
Date(s): Q C-- j' d C-F
Event Name: V4 4 NS61 e ( J 'Fct %% 4::f- 'fit VA
Event Location: 1�2cl ✓lei t: � a
Event time: D C7 . Y �✓ f c.7- S iZ
11) Check one
Food Truck
Caterer
Other: T?4�r-
12) Solid waste disposal plan:
T,4 1G6C `1Y4 34 C t ✓�
ov IM P,rit"72
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13) Water Source: /L (j i (,e
14) Sewage disposal plan:
I u'/A
15 ) Please give a brief description of the too to bg served:
lGir��s c,+li .Set(30 �er� c�4'1✓; l* l� ear l'><
f fia 4 CI d
Coca
16 ) Food will be prepared:
t-,-&site for immediate consumption
✓✓Onsite and held at proper hot/ cold holding temperatures
Offsite and held at proper hot/ cold holding temperatures
Offsite, cooled and reheated on site
Other:
17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Manager:
Allergen Awareness:
18) If applicable, please describe your FOG management plan or attach the written plan:
19) For caterers: Cityfrown where food establishment permit is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the permits:
I, the undersigned, attest to the accuracy of the information provided in this application and I 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 OP05 CMR 590.000 and the federal Food Code.
19) Signature of
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 relrt.u,mss and paid state taxes require4 under law.
20) Social Security Number or Federal ID: V ! .3 % c% .57 W y
`'o 4q ✓u A 'IT- P / _
21) Signature of Individual or Corporate Name: lTC.?L-. < t✓�
Food Protection Questionnaire for Catered Events
Date of Event: !0 `v // .5 11015-11� Event Time: :� f le ` _
Location of Event: '0 C, W5 6-C 1 d F= a I 1 7-e's'Tt'CL-Q-
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
cb rFIF€
�'aHie4Q 'sa.;a-I-cam .
Food Manager Certification Person Trained On Site? o Yes ,� No
Allergen Awareness Menu Label Present? o Yes �-No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
�Cf 1eg
(hT c�FCzC
ti-a 1' Ca G c
List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41°F?
How will the PHF be kept at or above 140°F?
Time of PHF? Setup
Served
Removed
List all equipment that will be supplied for an event, including but not limited to food
thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc.
CWQe ow. C.vi(t
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.
- G�
Signature of Individual or Corporate Name
Q I-l- 3/95-V/`/
"Social Security No. (Voluntary) or Federal
Id entifrcation 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\Dcsktop\Scotrs Doc=ents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc
Deparknent ofindustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Pease Print Legibly
Business/Organization Name: ll/� m A S r A AA
A r1 rlrP.ca• 3 � ? A3 () � -C -n v14
City/State/Zip: Vka)) �� (� MA 670y 0 Phone #: 66� 3 3 9 - 2 �12 Z—
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
q, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8.
[No workers' comp. insurance required]
,R"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
employees. [No workers' comp. insurance required]**
11.❑ Health Care
4. 2/o
We area non-profit organization, staffed by volunteers,
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 M.
I am an employer that is providing workers' compensation hnsurance for my employees. Below is the policy information.
Insurance Company Name: M,t 16 S 1 11 ruy<. °' C e- 4y e ''I C `jj
Insurer's
\u ye_ 6jae�l Nd?2T� , MA 673(o O
City/State/Zip: / 1 j
Policy # or Self -ins. Lic. # 00 (I' b `l {-� Expiration Date: Z Z 0
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 enaldes ofperjury that the information provided above is true and correct.
Signature:
/
I � Date:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitiLicense #
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