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Home My WebLink AboutNE Vintage Arts Society (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:. CATHERINE BISHOP Whose place of business is: NEW ENGLAND VINTAGE ARTS SOCIETY - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: Permit Expires: April 14, 2019 Food Fee: $150.00 License Number: NEFFA-4 BOARD OF HEALTH NlchaeCHeaCey, Chairman v FOR 13()AItD OF 1JEAL'1"N USIi"• UNL t4� DBte Received Permit Fee Approved By kr APR 9 3 21119 Aerm1 �sued Temporary Food Establishment Permit Application 1) Establishment Name: New England Vintage Arts Society 2) Establishment Address: '64 MaOlis Road, Nahant, MA 019o8 3) Establishment Mailing Address (if different): PO Box:9, Nahant, MA 01908: 4) Establishment Telephone No: 781-499-2589 (voicemail) 8) ppplicantrowner Name & TOW Catherine' Bishop, Director 81iApplloantlownerAddress: Same;asabove 7) ApplicanflOwner Telephone No: 781-718-8041 8) Applicant/Owner Email address: katybishop64ga gmail.com 8) Person Directly Responsible For Onslte Operations: Name&Tltie;, John'Burrows, and Catherine Bishop Address. 393 Union Street, Rockland, MA 02370 Telephone No: 781-261-6813 (Jolm) -Few, 781 718-8041 (Catherine) Emergency Telephone No: Same as above 1 g) Event Attending Aate(s); April 12, 13, 14.2019 Event Name: New England Folk Festival (NE'FFA) Event' Location: Mansfield Middle School, Mansfield, MA Event time; 4/12: 3pm-11pm; 4/13: Sam-tlpm; 4/144: Sam-6pm 11),Check-,one Food Truck>' Caterer x ,Other; Food Vendor 12) Solid waste disposal plan:; Town of Mansfield 13) Water Source: 'town of Mansfield 14) Sewage disposal plan; Town of Mansfield 18) Please give a brief description of the food to be served: Soups, sandwiches, baked goods; beverages, 18 ).Food will be, prepared: unite for rhtn tidlote cRrlaumplion, X 4nsite and held at proper boy cold holding temperatures Oft lree and field at propel hott cold holding temperatures: ousite, cooled and reheated on silt Other: 17) If pltF is being served, please list Utt person who has completed the following trahrings and attach appropriate cartlficates; X rood Safety Manager: C bris Mcciotti X ° Allergen Awareness Ckris Ricciotti 18) For caterers: Cityl7own where food establishment permit is hold. please atuaah a copy of the caterer's permit; NIA For food hacks, please list additional communities where a food permit is held and attach copies of the parmatet 1, the undersigned, attest to the acetlracy:of the information provided in this appltcatirn and I affirm that the food establishment operation will comply with'105 CMR 590,000 and all other applicable tawI have been instructed by the board of health on how to obtain copies;a6,'t 05 CMR S90.000 and the tedpral Food Code. 10) Signature otAppllcant: Pursuant to MGL Ch. $20, sec. 40A, i certify under the penalties of perjury that 1, to illy bast kherwiedgds and belief, aVe riled all state tax returns and paid state taxes required under law, 20) Sock4i Security Number or Federal ID: 21) Signature of individual or Corporate M TAX CERTIFICATION FORM t certify under the penalties of perjury that 1, to my best knowledge a1 belief, have filed all state tax returns and paid all state taxes required under law. Lilt A"Y'ke F ' Y 5igo,alure of individoal or, Corpcarale=lame Hy. Corporates officer fdsfajulalory, if ApplicafiW "'` # s, "Soda! Security No, (Voluril aryl or Federal E9 ilf rnfk,n e'Vai Idyer° *This license will nest 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 doermine whether you have met tax filing or tax payment obligations, Licensees who tail to correct their non -ding or delinquency, will be subject to license suspension or revocation. This; request is made under the authority of Massachusetts General Law C iapter 0C, section. 49A. 1. 11 , ,r......... e_ ..., n,._.......ril .:... rr.,-.r1 „6..._'Ye.m f aV 11w Y U. h` t ii1ti." WW ntl k_ The t onttnonwealth of'Massac'hoselts Department (iInrlusstriol Accidents i t)ifiY'4' of jInVQI tlat7atl3 600 ►i ashingtoli ,vireel Rmsion, MA 02111 nmttsn:ass.�airltlln Workers' Compensation InsurancerAffitiavits General Businesses Applicant Iaformation Plens� Print f eeiltty ItusincsslOrganization Nattle:.,. Ni._At -ji land Viiltagc Aril Soar -- Address: 64 Maoiis Road i'itxlhtatcrllir�: Nahant, MA ntgoli phone ii: 781-718,80 1 Arey'ou nn tempinyer? Check the appropriate box; Buntnss t 'pv iretiuireal:' 1, 0 1 am a employer Wide emplovcrs (bill andt 5: n Retail orpan•iirne}.' G,E]ResuturimuffimEatiagEstablishment I (J I alit a We Proprietor or partnership ;and have to T Ej Utiice andfor Solos rate). real es,ene, into, etc,) ca ployees }aarking for too at trny capacity. I No Worker` comp, insurance reynitedl x. ®Not -profit 1, ❑ we ore a corporation and its officers .hate "'crowd y. ❑ Elacriainillon llrair rlghLgf exctnption per c. 152, 1(4). and rye hovelil.( Mfluulauinrh?d no ctpployees, INo workers' comp. insurance reydnedl' 41.� lfealdicare 4, JXI we orc a non-profit organization, scatted by volnnfecrs, � a^lllite a WIMcm, emnt+cn iimpnficY 1>ieykrat+zt wut uuti ji /an{ rvr entptareClYrataspruv%ding warki'i`s" uonipensafion insurdnc frr tnv amphrvees. Below in lHe:psitiev anjbronnion, lnsnrattec t'n,npiutyNazne•_ ,. NiA _ ._..__._.__...._.,_..� Cnyi5tateaZip: _ __-__ Policy 4 or Self -ins; d,tc. _ _ Expiration Qatca_ _ Attach.a copy of the workers` compemsetion pollevdeclaration page showing the pollen another anti expiration,t(ate). (Metal use. urrty. An not A,*r in this area, to he compided by city or tare" it f eial City or Town: PermitfLicense 9 Issohfg Autiwriry (circle one): I, Board of Health 2. Buildiag Department 3. C1 y(fown Cleric 4. Hecasink t3oard 5, Seleeinten'a Office b'. dither Food Protection Questionnaire for Catered Events 4/12.3-ttpm; 4/13: 8a-ttpm; 4/4: 8a-6prn Date of Event: April 12-14, '2019 Event Time: Location of Event Mansfield Middle School Mansfield MA List all foods that your will be chilling; holding; cooking, and/or re heating at the event location: Oil ice/Refi'irgerated Cooking Reheating milk„cream, lemons, butter, Soup, scones, popovers Soup ham, cheese, lettuce, tomatoes Indian Pudding, crumpets macaroni and cheese maple syrup, cucumbers macaroni and cheese mayonnaise _ chicken salad, lobster- meat Food Manager Certification Person Trained On Site? X1 Yes No Allergen Awareness Menu Label Present? XI Yes F11 No List till Potentially Hazardous Food (PHF) and the individual intended temperature required; chicken salad nit an cream 41 egd reel or less lain, cheese, lettuce tomatoes, cucumbers of r' altlisted — List the required temperature for each food as it leaves your preparation site: milk and cream ILdegrees or less ehicken salad' ham cheese 'lettuce or a rste tomatoes cusum ers How will the PHF be kept at or below 41 OF? on ice How will the PHF be kept at or above 140"F? in a food warming unit Time of PHF? Setup 4/12 bpm Served 6pm Removed 10:30pm µ/13-14: 9:00am 9;30am 4/13:10:30pm; 4/14: 4:30pm List all equipment that will be supplied for an event, including bill not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. All of the above Storage containers. Aprons Food Warmers -He—id3carves _Foasi.ir' :ocesssies Gloves _ _�— Cooking utensils and supplies ab NEW i I 7 � ¥ t � . q 4 : .0 � ��04 } . � / e % 4B, V k } /