HomeMy WebLinkAboutMansfield School Lunch/High School - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name VVV9A^g L "`^^_�� �r \�
Establishment Address a.s0 E c`A S�• Y V S 1 `i L v\l\,% OaOq$
Establishment Mailing Address (if different)
Establishment Telephone No Gork, q(30
Applicant Name & Title:—Z:)tL\.Q V\ • h°^^ S "� ly %�
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Applicant Address ace F asT 94. VV\>, , Si2 I �
Applicant Telephone No.: 1�)D%• 241-1 \`dad X 331a4 24 Hour Emergency No.: C� Cft • qc� l
Applicant Email
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Owner Name & Title (If different fro ppli ant)
Owner Address a Po->r\(- "�' YV'\_khASt' L_ 1 j V'11A O'lA Lf
Owner telephone number cSa t ,:,01 .Viljoa
Owner email: pv� l t 'g
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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
An Individual
_
El A Partnership
"R Other legal Entity
Person DirectlyResponsibleFor Daily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title: �aCy.(2� 170p0 �ry
Address: ac'-n etsk Sl .) �_" $ j'L-C_ l
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Telephone No: 50%. ab 1 1L.QD I( �3I 24 Hour Emergency No: 4j0 94 I J
FAX: 80�6 • a\yi '1�\3
E-mail: kV\S�\; .. SC�1�Q \C��v �\N�BMS�\S ldS m�S, CANN,
Alt E-Mail:
District Or Regional Supervisor (if applicable) I
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Name & Title7�h •T
tt^Sl'�n
Address: la s� Lo'.A. S \o l� r vpM
Telephone No: cjtA-A\P` •'r\g00 x2 Hour Emergency No:
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FAX: �_Io� o1\p\•1�\3
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E-mail: �h • �0 � � W� LS . GC1�.�
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL: i t�
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS: VV\ - ('0 - a
Name of Person(s) In Charge Certified in Food Protection Management:
JC�I�-L CV,,e-v
Name of In Charge Certified in Allergen Awareness Training
IPeerrson(ss)
Name of pest control company routinely inspecting the premises for evidence of pests A 9-C- L lw\U k
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. '-Q Yes
Does this establishment require a FOG permit? __jQS If yes, please attach the F G permit application.
Length of Permit:
Establishment Type:
Annual
0 Retail Food $125.00 Q Mobile Food Consession
Temporary
Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00 ❑x Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00 Lj Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 [A Residential Kitchen $100.00
Rain Date:
:T Milk &Cream $10.00 Ell Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(thatMemperature controls required)
(Check all that apply): Non-PHFs -non-potentially hazardous food(no time/femperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no fudherprocessing)
' Sale of Commercially Pre -Packaged Non-PHFs oCI PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service
Ej Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
❑-d Sale of Raw Animal Foods Intended Susceptible Population Facility
�[] Reheating of Commercially
to be Prepared by Consumer Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non- Customer Self -Service contact alternative, time as a public health
Perishable Foods Only Q Ice Manufactured and Packaged for control)
Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
+ Vacuum Packaging / Cook Chill
Offers RTE PHF in Bulk Quantities 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 copies of 105 CMR590.000 and the federal Food Code.
Signature of Applicant: l V VI .
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties oYpeijury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law. t 1
Social Security Number or Federal ID:
Signature of Individual or Corporate Name;
4_.
11
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.
I
Signature of Individual or Corporate Name v
O4to - o O l • &, I
*"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandntory, if Appli able)
*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:\Usem\.sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date 10 I a 2 1 2-�
We,
organization )
request a waiver of the Food Service Permit Fee for the following reason:
This is a request from a town department.p
Please list the department: �c F001 32vvw � ' "� ""�'S�' 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:
❑ We are not charging a fee for food/drink being served.
❑ We are a religious organization.
❑ Other:
Thank you, tq
Signature
�7
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature:
Date: