HomeMy WebLinkAboutRuby's Ice Cream (Touch a Truck) - 9/21/2019FOR BOARD OF HEALTH USE ONLY k. % :1
Date Received Permit Fee
Approved By .; ` AUb rMI" I
Temporary Food Establishment Perm
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: uJo S I
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2) Establishment Address: CZ�f t° Q n /
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3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
5) Applicant/Owner Name & Title: l
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6) Applicant/Owner Address:
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7) ApplicanNOwner Telephone No:
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8) Applicant/Owner Email address: �-%✓'
9) Person Directly Responsible For Onsite Operations:
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Name & Title:
Address:
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Telephone No:
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r_ Fax: j
Emergency Telephone No:
6
10) Event Attending
Event Name:
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Event Location:
Mans
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Event time:
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11) Check one
it Food Truck
e Caterer
t% Other: { e G Kam 4n4
12) Solid waste disposal plan: qJ A
13) Water Source:
14) Sewage disposal plan:
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15) Please give a brief description of the food to be served:
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16 ) Food will be prepared:
❑ ,Offsite for immediate consumption
❑ Onsite and held at proper hot/ cold holding temperatures
u Offsite and held at proper hot/ cold holding temperatures
i l Offsite, cooled and reheated on site
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17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
1 Food Safety Manager:
Allergen Awareness: f!:j�2 l`'C 6?'/4. &
18) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit:
For food tucks, 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 1 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 obtain copies of 105 CMR W.000 and-JWlederal 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: c �- a F V
21) Signature of Individual or Corporate Name:
Food Protection Questionnaire for Catered Events
Date of Event:
Location of Ev,
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
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Food Manager Certification Person Trained On Site? ❑ Yes D/<o
Allergen Awareness Menu Label Present? es J 11 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:
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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 emoved
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.
4Gee r mcrv--f
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 or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
va-a i3S V,f
**Social Security No. (Voluntary) 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.
C:\Users\sleae\Desktop\Scoa's Docomcnts\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
Aug, 14. 2019 1:07PM
No.0541 P. 2
\ no Commonwealth ofM'assaMusetts
Department ofTrtdustrial kaidents
1 Congress sp'ee4 suite 100
Boston, AM 02114 20.11
wivm mass goildia
workers' Compensation Insurance Affidavit: General Businesses.
TO BE MXD WUH TEE PERMMING AUTHORITY.
BminesslOrganizafion
116
Are you an emp10- Cheek the appropriate box:
I.0 I am ploycrWiW emplayco9 (Rill sod/
part-timc).P
2; 1 am a sole proprietor or partnership and have no
emplayccs working for me in wry capacity,
(No workers' comp. insummcerequired)
3,1] We arc a corporation and its offlcttshavocxcrcietd
their right of exemption per o.152, § 1(4), and we have
no employees. [No workers' comp, insurance required.
4, ❑ We arc a non-profit organization, stiffed by volantears
With no employees. (No workers' comp, insoromoreq,
Badness Type (required):
5. []Retail
6, C]ltcstanraot/BufgatingEstablishmont
7, M O1fica and/or Sales (inoi. real estato, auto, etc.)
6. [] Non-profit
p, [] Naitertainment
10. ❑Manufacturing
i i-E ]HHtalth Care
12.U 'tbex lr i<.r-ea&21�
aAayappIImr[hat Awks box#7 must also fill opt tboseonm boluw ShOMUg mev wormm mnponaluanpal, x—,,-,o.,—.
#fUthe eorpWaleo$oCrr hava cxmp(ed ibaraaclves, but tho wrporatioobu otbucmPloyeu, awoakm` cpmpepaaFoq policy is roquind ud tueban
organizadoa ADM e6eck1)01 F4.
f am art upployer that fs protddtng workers' co7npenradon hisurancefor my employees. Below is the Polley inforafuraOki
lnsarance, Company Name,
Insurer's
Policy#or Self-ins,Lic.#- BxpirationDeu:
Attach a copy of the workers' compensation policy declaration page (si ovhng the policy number and expiration dale).
Itailme to secure coverage as required under Section 25A of MGL o. 152 can lead to the imposition of C&I"at penalties of a
lino up to $1,500,00 and/or one -you Imprisoumont, as well as civil penalties in the form of a STOP WORK ORDgk and a Fine
of tip to $250.00 a day agaiuut the violator. Bc advisod that a copy of ibis st domcnt may be forwudod to tho Office of
lnvesfigadorrs of the DLA for insurance coverage verification,
of pajaty drat the
rSi"UM
olfrclal use only. Do not writs to this area, to be completed by city or raivu official
City or Town:
PermiNLlceuse
above U true
Lssuiag An thority (circle one):
L. Soard af73ealtl 2, B dldingAepartment 7, C ty/Torru GJeTk 4. Licensing Board 5, Selectmen's Office
6.Other
contact Person!
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date a / (/(j
We,
nt/ 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
organi ation. *
We are donating ALL proceeds earned directly to a 501(c)(3) organization. "
Please list the organization: lk4a/i C-a L()ra
❑ We are not charging a fee for food/drink being served. "7
❑ We are a religious organization.
❑ Other:
Thank you,
Sign
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date: