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Home My WebLink AboutTrolley Dogs (NEFFA) - 4/14/2019Commonwealth 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 - NEFFA 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:. JOYCE DENTE Whose place of business is: DENTE ENTERPRISES, LLC DBA TROLLEY DOG - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: JOYCE DENTE Permit Expires: April 14, 2019 Food Fee: $150.00 License Number: NEFFA-2 BOARD OF HEALTH NichaeCHeatey, Chairman MD Rrt Ann nc rrr7Ar 11.. �, IIuni,In Uon V1VLY � Date Received Permit Fee Approved By Permit #Issued i emporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the nlannprl nnanin- 1) Establishment Name: 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: ///Z 7 (p 5) ApplicantlOwner Name & Title: 6) ApplicantlOwnerAddress: 7) Applicant/Owner Telephone No: S 8) Applicantiowner Email address: O PName —F� ....... ror unsne uperatnons: &Title:ss:hone No: Emergency Telephone No: ! ,7 10) Event Attending Date(s): Event Name: Event Location: Event time�a/60 b O0 Ices 11) Check one V Food Truck Caterer Other: 13) Water Source Please give a brief description c fits c�L Y-44.� Fax: J( 161 v. 9:r00 o t ' ® a 12) Solid waste disposal plan: 14) Sewage disposal plan: t9,lu.t d ttl M prepared:r immediate consumptiond held at proper hot/ cold holding temperatures d held at proper hot/ cold holding temperatures oled and reheated on site 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager:�j6S� µnt Allergen Awareness: 18) If applicable, please describe your FOG management plan or attach the written plan: 19) 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 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 tain copie f 105 MR 590.000 and the federal Food Code. 19) Signature of Applicant: P 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 ID: 0 7 3a 79 21) Signature of Individual or Corporate Name: TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. ,:44 r",ti)6�w r Signature of Individual or Corporate Name 0�6;07/1I YBa "*Social Security No. (Voluntary) or Federal Ident�flcation Number A�� zfLz By: Corp rate 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. C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Food Protection Questionnaire for Catered Events /0;00 -Y �o Date of Event:_ �} _ rEvent Time: 5� .•v a /0 ; O O Location of Event: MA-JeA� " ,Owa-i List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: Cooking Reheating ,q. Food Manager Certification Person Trained On Site? Yes o No Allergen Awareness Menu Label Present? ch Yes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: Aj List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 °F? 6� ,(sat 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 to600d thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. rvdd—1 7'W'Ck - L �i Busines: Address: City/Stag, --F. 1he Commonwealth of Massachusetts Department of IndustrialAccidents Office oflnvestigations 1 Congress Street, Suite 100 Boston, MA 021I4-2017 www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Are you an employer? Check the appropriate box: — I. i am a employer with employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' camp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. I52, § 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 Phone #: A / 7 — Business Type (required): ---------- 5 ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) S. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.0 Health Care req.I 12.0 Umer *An the Corporate to o fichecks have ex mpted t o fill out the section below showing their workers compensation policy mfomtation, **If the corporate officers have exempted themselves, butthe corporation has other employees, a workers' compensalion policy is required and such an organization should check box tit . I am an employer "U, is providing workers' compensation insurance for my employees. Below Insurance Company Name:_ / flee- LJA��y is the polity information. Insurer's Address: City/to/Zip: Policy # or Self -ins. Attach a copy of the workers compensation polwy declaration page (showing the ptolicy number a�expi �tion date), Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to thz imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civic penalties in the form of a STOP WORK ER and a fine In es to bons 0 a day against the vio]ator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce/rl�ify, under ikepains on, enalties ofperlury that the informationProvided above is hire and Sinnatnre- C"JA in J(1 ,� correct. 1017- Offlcial use only. Do not write in this area, to be completed by city or town official. City or Town: 1 Permit/License # ssmng Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4, Licensing Board 5. SeICCtmen's Office 6.Other Contact Person: Phone #: 01 5 Harrison St Phone: 508 450 9284 1 1 Worcester, MA 01604 Email: thedogfathertruck@gmail.com 2019 02/06/2019 This letter is to serve as notice that Dente Enterprises llo, dba/Trolley Dogs/Boston Italian Ice, has authorization to use our facility for the purposes of cleaning and sanitizing equipment, emptying waste water, food prep, cooking, food storage, and other uses to be determined, to comply with the city of Worcester Inspectional Services Department ordinances for proper food truck operations. This authorization expires on 01/01/2020, or before, upon notice by either party of termination. Inspectional Services Permit Number FM-18-1441 Mark Gallant Owner PIN: FM-18-1441 EFFECTIVE DATE: CITY OF WORCESTER, MA Department of Inspectional Services 25 Meade Street, Worcester, MA 01610 Phone: (508)-799-8539 FOOD ESTABLISHMENT PERMIT Tuesday. January01. 2019 r • PERMIT EXPIRES Tuesday. December 31, 2019 250.00 In accordance with Regularions promulgated under authority of M.G.L. c. 94. ss 305A; c. 111, ss. 5 123A, 105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to: Name of Permit Holder DOGFATHER VENDING LLC Address of Permit Holder 48 CHANNING STREET Name of Food Establishment DOGFATHER VENDING LLC Address of Food Establishment 5 HARRISON ST OPERATIONS PERMITTED Food and Drink Establishment 1 - 100 Occupancy Comments: Restrictions: Common Notes: Renewal of Permit: DURATION OF PERMIT Annual An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the expiration of the permit. Notification of Changes: This permit is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If this business is to close or there is a change in ownership, The DIS must be notified at least two weeks prior to closing and this permit must be returned to the DIS. Director of Housing and Health Inspections Post Conspicuously m W a. CA n W w m z C 3 m m A �. o Po � ��' •� _.i2��N 5 ._•(nUl o N 6 h S r�� !O b ^i4 E � u C o 4 � Q O v a Health Division 1010 Massachusetts Avenue Boston, MA 02118 Telephone: (617) 635-5326 Martin J. Walsh Mayor' Owner gstablishmenGDBA BOSTON ITALIAN ICE #2 BOSTON ITALIAN ICE #2 J. DENTE BOSTON ITALIAN ICE #2 CITYWIDE 26 CLAUDETTE CIRCLE BOSTON MA, FRAMINGHAM, MA 01701 HEALTH PERMIT 2019 PERMIT NUMBER PERMIT TYPE PERMIT DESCRIPTION 26909 fD Frozen Desserts 25908 MF Mobile Food Server THIS PERMIT EXPIRES: 12131/2019 his Permit Must Be Posted in a Conspicuous Public Place aints regarding the sanitary condition of this establishment may be referred to the Health Division at: (617) 635-5326 www.citvofbostongov/isd/health lawo I Will nVarcv I 1%j19HL JGrtV Kor-0 IJCYAm 1 IVIt1V I • Health Division 1010 Massachusetts Avenue Boston, MA 02118 Telephone: (617) 635-5326 Martin J. Walsh Mayor Owner EstablishmenHDBA BOSTON TROLLY DOGS BOSTON TROLLY DOGS GERALD DANTE 1 CITYWIDE ST 26 CLAUDETTE CIRCLE BOSTON MA, 02128 FRAMINGHAM, MA 01701 HEALTH PERMIT 2019 PERMIT NUMBER PERMIT TYPE PERMIT DESCRIPTION 139282 MFW Mobile Food Walk On THIS PERMIT EXPIRES: 12/31/2019 is Permit Must Be Posted in a Conspicuous Public Place tints regarding the sanitary condition of this establishment may be referred to the Health Division at: (617) 635-5326 www,cityofboston.gov/isd/health