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HomeMy WebLinkAboutA.J.Bruno Concessions LLC - 12/31/2019Commonwealth 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: XFINITY FOOD PERMIT 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN' DOTS 2 PERSON(S) IN CHARGE: I l► i i:Le7'NIA 2 WP. [�7 Permit Expires: December31,2019 Food Fee: $175.00 License Number: XFS-25 BOARD OF HEALTH w(ichaeC,T(eaCey, Chairman Commonwealth 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: XFINITY FOOD PERMIT 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:. ANTHONY BRUNO Whose place of business is: A. J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN' DOTS 1 PERSON(S) IN CHARGE. ANTHONY BRUNO Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-24 BOARD OF HEALTH NichaeCHeaCey, Chairman Commonwealth 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: XFINITY PUSHCART PERMIT 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - PUSHCART PERSON(S) IN CHARGE ANTHONY BRUNO Permit Expires: December31,2019 Food Fee: $50.00 License Number: XPA 1 BOARD OF HEALTH Michae(HeaCey, Chairman Commonwealth 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: XFINITY PUSHCART PERMIT 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:. lel10ii7C07.NFA 3:Allki �7 Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - PUSHCART 1 - COFFEE PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2019 Food Fee: $50.00 License Number: XP -7 BOARD OF HEALTH Nichae[HeaCey, Chairman Milk & Cream Commonwealth 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: XFINITY FOOD PERMIT 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:. ra0r0:cILIVA N I I Z Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - LOT 9 - SHED 1 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-26 BOARD OF HEALTH MichaeCHeaCey, Chairman Commonwealth 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: XFINITY FOOD PERMIT 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - TRAILER 1 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-28 BOARD OF HEALTH AichaeCHeaCey, Chairman Commonwealth 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: XFINTY FOOD PERMIT 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC - TRAILER 2 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-5 BOARD OF HEALTH Michae(Heafey, Chairman Commonwealth 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; XFINITY FOOD PERMIT 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:. Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - SHED 2 PERSON(S) IN CHARGE. G1Zi1:[61'k,VA--]WIZ Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-2 BOARD OF HEALTH MichaeCHeaCey, Chairman Commonwealth 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: XFINITY FOOD PERMIT 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:. ANTHONY BRUNO Whose place of business is: A. J. BRUNO CONCESSIONS LLC - EMPLOYEE BARBEQUE 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: XFS-31 BOARD OF HEALTH Michael 9HeaCey, Chairman S, FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned Establishment Name: A 6 i -,^a Establishment Address: I �,A Establishment Mailing Address (if different): Establishment Telephone No: S -c $ _ 2 If 4 Applicant Name & Title: A'14k.7 &-A0 IU -,4 - Applicant Address: 3C LG 44,A L -4t A�"O:e(d /0,+ Applicant Telephone No.: )-a tilt -, k 84 24 Hour Emergency No.: Applicant Email: Owner Name & Title (If different from applicant) Owner Address: Owner telephone number: Owner email: Establishment Owned By: ID An Association (,A Corporation El An Individual ❑O A Partnership O Other legal Entity MAY 3 0 2019 j 0_)o 4 If a corporation or partnership, give name, title, and home address of officers or partner. Title Address I tu.le.q Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: SIC Address: „ Telephone No: FAX: E-mail:�`�` Alt E -Mail: District Or Regional Supervisor (if applicable Name & Title: Address: Telephone No: FAX: E-mail: 4)75 Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees ( (U DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): t' Location: Q Permanent Location Establishment Type: Caterer $35.00 T11 Mobile Mobile Start Date: Retail -NO FOOD PREP ( Sq. Ft) $125 Milk & Cream $10.00 Mobile End Date: Mobile Comments: VFo,' Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Q Food Service for 101 -200 seats $250.00 i Mobile Food Consession NO PHF PREPARED ON SITE $100.00 ii Manufacture Frozen Desserts/Ice Cream $25.00/1reezer th of Permit: Lr r� Annual E'I Food Service for 201+ seats $300.00 Q Supermarkets $400 I] Pushcart $50.00 # of Pushcarts: E Residential Kitchen $100.00 Q Tobacco Products $150.00 Retail Snack Food $50.00 ---- ii] Seasonal Seasonal Dates: _ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: Definitions. PHF- Potentially hazardous food (timelemperatum controls required) Non-PHFs - non -potentially hazardous food(na time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑€l" Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ist3 Sale of Commercially Pre -Packaged PHFs Q Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility €L Delivery of Packaged PHFs - Sale of Raw Animal Foods Intended to be Prepared by Consumer Q Reheating of Commercially Processed Foods for Service Within 4 Hours i�U" Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) EJ Customer Self -Service of Non PHF and Non- Perishable Foods Only o Customer Self -Service 0 Ice Manufactured and Packaged for Retail Sale iJ Preparation of Non-PHFs Other Food Operations i] Juice Manufactured and Packaged for Retail Sale Q Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Q Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application 0 waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal Food Code. Signature of Applicant: c' .W X.'2 Pursuant to MGL Ch,620, 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. Social Security Number or Federal ID: iC ` 4t 4 C6 35 2 Signature of Individual or Corporate Name: �_ FOR BOARD OF HEALTH USE ONLY Permit# Issued XFS-26 - �_0 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET - LOT 9 - SHED 1 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508)962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association 0 A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers . or partner. Name Title Address Address: 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: — - FAX: E-mail: AJBRUNOCONCESSIONS@GMAIL.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: ..Email: 0 t� '0�5 � * 06►-i.J. " Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No, of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Moblie Mobile Start Date: ❑ Retail ( Sq. Ft) �� ❑ Milk & Cream $10.00 Mobile End Date: Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $1S"O ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $25,00/freezer 21) Length of Permit: W Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Seasonal or 25'+ PHF display $275.00 ❑Retail Food $100.00 Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: Potentially hazardous food(timeltemperature controls required) 23) Food Operations Definitions: PHF- Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑d PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑d Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer - ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours E] Use of Process Requiring di Variance and/or HACCP Plan (including bare hand E]Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Animal Origin ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $125.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal Food Code. 24) Signature of Applicant: i 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. 25) Social Security Number or Federal ID: 36-4866352 26) Signature of Individual or Corporate Name: FOR BOARD OF HEALTH USE ONLY Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: A •_) 9r✓nu (,("Ace5}',c. i -Lt C' Establishment Address: Such n 5!-r<I — S_Ar ( Z Establishment Mailing Address (if different): Sc/ Establishment Telephone No: nn Applicant Name & Title: 1q1)4(,,,j Applicant Address: �3( (FJr, C"'( U)041 Applicant Telephone No.: � vS - 84 ( 24 Hour Emergency No.: Applicant Email: '4 etiy Co 1 o Owner Name & Title (If different from applicant): Owner Address: Owner telephone number: Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. %A Corporation Name Title Address U An Individual AAiG"' 6"o O A Partnership 0 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: '5e -,- c• Gc'-'�– Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: -c- Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: ra Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) No. of Food Employees: DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. y�nij� `I /gip Person Trained in Anti -Choking Procedures (If 25 Seats or more): Ell Location: E] Permanent Location Establishment Type: FJ Caterer $35.00 doii Mobile Mobile Start Date: Q Retail -NO FOOD PREP ( Sq. Ft) $125 !-.-! Milk & Cream $10.00 Mobile End Date: Mobile Comments: Q -Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Q Food Service for 101 -200 seats $250.00 Q Food Service for 201+ seats $300.00 Q Supermarkets $400 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 t!J Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $50.00 # of Pushcarts: [E3 Residential Kitchen $100.00 Ej Tobacco Products $150.00 Retail Snack Food $50.00 Length of Permit: ]'Annual ---------------------------------- G1 Seasonal Seasonal Dates: L Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions:PHF - Potentially hazardous food(timeRemperatum controls required) Non-PHFs - non-potenfially hazardous food(no time/temperatum controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) El Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service E -J Sale of Commercially Pre -Packaged PHFs [EJ Preparation of PHFs For Hot And Cold Holding For Single Meal Service a PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs IJ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑t, Reheating of Commercially Processed Foods for Service Within 4 Hours EJ Vacuum Packaging / Cook Chill �❑-' Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) IJ Customer Self -Service of Non PHF and Non- Perishable Foods Only !❑_ Customer Self -Service !"( Ice Manufactured and Packaged for Retail Sale S] Preparation of Non-PHFs Other Food Operations ESS Juice Manufactured and Packaged for Retail Sale I-1 Offers Raw Or Undercooked Food Of Animal Origin tl Prepares Food/Single Meals for Catered Events or Institutional Food Service E] Offers RTE PHF in Bulk Quantities Q Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application E7 waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal Food Code. 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. Social Security Number or Federal ID: -3G, 4 SC 6.3 Q Signature of Individual or Corporate Name: atdT�I &_ FOR BOARD OF HEALTH USE ONLY Permit# Issued XFS-28 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET -TRAILER 1 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name Title Address ❑ An Individual ❑ A Partnership _❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: Telephone No: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 (508) 962-9984 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONS(cb-GMAIL.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN L16) DEP Public Water Supply No: (If applicable) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (if 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Moblie Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Date: 0 Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF displayo ZS �^ ❑Food service up to 101 I -zoo Manufacture Frozen Dessertslice Cream $25.00/freezer 21) Length of Permit: ❑� Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Seasonal or 25'+ PHF display $275.00 ❑Retail Food $100.00 Seasonal Dates: ❑ Temporary ❑Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: -- ----- 23) Food Operations Definitions:PHF- Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) (Check all that apply): RTE - mady-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) _F ❑ Sale of Commercially Pre -Packaged Non-PHFs F PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly -- --- ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service --- Susceptible Population Facility --"--- ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially ❑ Vacuum Packaging/ Cook Chill Processed Foods for Service Within 4 Hours —_ ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ------ ❑ Customer Self -Service of Non PHF and Non- ---- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health --_control) _ ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities . Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date _ ----- or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $125.00 --""--- Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.0/00��and / the federal Food Code. 24) Signature of Applicant: G�1WvN t5";� 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. 25) Social Security Number or Federal ID: 81-2524629 , 26) Signature of Individual or Corporate Name: FOR BOARD OF HEALTH USE ONLY Permit # Issued XP -7 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET -PUSHCART 1 -COFFEE 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY J. BRUNO, OWNER 6) Applicant Address 996 CHARLES STREET, NORTH PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 OR 9985 24 Hour Emergency No.: (508) 261-7198 8) Owners Name & Title ANTHONY J. & SHANNON BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, NORTH PROVIDENCE, RI 02904 Owner's telephone number 10) Establishment Owned By: ❑ An Association ❑A A Corporation ❑ An Individual ❑ A Partnership El Other leoal Entity 5089629984 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 13) District Or Regional Supervisor (if applicable) Name & Title: 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, NORTH PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: (908) e61-7198 FAX: E-mail: AJBRUNOCONCESSIONS@GMAIL.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: SHANNON BRUNO Address: 100 SOUTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: (774) 244-1089 24 Hour Emergency No: FAX: E-mail:.. M 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑� Definitions., PHF-Potentially hazardous food (timeltemperature controls required) 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) ❑N Milk & Cream $10.00 Moblie End Date: ❑ Food Service up to 100 or_ a„e % ❑ Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $1Y5r0 ' ' ❑ Food Service up to 101 -200 Li Manufacture Frozen Desserts/Ice Cream $25.00/freezer .,_ { , '� 21) Length of Permit: Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + ❑� Pushcart # of Pushcarts: 1 ❑ Residential Kitchen $100.00 ❑ Seasonal Seasonal Dates: CONCERT DATES or 25'+ PHF display $275.00 E]Retail Food $100.00 ❑ Temporary ❑ Food Service - Institution E]Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions., PHF-Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no tlmeltemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furfherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑� Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly E] Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer E]Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Perishable Foods Only Preparation of Non-PHFs Other Food Operations and Non- I I. I Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Juice Manufactured and Packaged 1 Retail Sale Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Oriain ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date ------- ' or Reconditioned Food To be completed by the Board of Health --"—"--- ....--- — Total Permit Fee: $25.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal Food Code. 24) 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. 25) Social Security Number or Federal ID: 36-4866352 26) Signature of Individual or Corporate Name: Imo— FOR BOARD OF HEALTH USE ONLY Permit# Issued XP -8 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET -PUSHCART 2 - DIPPIN' DOTS 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association * A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 24 Hour Emergency No: FAX: 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: AJBRUNOCONCESSIONS@GMAIL.COM FAX: E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 66 Mobile Moblie Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer�co 21) Length of Permit: Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + Pushcart $Y� # of Pushcarts: 1 ❑ Residential Kitchen $100.00 ❑ Seasonal Seasonal Dates: or 25'+ PHF display $275.00 ElRetail Food $100.00 El Temporary ❑Food Service -Institution ❑ Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: TemporaryTime: Rain Date: --..—..- -----...--.._.... 23) Food Operations Definitions: PHF- Potentially hazardous food (timellemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑� Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service --a Sine E] Delivery of Packaged PHFs Cold Holding For Single Meal Service E]PHF and RTE Foods Prepared For Highly E]Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours ------------- Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for Retail Sale contact alternative, time as a public health control) _ ❑ Offers Raw Or Undercooked Food Of Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Animal Origin ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities ._ Catered Events or Institutional Food Service or Reconditioned food Tobe completed by the Board of Health Total Permit Fee: $26.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal Food Code. 24) Signature of Applicant: t lr Pursuant to MGL Ch.62C, sec. 49A, I certify and paid state taxes required under law. the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 36-4866352 26) Signature of Individual or Corporate Name: FOR BOARD OF HEALTH USE ONLY Permit # Issued XP -10 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A. J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET - DIPPIN' DOTS 1 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9948 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508)962-9948 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 10) Establishment Owned By: ❑ An Association ❑O A Corporation ❑ An Individual ❑ A Partnership ❑ Other le al Entity 5089629948 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONS@GMAIL.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 1011/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: 21) Length of Permit: ❑� Annual up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer `� a~ ❑d Pushcart $'x26.00 # of Pushcarts: 1 ❑ Residential Kitchen $100.00 ❑Retail Food $100.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: _................ ..._._._.. 231 Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs ❑ --"" Delivery of Packaged PHFsFacility--- ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service --- ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially E] Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date------ or Reconditioned- Food _ To be completed by the Board of Health Total Permit Fee: $25.00 Payment is due with application ❑ we I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal. Food Code. 24) 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. 25) Social Security Number or Federal ID: 36-4866352 26) Signature of Individual or Corporate Name: FOR BOARD OF HEALTH USE ONLY Permit# Issued XP -11 'l FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET - DIP?IN" lXOTS 2 i eta Ca e 1 Je n 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association W A Corporation ❑ An Individual ❑ A Partnership _UjQjWEjQqaI Entit 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: ANTHONY BRUNO 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: 24 Hour Emergency No: AJBRUNOCONCESSIONS@GMAIL.COM FAX: E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate [l 9) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer &V 21) Length of Permit: ❑Q Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 0 Pushcart $2� # of Pushcarts: 1 ❑ Residential Kitchen $100.00 El Retail Food $100.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: Potentially hazardous food (timeRemperature controls required) - non -potentially hazardous food(no timeRemperature controls required) ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 23) Food Operations (Check all that apply): Definitions: PHF- Non-PHFs RTE- ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service E]Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ---"--.._k Chill ❑Vacuum Packaging /Cook Chill ❑ Delivery of Packaged PHFs ----"— ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer - -""ed ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours [:] Use of Process Requiring di Variance and/or HACCP Pian (including bare hand contact alternative, time as a public health control) E]Customer Self -Service of Non PHF and Non- Perishable Foods Only E]Customer Self -Service ❑ 9 --" Ice Manufactured and Packaged for Retail Sale _,_ ❑ Preparation of Non -PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $25.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 590.000 and the federal Food Code. 24) 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. 25) Social Security Number or Federal ID: 364866352 26) Signature of Individual or Corporate Name: ar� � l �� -�'7 FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-31 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A. J. BRUNO CONCESSIONS LLC - EMPLOYEE BARBEQUE 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508)962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association ❑O A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address _ _ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: AJBRUNOCONCESSIONS@GMAIL.COM FAX: E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Is 1'7S, d --d Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: V Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) [] Food Service up to 100 or up to 10' PHF display $1*.r.68-- ❑ Food Service up to 10 -20020 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution Meals/Day) ❑ Caterer $25.00 I I Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no time4emperature controls required) (Check all that apply):RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs 0 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑� Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packed PHFs Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly ❑ �' 9 ,—, — , -- TT_=_.. Susceptible Population Facility Reheating of Commercially Processed Foods for Service Within 4 Hours u to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill _ E] Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only Preparation of Non-PHFs ElCustomer Self -Service "- ❑ Ice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health "-------"--""—"------""--" Total Permit Fee: $125.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and 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 59000..000 and the federal Food Code. 24) 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. 25) Social Security Number or Federal ID: 36-4866352 26) 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. _ J� IJtoa) �.nctSSl.nS �(-C• I/�..' Signature of Individual or Corporate Name By: Corporate Officer (Mandaton/, if Applicable) **Social Security No. (Voluntanj) 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\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly I Business/Organization Name:. y� �1� i os' o' ._o W --q 0 � � u 0-4 Wl* om-� Q) z � z Un � � 4 � z W4 (M� P4 ; T1114 � � � } � � [ \«$7 ) m / \ \ tv c 3 j / � } � � [ \«$7 ) m Jane Doucette From: Anthony Bruno<anthony@ajbrunoconcessions.com> Sent: Wednesday, June S, 2019 12:55 PM To: Jane Doucette Subject: Re: Xfinity Food Permits Hey Jane, 36 Lantern lane is fine and the FID beginning in 36 is the the one we have been using. On Wed, Jun 5, 2019, 12:20 PM Jane Doucette <Jdoucettegmansfieldma.com> wrote: Hi Anthony, I have 3 different addresses for you on the pre -filled applications but the ones you filled out this time have 36 Lantern Lane. 996 Charles Street in Providence and 31 Oxford Road are on the pre -filled ones. Also, the pre -filled ones have a FID number of 36-4866352 and 81-2524629. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This ernail has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. 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