HomeMy WebLinkAboutThe Barn Food & Spirits, LLC (Taste of Tri-town) -10/1/2019m r= FOR BOARD OF HEALTH USE ONLY
4 V, vett Permit Fee Approved By Permit #Issued
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°`—_._-_._ J -__--_._^Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: '5�,,k. LLC
2) Establishment Address: 13 S 4.I u 1 �, ,. � 1 !"� /1 6 � -7 o,4
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3) Establishment Mailing Address (if different):
4) Establishment Telephone No: v�5 - qS S-- psi, O L
5) Applicant/Owner Name & Title: w- i CC, r l Su
6) Applicant/Owner Address: 'Z acs G i< o , 44G-�,,. MA 6D-7
7) Applicant/Owner Telephone No:
8) Applicant/Owner Email address: b� O
9) Person Directly Responsible For Onsite Operations: (/� I r(•
1 I 1 L1.h � � e Wt (:�N � ✓l
Name & Title: ,
Z
Address:
Telephone No: Fax: 5-,D /z� 7 2 - 3 Z Z
Emergency Telephone No: t -7 . �-6 3 q - 5 C( ci .
10) Event Attending
Date(s): 10/16/
Event Name:
Event Location:
Event time: — ` roe,
11) Check one
Food Truck
Caterer
Other:
12) Solid waste disposal plan:
13) Water Source:
14) Sewage disposal plan:
15 ) Please give a brief description of the food to be served:
771eConnnoiatvealth of Massach usetis
Departinent of Industrial Accidents
Office of Investigations
600 Wash ingion Street
Boston, MA 02111
wwminass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 3: IF, j Sit; v, t5, L L L
Address: 1 G S C o- n . am u t I c A 1"-Cio k�lt. b, Nl 4 6 J ^f c 3
City/State/Zip: A44", MA c,)-7 u 3 Phone #: L(C 1 — t; i q � `l5 )
Are you an employer? Check the appropriate box: Business Type (required):
1. P 1 am a employer with 10 employees (full and/ 5. ❑ Retail
or part-time).* 6. Cg�Restaurant/Bar/Eafing Establishment
2.0 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.
[No workers' comp. insurance required] S. ❑ 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
no employees. [No workers' comp. insurance required]**
4. ❑ We are a non-profit organization, staffed by volunteers, 1 L❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Ary applicant [hal checks box HI must also fill out die section below showing [heir workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation his other employees, a workers' compensation policy is required and such an
organization should check box k I.
I pat an employer that is providing workers' compensation insurance for my employees. Belot, is the policy information.
Insurance Company Name: 11 0 o_. -� i., I '� 5 r11,� � rr ' C c .
Insurer's Address: { 0.r, 'i ,,-cA �� W7 -C,
City/State/Zip: H t Y d r C� {�
Policy # or Self -ins. Lic. # 0<3 Lu r�( A Ao 5.40 Exp ration Date: Z 1-7 -c-c7
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 ofcriminal 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 pales mud penahies of perjttry that the information provided above is trite and correct
AA �
Signature: /Lj4 4 - C. J( Date: G( 1 1 '71) -Z- c l I
Phone #: (d: 1 7 - 4 '> `-A -� �j ctN
0jr1elal use only. Do not write in this area, to be completed by ci0, or lawn official.
City or
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Contact
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Food Protection Questionnaire for Catered Events
Date of Event: ` / ( Event Time: / t�
Location of Event: S'S
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cook' Reheating
�R�",."-pu
Food Manager Certification Person Trained On Site? 7 Yes m No
Allergen Awareness Menu Label Present? Oa Yes o No
Li tall Pote tia y H zardous Food (PHF and the individual intended temperature required:
List the required ttel/mp�erature for each food as it leaves your preparation site:
c�
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
6�)q (? /)-� 2 4
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.
s4z ✓ "e -s
h/S`
e -r
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date Gj_�(
We, –Hip &«,,,,. Eoj r 5s�.:-.V-,, SLC (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,
t� ky—i('�C'
Signature
r) w.
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature:
Date:
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