HomeMy WebLinkAboutFork & Bibb (Touch a Truck) 9/21/2019'09/03/2019 16:50 85082850266
FOR BOARD OF HEALTH USE ONLY
PAGE 01
e) 61 O'ar.c y-z
Date Received Peffnit 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 Noma: >
Establishment Address: ) s 5 5, Waa--s'Fe�— 6+- ( ` OCAM-1 1' 1' 114 o `a �,
Establishment Mailing Address (if Moroni):
Establishment Telephone No: -7 74 D S9 n i Jr
2) MpilcanVOwner Name & Title: ) c ost a k I
ApplicanUownerAddress: Spur {
b
/►
Applicantowner Telephone No: SC,.� A6WZ
Appficant/Owner Email address: 'fO rk 66r wn; l Oe"
3) Person In Charge of Onalte operations & Trde:�t ,GSd V1 -r->" O W W2! I GL-W-"t
PIC Address: SG/k
PIC Telephone No: Em(nency/onsite Telephone No:
PIC Email Address:
4) Event Attending: "jooci,� w Ttick
Date(s):
Event Name: 'T CUA f
Event location: OD(prj- 4-
sS
Event time: A (I
F+
S) Check one
ger food Truck
o Caterer
M Other.
6) Solid waste dial plan:
r s
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7) Water Source:
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N&rf DA J'own
S) Sewage disposal plan:
1
�w QPiS SG-je T141�
9 ► Please give a brief doscrlptbn of the food to be served:
�1$>4 tt�t Sys I s sit l �(4A
At\ P�� �c-oJ q-A 4e-A-,5 n,oat^
09/03/2019 16:50 85082850266 N PAGE 02
10) Food will be prepared:
dw
t�Onale for Immediate consumption
m Onsite and held at proper hot/ cold holding temperatures
G7 Offske and held at proper hot/ cold holding temperatures
O Otfsite, cooled and reheated on site
o Other. t1 QiL TJr ti4 ia.��v� �� LQ�
11) If PHF Is being served, please list the person who has completed the following tminl gs and attach appropriate
car"Cates: Food Safety Manager: )y,-
Allergen Awareness: Jc
12) Please describe on $11 a hand washing faculties that will be utilized:
;nit t,� He.o_" jA., 1 SoN� S �v�; ,z I
13) Please list all sanitizing solutions that will be on site:
14) If applicable, please describe your FOG management plan or attach the written plan:
15) For caterers: Cltyfrown where food establishment permit is held. Please attach a copy of the caterwa permit:
For food trucks, pkme list additional communlles where a food permit Is held and attach copies of the Base of Operations
or Commissary permit:
1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food
establishment operation will complywith 10 ell other applicable law.1 have been Instructed
by the board of health on how to CUR 5?rWW and the federal Food Code.
19) signature of
Pursuant to MGL Ch. 62C, sac, 49A,1 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 ID: o3b — .50 — 9000
21) Signature of Individual or Corporate Name:
85082850266 N PAGE 04
ne l.ontmonweatto aJ /nuww..••-�
peparnnent of Industridd Accidents
Ofce of Investigations
600 Washington Street
Boston, MA 02111
wnnv.Mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/organization Name: i-�.l" k, ,bb r L
I.S`5 ,.,a -I- �1-rn MRGM6G—
S_ u1Gr&si�
c�� �^^ ►�✓YlA rrM a
ity/state/zip:
Are yo n employer? Check t ppropriste box:
I . 1 am a cmployer with=employees (full and/
part-time).•
2. 1 am a sole proprietor or Partnership and have no
employees working for roe in any capacity -
[No workers' comp, insurance rcgllkM]
3.0 We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp- insurance required]**
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees- [No workers' comp. insurance req_]
r�r -77-t a54 , 1-5
Business Type (required):
5. [] Retail
6- n RestauranV%ar/Fsating )establishment
7. (] Office and/or Sales (incl. real estate, auto, etc.)
8- ❑ Non-profit
9. 0 kntertaioment
10,0 Manufacturing
110 Health Care
12.0 Other i1/tpie+ I t.
Any appacant drat checks box #1 mustlso fi all ant the sxtimbelow showing meirworke� compmatiOn PolicY infompation.
•If the corporate officers have exen4no thcupselves, but the ootpara M has other MVIOYe a wod:cts' convatsadot pokey is mruimd and such an
rsaniretion shwld cheek box #1,
act an employe► that is p►onidfng workers' compensation intntanee for my emphryees Below !s dre policy htjormadon
nsuraucc Company Name:
Asurer's
ity/State/Zip:
'olicy 0 or Self -ins. Lie. # Expiration Date:
kuach a copy of the workers' compensation policy declaration page (showing the policy number and expiration daft).
-ailurc to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine up to $1,500.00 and/or one-year imprisornnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine
>f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ovestigations of the DIA for insurance coverage verification.
'do
-asy- r749
that dre lnformadon provided allove is true and correct
QB'iclal use only. Do not wrhe in this areo, to be completed by city or town ofJle&L
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone #:
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