HomeMy WebLinkAboutThe Loft @ Plainridge (Taste of Tri-town) - 10/1/2019k
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FOR BOARD OF HEALTH USE ONLY
Date Received Permit Fee Approved By
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
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1) Establishment Name:`", ,tom ` I', a.� ��, t OL` /�,,3
Establishment Address: 3-01 ll v Q `J v X1,.7 � Y'l 6 -�- 1 Q+ 1 n 1? i \j,
Establishment Mailing Address (if different):
Establishment Telephone No: J 0,� -S 7 _ H LI `"7 L4
2) Applicant/Owner Name & Title:
Applicant/Owner Address:
Applicant/Owner Telephone No:
Applicant/Owner Email address:
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3) Person In Charge of Onsite Operations & Title:
PIC Address:
PIC Telephone No:�r"- , ��' "'�.. ._ q H'1 0 Emergency/onsite Telephone No:
PIC Email Address: Gi, Q Q,` s,(- ;,. V- fl Gt_D M t i') a Jyt.—
4) Event Attending: } �� ; (A S ,ir C � ��,, t , W rN
Date(s): 1 , _
Event Name: 7T7
Event Location: o V tt� 5 S' } VIT) S -
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Event time: 5 -7
5) Check one
o Food Truck
-tQ Caterer
o Other:
6) Solid waste disposal plan:
7) Water Source: b)Q�. �'
8) Sewage disposal plan: r
9 ) Please give abrief description of the food to be served:
Cry 0,405 �')I
16 ) Food will be prepared:
Onsite for immediate consumption
Onsite and held at proper hot! cold holding temperatures
—�OHs to and held at proper hot/ cold holding temperature<-
Offsile, cooled and reheated on site
Other:
17). If PHF is being served, please list the person who has completed the following traintngs and attach appropriate
'certificates:
Food Safety Manager: Y QX0It'Ct�oS�� v(Y\y�(\rnQ �
Allergen Awareness: Q�o .t�LCfY*A s R�1
18) If applicable, please describe your FOG management plan or attach the written plan:
19) For caterers: CltyrTown 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 890.000 and all other applicable law. I have been instructed
by the board of health on how to obtain copies of 10505 C0 and the federal Food Code. ..
19) 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.
20) Social Security Number or Federal ID:
21) Signature`ofIndividual orCorporate Name: I�IQinU111fl- r YYIi ePl�Q.Uf_iaptamt uc
dba -PIgiorld1c Pari; casino
Food Protection Questionnaire for Catered Events
Date of Event: °i �� \1 `t.� Event Time: 5 � � '
Location of Event: 7r,
List all foods that you will be chilling, holding, cooking, and/or reheating at the event location:
On ice/Refrigerated Cooking Reheating —
r e �
_ 0. a.S
Food Manager Certification Person Trained On Site?
,q Yes
o No
Allergen Awareness Menu Label Present?
Yes
o No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
(FSA d
List the required temperature for each food as it leaves your preparation site:
off'. LAO %i.
How will the PHF be kept at or below 41 °F?
How will the PHF be kept at or above 140°F? \A0 j- -y
Time of PHF? Setup W,00%rA Served cz `, Removed <3 r �e
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.
&t 'u ��
a d
16 ) Food will be prepared:
Onsite for immediate consumption
Onsite and held at proper hot/ cold holding temperatures
Offsite and held at proper hot/ cold holding temperature
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: r (�
Food Safety Manager: :
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date t \ l
We, _! !-� �cr C � �QLWN V : c Cn& \ X15 I M(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: TASTE OF THE TRI -TOWN
Thank you,
Signature
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www,mass,gov/dia
Form Revised 5-26-05
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