HomeMy WebLinkAboutFood & Friends Kitchen - 12/31/2021II FOR BOARD OF HEALTH USE ONLY r Permit# Issuedf
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opefring date) l c ✓
Establishment Name //5-//
Establishment Address J-2 ILI, /`%%/�j 5� %�%y�s. �/�/J /9V QED
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title:
Applicant Address �� v�i �%%CZji� S1� (// /�' �d/®i i • Z�r
Applicant Telephone No.: 24 Hour Emergency No.:
Applicant Email
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
'I An Association
partner.
A Corporation
Name Title Address
An Individual
10 A Partnership
H Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: 0 Qh^toll,,r
Address: J. me"" 5�,// �%�A,�/
Telephone No: j Q j a� �j 24 Hour Emergency No:
FAX:
E-mail: yj 2 / veul'l?
Alt E-Mail: JJ
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
No. of Food Employees: p
DEP Public Water Supply No: (If applicable)
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DAYS/HOURS: a G vi �i�T Jr2 /ora R/rye 'W
Name of Person(s) In Charge Certified in Food Protection Management:
Name ofPeerrs�on(s))IIn Charge Certified iinnJAllergen Training
�Awareness
Name of pest control company routinely inspecting the premises for evidence of pests f
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. Yes
Does this establishment require a FOG permit? IVO If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
'[Annual
[g Retail Food $125.00
Q Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
❑`i Temporary
I"' Food Service up to 100 INCLUDING
FOOD TRUCKS $175,00
1, Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
i Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400
,
� Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
E] Caterer $35.00
Food Operations: Definitions.,PHF- Potentially hazardous food(time4empereture controls required)
(Check all that apply): Non-PHFs- non -potentially hazardous lood(no timertemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
i Sale of Commercially Pre -Packaged Non-PHFs W1`pHFCooked To Order
E] Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs [FA Preparation of PHFs For Hot And
for More Than a Single Meal Service
Cold Holding For Single Meal Service
Delivery of Packaged PHFs
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Ej Sale of Raw Animal Foods Intended
® Reheating of Commercially to be Prepared by Consumer
i Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
O Customer Self -Service
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
contact alternative, time as a public health
Perishable Foods Only i] Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
Offers Raw Or Undercooked Food Of
0 Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
ED Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food Service
or Reconditioned Food
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 copigs of 105 CMR 590.000 and the federal) EooccL Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to y best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date A4 / �Zc7
We,
organization )
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
L_I We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. *
Please list the organization:
IK We are not charging a fee for food/drink being served.
X We are a religious organization.
❑ Other:
Thank you,
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
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CERTIFICATION
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gssCFltleF Commonwealth of Massachusetts Letter ID: L0207739520 O 17
.1 Department of Revenue Notice Date: December 3, 2018
Christopher C. Harding, Commissioner MA Taxpayer ID: 10292519
�5;y�peQ mass.gov/dor
CERTIFICATE OF EXEMPTION
�IIIwIIIPII�IIIt�II�rIIIPlnp�ll4l�ulll���l1i1i0lullll�l
FIRST BAPTIST CHURCH OF MANSFIELD
52 N MAIN ST
MANSFIELD MA 02048-2230
Attached below is your Certificate of Exemption (Form ST-2). Cut along the dotted line and display at
your place of business. You must report any change of name or address to us so that a revised ST-2 can
be issued.
DETACH HERE
�s5�5trT MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-2
Certificate of Exemption
FIRST BAPTIST CHURCH OF MANSFIELD MA Taxpayer ID: 10292519
52 N MAIN ST Certificate Number: 324392960
MANSFIELD MA 02048-2230
This certifies that the organization named above is an exempt purchaser under Chapter 64H, section 6(d) or (e) of the
Massachusetts General Laws. All purchases of tangible personal property by this organization are exempt from taxation to the
extent that such property is used in the conduct of the business of the purchaser. Misuse of this certificate by any tax-exempt
organization or unauthorized use of this certificate by any individual will lead to revocation. Willfid misuse of this certificate is
subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. This certificate is
non -transferable and may be suspended or revolted for failure to comply with state laws and regulations.
Effective Date: January 4, 2019 Expiration Date: January 3, 2029
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.
T_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.
/
V 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.
Applicant Signature
Applicant Name (please print clearly)
Facility Operational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation):
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday
Thursday
Sunday
71U 27c'4trl-"l
Tuesday 3 _1_1�
Friday
Wednesday
Saturday
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
3 compartment sink
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
Ice Making Machines
Fryolators
Grills or vens
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed? nr Yes No
If yes, at what station/sink?
1/LC l U11 //LV/LwCULI/L Vf LIl UJJUI. /L UJCLLJ
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
Business/Organization Name:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
LF
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
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ Non-profit
3.❑
[No workers' comp. insurance required]
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 staffed by volunteers,
I LF Health Care
are a non-profit organization,
with no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box #I 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 #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration Date:
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 thepains andpenalties 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 Person: Phone #: