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HomeMy WebLinkAboutPlymouth Party, LLC - 12/31/2021FOR 130ARD OF HEALTH USE ONLY .08ite,Rke'ived Permit Fee Approved By Permit' Issued Mobile Food Establishment (MFE) Permit Application (Application must be submitted at least 14 business days before the planned opening date) 1) MFE Name: 2) Applicant/Owner Name & Title: Applicant/Owner Address: 1-% /C( 'e / v o75 Applicant/Owner Telephone No: Applicant/Owner Email address: / J 3) Person In Charge of Onsite Operations & Title: SG, PIC Address: ✓arA PIC Telephone No: Emergency/onsite Telephone No:5-0 0_0_r ^ yS PIC Email Address: 7 -t'— 4) Location of Service: x i P� % r /��uA Date(s) if applicable: // on C'10/ Y S Event Name if applicable: Event( Service Location: Event/ Service time: 5) Length of Permit: 6) Solid waste disposal plan: f� �� CDAnnual (� ratio �� �,S/ C Gncy o Temporary Dates: 7) Water Source: %/ ��. c9ti �� 8) Sewage disposal plan:`�n -n 9) Food ill be prepared: 7C Onsite for immediate consumption ED Onsile and held at proper hot/ cold holding temperatures 0 Offsite 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: io Jltpc/a^l ( � G S' 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: � / " Food Safety Manager: AZI rr.4 �(�//�y—,u � �/ c Allergen Awareness: �d J A /A 12) Please describe on site hand washing facilities that will be utilized: 31 13) Please list all sanitizing solutions that will be on site: 14) Do you have propane, fryolators and/or hoods on your truck? 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:, j ( e e'77 e^C ar _' /-(,, �/c VV r i . /[('� Please attach copies of Base of Operations or Commissary Perrin n / 17) Please list additional communities where a food permit is held: 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 1055 R.59jV 0 and all other applicable law. i have been instructed by the board of health on how to obtain copi¢i f 105 590.000 and the federal Food Code. 18)Signature of Pursuant to MGL Ch. 62C, sec. 49A,1 a have filed all state tax returns and paid 19) Social Security Number or Federal 20) Signature of Individual or Corporat artifV under the penalties of perjury that I, to my best knowledge and belief, state taxes required under law. Z e • E � |�1 e! |\/{ ! ®aE. I ji! f ? 7 \ = ° o m 2 % � . k § m rn � � � � z M � � � z on* z O' � � � 0' 2 o' CD � O CN Z CV) a CN N o 0 = Q w o _ Q w � Y U) Z ►i c b4 _ Cn i Z 0 0 2 O 'Q w o Z z wCD w O CL m Y g ix 0 Ix a °- UJ o m W z z w r Cl)Cl)w a `` • Z z vi \. 3 O o = Q W; J a w Q a_' Q a o t' ' o w N = J a Z �' W ) _ } a J �1 O o Z y LL w I"Q ►- z =o Q J (� � N Z a. N r N m z 3' H W 0 O ''' W M z °a W W O t) = m LL w F- V% z w _ zw Li W z o �; z ow) o, N Ix Z 1 c d W y a 3 X y m O z w m m z V to V ) ! o 2 � N a N H �' . a "fIIIS (:0:.::(li::\\'. SSACHIUS1:17S LIiB.IAC REALTH DEPARTMENT 2020 BUSINESS LICENSE PLYMOUTH PARTY LLC 25 LADY SLIPPER DRIVF. PLYMOUTH, MA 02360 DBA: PLYMOUTH PARTY LLC CID 4: 312422 BL ID #: 102234 LICENSE T: 4967 Your 2020 Business License for A LICENSE TO OPERATE A CATERING ESTABLISHMENT is printed below. Please retain a copy for your records. If you have any questions, please call the Public Health Department at 508-747-1620 ext. 10118. This is to certify that: Doing Business In: Has been granted: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH PUBLIC HEALTIi DEPARTMENT 2020 PLYMOUTH PARTY LLC PLYMOUTH, MA 02360 A LICENSE TO OPERATE A CATERING ESTABLISHMENT FEE $ 160 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws and 105 CMR 590.000 Expiration date: December 31, 2020 Sigracurc ICENSI:S ARE NOT TRANSFERABLE 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. Signature of Individual or Corporate Name By: C po Officer (Mandatory, if Applicable) a - / rs� ys� **Social Security No. (Voluntary) 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 Establishtneuts- Temp\TAX CERTIFICATION FORM.doc �\ u.c a.vsnussrn rressas.s J uiawsscn nuuw Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Business/Organization Name: 1r -7o d% G �w Phone#: Are you an employer? Check the appropriate box: Business Type (required): LF1 I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am 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. 8. ❑ Non-profit [No workers' comp. insurance required] 3.d We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, 1 L❑ Health Care with no employees. [No workers' comp. insurance req.] 12.©'6ther 6 'tC% e "Any applicant that checks box #t 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 and such an organization should check box #l. I ane an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. # Expiration Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 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 pain m nalties 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 www.mass.gov/dia Phone TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. ' c 1 ,i Applicant Signature d -�.� Date Applicant Name (please pri�t clearly / At G� ��- � l% 11'�U- PLYMOUTH PARTY LLC MENU COTTON CANDY SNOW CONES FROZEN DESERTS POPCORN CANNED SODA BOTTLED WATER