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HomeMy WebLinkAboutBritish Motorcars of NE (Taste of Tri-town) - 8/17/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: TEMPORARY FOOD PERMIT 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:. ALAN ROSEMAN Whose place of business is: BRITISH MOTORCARS OF NEW ENGLAND - ROTARY VINTAGE SHOW 265 FRUIT STREET PERSON(S) IN CHARGE: ALAN ROSEMAN Permit Expires: August 17, 2019 Food Fee: $50.00 License Number: T-31 BOARD OF HEALTH AichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY 1,31 Date Received Permit Fee Approved By Temporary Food Establishment Permit ApPlh (Application must be submitted at least 7 business days before the pianr, opening date) 1) Establishment Name: �� y"tU Tb 0-G-pa(L ©K Establishment Address: 60 Establishment Mailing Address (if different): Establishment Telephone No: Z161 y,FZ/ ` (� 2) ApplicantlOwner Name & Title: Applicant/Owner Address: S v� Applicant/Owner Telephone No: Applicant/Owner Email address: � � v 1 M e IJ f-U!✓; 3) Person In Charge of Onsite Operations & Title: PIC Address: 11/14 & (5� PIC Telephone No: ywl _ (� �(�,. / 6 Emergency/onsite Telephone No: � PIC Email Address: A e-.51 Y 4) Event Attending: Date(s): Au G . Event Name: �/S L >d7'i7'� Event Location: Event time: .W 6) Check one o Food Truck o Caterer Ih7 Other: Z` A)7 - �S'ouurce: 6) Solid waste disposal plan: 7) Water 8) Sewage disposal plan: 9 ) Please give a brief description of the food to be served: an S _ �rf� n4f p „- R44 SJ�T /JiZ/A>!GS CDU K!£S - Cln�PS 10) Food will be prepared: �Onsite for immediate consumption o Onsite and held at proper hot/ cold holding temperatures o Offsite and held at proper hot/ cold holding temperatures E3 Offsite, cooled and reheated on site o Other: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager: Allergen Awareness: 12) Please describe on site hand washing facilities that will be utilized: 13) Please list all sanitizing solutions that that will be on site: 600, � f Qmi "Md � 0tfl z � 14) If applicable, please describe your FOG management plan or attach the written plan: 15) For caterers: City/Town 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 Base of Operations or Commissary permit: 60 f}2� 17D�Ju� i�/S Ax 6 C L141 Pit,( l h is /1'6r Dom- "%,u7 I, the undersigned, attest to the accuracy of the inf establishment operation will comply by the board of health on how to o in co s of 1 19) Signatureof i provitlied in this application and I affirm that the food and eXother applicable law. I have been instructed 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: (7 L1 - 014 3 63 21) Signature of Individual or Corporate Name: Food Protection Questionnaire for Catered Events DateofEvent: tquq p Event Time: LlDC Location of Event: p�tJ14 S e1� cQ� Rd'_%'__ List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location: On ice/Refrigerated Cooking Reheating ?'fib l- nc,G S Food Manager Certification Person Trained On Site? o Yes o No Allergen Awareness Menu Label Present? o Yes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: 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 Please describe hand washing and sanitizing supplies that will be provided on site: 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. kor W 6.. 6TS&pb a__ 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. Signature of Ihdividual or Corporate Name By: Corporate Officer (Mandatonj, if Applicable) 6t-I 'o 9— **Social Security No. (Voluntanj) 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. The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations %I 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: l4jc cJ S vtc [6tL J Address: C 4 City/State/Zip: Phone #: 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.❑ 1 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] 8. ❑ 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. N We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.® Other Ro"T Dc,6-- -V Aj *Any applicant that checks box #t 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: 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 of the DIA for insurance coverage verification. I do hereby-eert' un r thoitins and penalties ofperjury that the information provided above is true and correct q - zat9 Phone #: L%61- diet - l 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: Bank Packet town or mansneia SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER Department: iBoard of Health Schedule #:iJE0081619 - - Date: 08/16119 Source i Account Number Amount i__. Description of Acccount 01512-445006 BRITISH MOTORCARS OF NE $ 50.00 FEE FOR TEMPORARY FOOD PERMIT i 7— TOTAL: 1 $ =:60.00 To The Officer Making the Payments iI The above is a detailed list of moneys collected. by me, amounting inthe-aggregate to:_. $ 50.00 1for the period ending -� a � which I have paid to the Town Treasurer whole receipt I hold therefor, TOWN OF MW13FIELD € AID AUG 1 6 2019 AMT __5� Commonwealth 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: TEMPORARY FOOD PERMIT 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:. ALAN ROSEMAN Whose place of business is: BRITISH MOTORCARS OF NEW ENGLAND - ROTARY VINTAGE SHOW 265 FRUIT STREET PERSON(S) IN CHARGE: ALAN ROSEMAN Permit Expires: August 17, 2019 Food Fee $50.00 License Number: T-31 ,-OWN OF MMSFISLI) RAID BOARD OF HEALTH AUG 1 6 2019 NichaeCHeaCey, Chairman C' CHECKS__ N Commonwealth 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: TEMPORARY FOOD PERMIT 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:. __TM TS __It'► Whose place of business is: BRITISH MOTORCARS OF NEW ENGLAND - ROTARY VINTAGE SHOW 265 FRUIT STREET PERSON(S) IN CHARGE: ALAN ROSEMAN Permit Expires: August 17, 2019 Food Fee: $50.00 License Number: T-31 BOARD OF HEALTH MichaeCHeaCey, Chairman PAID 2019 0