HomeMy WebLinkAboutJerry's Food Concessions - 12/31/2021a r
FOR BOARD OF HEA ,11 USE ONLY
Date Received Permit Fee Approved By �rmit #
Mobile Food Establishment (MFE) Permit Applicati
(Application must be submitted at least 14 business days before the planned opening
1) MFE Name: 1 D13A JEROYS A ors OoAlsasslOAIS
2) Applicant/Owner Name & Title: " WAI
Applicant/OwnerAddress: 111 R4 ilLe).-,Fs /J aiv 13 &q c1l 3 3 V 3
Applicant/Owner Telephone No: ri/, 7 S_
Applicant/Owner Email address: t?'/M PfG !ty® , co
3) Person In Charge of Onsite Operations & Title: -JS ApJO& 'Ii.4-wigiz
PIC Address: 6619t AS t,Is
PIC Telephone No: SA/le1/ Emergencylonsite Telephone No:
PIC Email Address: SA141t $ GV
a) Location of Service:
Date(s) if applicable: RIL , QCr
Event Name if applicable: AAIRS i f,2'c5r1V,41-S
Eventl Service Location: MASS
Event/ Service time: VARX
5) Length of Permit:
6) Solid waste disposal plan:
manual
o Temporary
Dates:
16 LC*01,01YY WAX
7) Water Source:
8) Sewage disposal plan:
l W Ji
16 cL,)pLO/J WA
9) Food will be prepared:
site for immediate consumption
o Onsite and held at proper hot/ cold holding temperatures
o Oifsite and held at proper hot/ cold holding temperatures
o Offsite, cooled and reheated on site
o Other.
10) Please attach a menu or a website link to the menu or give a brief description of the food to be served:
fRlFl-) oorwl FR i✓r/� F/?/FS
f=A1f0 CFRFoS ASSORreO lDAl1✓t7
11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Manager: JP1 4PRFL,
Allergen Awareness: JO 14PN'L
12) Please describe on site hand washing facilities that will be utilized:
1-114 Nn - c- STAL/01.1
13) Please list all sanitizing solutions that will be on site:
L CN sr smips
14) Do you have propane, fryolators and/or hoods on your truck? A10
If yes, you must first be inspected and approved by the Mansfield Fire Department. Phone number: 508-261-7321
Fire Department Signature of Approval:
15) If applicable, please describe your FOG management plan or attach the written plan:
16) Location of Base of Operations or Commissary:
(e OZo cOi-onlY w,4Y ,MMSPtL0
Please attach copies of Base of Operations or Commissary Permit.
17) Please list additional communities where a food permit is held:
AT
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 obtain copies of 105 CMR 590.000 and the federal Food Code.
18)Signature of
Pursuant to MGL Ch. 62C, 46. 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.
19) Social Security Number or
20) Signature of Individual or C
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.
tturee of In ' ' ual or Corporate Name
61,? S".2C7 9-3
"Social Security No. (Voluntary) or Federal
Identification Nnrnber
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.
CAUwn\s(eite\Desktop\SwtVs Do mwts\Food Establisbmmts. Temp\TAX CERTI[CATiON FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
aq 600 Washington Street
Boston, MA 02111
- www.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: r tS AM D54 ?MRYS reGGn CQoiK.FSSIG/+IJ
Address: $/7/ Rol yeA11VA LAk-t'S D8
#: 791- y 7 5`0 99&
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a employer with employees (full and/
5. ❑ Retail
or art -time).*
6. E)RestaurantBar/EatingEstablishment
2. m a sole proprietor or partnership and have no
T ❑ Office and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
S. ❑ Non-profit
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised
9. nEntertainment
their right of exemption per c. 152, § 1(4), and we have
100 Manufacturing
no employees. [No workers' comp. insurance required]*
4.n We are a non-profit organization, staffed by volunteers,
110 Health Care
with no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information,
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required mid such"
organization should check box Nl.
I am an employer that is providing workers' compensation insurance for my employees. Below is thepo/icy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. 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 certify, under the painq and penahes ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact
Phone
www.nrass.gov/din
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DATE OF EXPIRATION
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