HomeMy WebLinkAboutSix String Grill & Stage (Taste of Tri-town) - 10/1/2019SES FOR BOARD OFHEALTH USE ONLY
Date Received k y t Permit Fee Approved By Permit # Issued
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Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: Svx SfiC✓
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2) Establishment Address: `�
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3) Establishment Mailing Address (if different):
4) Establishment Telephone No: 14 `—
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5) Applicantlowner Name & Title:
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6) ApplicantlOwner Address:
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7) Applicant/Owner Telephone No: _
6) ApplicanttOwner Email address:
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9) Person Directly Responsible For Onsite Operations:
Name & Title: Y
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Address:
Telephone No: - -:�)r (l \
Fax: ---
Emergency Telephone No: t _
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10) Event Attending
Date(s): \
Event Name: m
Event Location:
Event time:
11) Check one
Food Truck
stere
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:
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Food Protection Questionnaire for Catered Events
Date of Event: It
Location of Event:
gventTimc: Thdc C- Tfl f
List all foods that you will be chilling, holding, cooking, and/or reheating at the event location -
On ice/Refrigerated Cooking Reheating
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Food Manager Certification Person Trained On Site? m'�'es o No
Allergen Awareness Menu Label Present? EVIIes o No
List all Potentially Hazardous Foodd (P—Hl�d the individual intended temperature required:
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List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41'F? k)()
How will the PHF be kept at or above 140°F? fl ift' nc s i�A n� `$ wre
Time ofPHF? 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.
PIN
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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.
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Signature of Individual or Corporate Name
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""Social Security No. (Voluntary) or Federal
ldenti icationNumber
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. 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.
CAUscrs%-IciroNDnklup\9wtP9 Ducumenis\Fuod rstoblishments• Temp%TAX CERTIFICATION FORM.dbc
The Common nwalth oJ't11 rssctclrnsetis
Department of lnditatricd Accidents
Q%free q/Inwsvtigatiomy
600 I7Waslriagton Street
Boston,ikbf 02111
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Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
BusinesslChgani�ntionNsune:.�4XIJpYQ �h0&,'�•1}g11�4�,
---------
City/saltc/Zip:4A- 020.5 Phone 11: 11.fN ]41I _
Art
ou on 1:11113101011? Check (lie appropriate box:
Business Type (required):
I.
I not a employer �t•ith'7Q4 employees (Lull and,'
5. 2 Retail
or part-time).*
G. 2esmurandl3adGaling 11stabl6looem
2.0
1 ant it sole proprietor or put tnership and have no
7. ❑ O(Ptee and/or Sales (incl. real estale. ante. etc.)
employees working 1-ur me in any capacity.
8. ❑Nen-profit
[No workers' comp. insurance re,quiredi
3.❑
We are a corporation nnd its officers have excrc ised
9. ❑ Entertainment
their right of exemption per c. 151 § 1(4); and Nye have
IO.❑ Manufacturing
no employees. iNo norkcrs' comp, insurance tvquiredj*.'
i I.❑ FlcalUn Care
4.E]
We area non-profit organization, sntl'ki 1)), volunteers,
with no employees. [No workers' comp. insunpwe req.]
12.❑ O tier
'Any -applicant that clack, hm PI nnlNI ala. fill "tit the ucdaa beat,slum isle (heir tuvkco-eunaavlcatioa iwiiel' in furnmtion,
—11,11w corhn,raw onicaa hare exempted thenuckec tut the coritnratioo Ila, olio, enq,loyeaa. awirkm admpmslll ua poli,z iA re'lu"M aodsuclt m1
otmninaiau Ahoald dmck lm al.
1 mu an enplorer dem is pronlding workers, Compensation instmmee fora+,l• emphrt•ees. Beton, is the polier hijimi ration.
Insurance Company Name:_(-{'-.Gl'(1}1.L....,�l1AY.i4,.C_.--------.------.—.._...._......----- .... ----- ....-----
Insurer's
Citp,Stato'Zip:—
Policy r: or Self -ins. Lic. t' 1niL Q.Q 'ZQ' Q0-_.---------..-.______f•spiralion Uale:_ �,� ,�.i)�.p __.
Atmdt a copy. of the viorhers' compensnlion policy otcla ra(Imt page (shloving the policy mmllber and expiration late).
Failure to secure coveroge as required under Section ?M of MOI., c. 152 can lend to the Imposition oletiminol pmadlies nl'a
fine tip to S 1.500.00 nnd%orrnte-pear intprisonuten(. as ty.ell as civil penalties in the lbi m of a STOP WORK ORDER and It line
ol•up to 5250.00 it day noainst (he violator. Be advised that It copy of this stolenient maybe 1'm'svarded to the Oilice of
Investigations of the DIA liar utsurancc coverabe verification.
f da head!). certflS ¢neer 1/ra paJus mtrl peunfli¢s n/'petjtn;r thin due tiilorumtinn prorhled ahnre !s brae nm/correct.
Signa me' M, .� Dolma W.101
OJJlcial a.se onlP. Do not urine in d)Ls urea, to he completed hr clQr or town gffie•inl.
City or
it/License it
Issuing Anthority (etrele one):
1. Board of Health 2. Building Department 3. City/Toon Cierl: 4. Licensing Board ,. Svivelmen's Office
0. Other
Contact Person; I'hooe
Mansfield Board of Health
Request for Fee Waiver for Food Permit
We, _ 5) )c ? 6C) 11 i s'y9 Z (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
✓ Oth'er: TASTE OF THE TRI -TOWN
Thank you,
/1��_
Signature
gis C-aachnCI
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
16 ) Food will be prepared:
Onsite for immediate consumption
Orate and held at proper hof/ cold holding temperatures
Offsite a d held at proper ot/,,d_holding temperatures
ffsile, caoled an re Bated on site
u1ner:
17) If PHF Is being served, please list the person who has completed the following trainings and attach appropriate
certificates: r
Food Safety Manager:_ k ,1) Le (a
c i ef��a n Kc�i�uj «'C1
Allergen Awareness: M l ke 0—rorl'e r lk--4o i �,}of 1CC-
18) If applicable, please describe your FOG management plan or attach the written plan:
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19) For caterers: Cityrrown where food establishment permit is held. Please attach a copy of the caterer's permit:
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For fopd trucks, please list additional communities where a food permit is hold and attach copies of the permits:
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I, 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 690.000 and all other applicable law. I have been instructed
by the board of health on how to obtain cop i sof 105 CMR 690.000 and the federal Food Code.
19) Signature of Applicant: ' t' r Vii
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 Numberor Federal ID, !_YlZ S9 - Z c "1 V `l
21) Signature of Individual or Corporate Name:
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