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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 TRUCK
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..
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Whose place of business is:
MYROLLINGCAFE - THE ROTARY VINTAGE SHOW
265 FRUIT STREET
PERSON(S) IN CHARGE:
CLAUDIA FRANKENBERGER, OWNER
Permit Expires: August 17, 2019
Food Fee: $50.00
License Number: T-29
BOARD OF HEALTH
MichaeCHeatey, Chairman
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Date Received Permit Fee
USE ONLY
Approved By
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Temporary Food Establishment Permit Application
(Application must be submitted at least T business days before the planned opening date)
1) Establishment Name: {'0 LG i ar
2) Establishment Address: ; e��y(jJ O % uAi7/ t12/ e�
3) Establishment Mailing Address (if different): 5 �-
4) Establishment Telephone No: 0
5) Applicent(Owner Name & Title: . Q
8) AppllcangOwnerAddreas: SCG' r,7 O /J 12� e1j,"7
7) Applicant/Owner Telephone No:
8) Applicant/Owner Email address: Ny i/d116.0
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9) Person Directly Responsible For Onsite Operations: All,
Name & Title:
Address:/
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Telephone No:
041" Fax:
Emergency Telephone No:
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10) Event Attending
Date(s):
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Event Name:
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Event Location:
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Event time:
11) Check one
X Food Truck
❑ Caterer
❑ Other.
12) Solid waste disposal plan:
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13) Water Source:
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14) Sewage disposal plan:
15 ) Please give a brief description? of the food to be served:
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16 ) Food will be prepared:
Jam' Onsite for immediate consumption
❑ Onsite and held at proper hot/ cold holding temperatures
ri Offsite and held at proper hot/ cold holding temperatures
❑ Offsite, cooled and reheated on site
❑ Other: ��`�!7_t�%o� � �sr_ -i i✓e�L/�'
17) If PHF la being served, please list the person who has completed the following tralnings and attach appropriate
certificates: / 0
Food Safety Manager: �Gr a r i2 7Y�iY i1 ✓ �/9�
Allergen Awareness:
18) For caterers: CltyRown 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:
1, 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 obtainyapies of IP5 CM 590.000 and the federal Food Code.
19) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, 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 10: t f o-/ 02-5- ) /
21) Signature of Individual or Corporate Name:
Food Protection Questionnaire for Catered Events
Date of Event: 0Y//7 //F,vent Time: 7_ 4/Jvn
Location of Event: 4 a f l"eZ 4Ve /
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
Food Manager Certification Person Trained On Site? Yes Cl No
Allergen Awareness Menu Label Present? Yes El No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
List the required temperature for ouch food as it leaves your preparation site:
-------------
How will the PHP 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.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
7 Congress Awet, Suite 100
Boston, MA 02114-2017
wwmmass.gov/dia
Workers' Compensation rnsurance Affidavif: General Businesses.
TO BE PILED WITH THE PERMI MC; AUTHORITY.
Applicant Information Please Print Letribly
Business/Organization
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with` employees (full and/
or part-time).*
2 I am it sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp, insurance required]
3, ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no omployecs, [No workers' comp. insurance required
4, ❑ We are A non-profit organization, staffed by volunteers
with no employees. [No workers' comp. insurance req.
Phone !kaf IZ V -S2
Business Type (required):
5. F-1 Retail
6, FlRestauranVBar/Bs6ngEstablishmmt
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. ❑ Entertainment
10, ❑ Manufacturing
11. ❑ Health Cara
1211 Other
rAny Applicant Ihnt checks box NI must algin fill out the section below showing their workers' compensation policy IoAc mation.
raEtbe cerpowcofficers bavoexemplat thow-lva,but rbacarporatioo has othvcmployx,awarkers'compowntion policy is required oW such as '
organim6an should cbwk box ql.
Yam an employer that is providtng workers' contpensailoit lrtsurance for my employees. Betow is ttte policy infarutatiaL
insurance Company Name:
insurer's
Policy# or Sclf--ins, Lie, #' Expiration Date:__ _
Attach a copy of the workers' compensation policy declaration page (sbowing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do Hereby cartify, ynder thepafnYtdperraUW of perjury that the h1fannatton pravided above is "a and correct.
Offrctal use only. Do not write tut this area, to be completed by city or town ofjletal
City or Town:
Pormlf/Lieense
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Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric 4, Licensing Board S. Selectmen's Office
6. Other
Contact Person: ._.
TAX CERTIFICATION FORM
1 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
Y�nrlerlacy,
Signature of individual or Corpgrate ate Name
*"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. Ucensees 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.
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Jane Doucette
From: Amy Donovan -Palmer
Sent: Tuesday, July 23, 2019 7:54 AM
To: myrollingcafe
Cc: Jane Doucette
Subject: RE: FW: Mansfield Temporary Food Permit
Good morning, Claudia,
Alan came up with a solution that you would only sell non-PHFs and only store food on the truck before the event.
I won't require a pre -event inspection based on the inspections you have sent and that you will not be serving any PHFs.
If my schedule allows, I will be at the event for an inspection.
Does this still work for you? Jane can process the paperwork and send you the temporary permit if it does.
Thanks,
Amy
From: Amy Donovan -Palmer
Sent: Monday, July 22, 2019 2:06 PM
To: 'myrollingcafe'
Subject: RE: FW: Mansfield Temporary Food Permit
Hi Claudia,
According to the Retail Food Code Standards for Mobile Food Establishments from the DPH
(https://www.mass.gov/files/documents/2019/06/17/mobile-food-establishments-standards.pdf), at the bottom of
page 2, under Food Source and Temperature Control, 1. Approved Source:
b. All locations used for preparation of ice or other food items as well as proper storage of those items must be
permitted. (590.008; FC 8-301.11)
I'm sorry but I can't issue you a permit unless you have a permitted location to store the items before they are on the
truck.
Please let me know if you have any other questions.
Amy
From: myrollingcafe [mailto:myrollingcafe@mail.com]
Sent: Monday, July 22, 2019 1:34 PM
To: Amy Donovan -Palmer
Subject: Re: FW: Mansfield Temporary Food Permit
Amy,
we purchase the items and store them in a freezer at home andUl the truck freezer and fridge before we head to
a event.
We do run the Freezer and fridge with a power inverter during traveling and run it with a generator if we can
not plug in to a shoreline at the event.
Attached you find our last Health Department inspection form from 06/22/2019 at federal hill in providence
where everything was fine. You also might contact our east bay inspector Andrew Vitagliano at 401 222 2750
at the Health Department ( attached his last report).
I hope you don't have to inspect us at a pre -event inspection, because that means a 2 br. round trip with our
truck to get licensed for a one time event.
We are asked to set up at 7a.m, might be there is a chance to inspect us there?
Sincerly
Claudia
On 22.07.2019 13:02, Amy Donovan -Palmer wrote:
Hello Claudia,
Jane has been relaying the messages to me.
Do you purchase the items for events and store them only in the truck? How do you guarantee constant
power source?
We'll need to schedule a pre -event inspection. Are there any days that work best for you? I will not be
in the office the week of August 5th. Or the 15`" or 16th
Thanks,
Amy
Amy Donovan -Palmer, MPH, RS
Health Agent
6 Park Row
Mansfield, MA 02048
Phone: 508-261-7366
From: myrollingcafe [mailto:myrollingcafe@maii.com]
Sent: Monday, July 22, 2019 10:14 AM
To: Jane Doucette
Subject: Re: Mansfield Temporary Food Permit
Jane,
we do not have a commissary/or base of operations, because we do not cook! We only serve pre
made frozen desserts, Gelato and Patties, which we buy at reliable distributors.
Claudia
On 22.07.2019 09:39, Jane Doucette wrote:
Hi Claudia, I received your temporary food application for the August 17`" event at
Mansfield Airport but I need to know your base of operations/commissary license.
The information contained In this communication from the Town of Mansfield is confidential. It is
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The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for
use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that
any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly
prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast
Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your
human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here.