HomeMy WebLinkAboutMansfield School Lunch/Qualters Middle - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued �S
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name I V t, M S �Q tc� m` °O
Establishment Address Dqo E qA •
Establishment Mailing Address (if different)
Establishment Telephone No 6oc6 . A �o � • 'l5 3 O X Q1 6 m%
Applicant Name & Title: r--bo-W., `M . ^-far. �(`yy , rsb
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Applicant Address ay o �A_t;V Sk•� VVvwf%% a ld
Applicant Telephone No.:r50%,a41.-140oXbJ jvl�24Hour Emergency No.:CjOcc•'y3q•-7W%
Applicant Email
Owner Name & Title (If different frA ap licant) t, w� -w� VVNArn6Y" Spool
Owner Address 'a QgY�`�a r VWk_' jkjj
Owner telephone number Sa� . a4l - -15oo
Owneremail: Wu✓•(fit)
Cay,
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
M An Association
partner.
EJ A Corporation
Name Title Address
0 An Individual
_
0 A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: rGn D— CA V-M �Q. li:oo o J2.vwto. Vyl�_,
,
Address: a.A0 cAAgr Vr4_w6V'I8
Telephone No: 5 oc6, Dt4 \ • -15260 N, of fbi off{ 24 Hour Emergency No: ` ,YS ,
FAX: �JpFS. a�Dl l�%t3 f1
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicabl@1) _
Name & Title: L-_jw_• M , t
Address: vise, F-"4 <-.
Telephone No: 5pS. a�o\.Ijgpo �-b+SkaU,24Hour Emergency No: 50r6• oV o• kt�Z
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FAX: GjoS. rj%A13
E-mail: I
1�5C.�oIS.
Food Establishment Information
WATER SOURCE: ��
AGE DISPOSAL:
LNo.
of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS: yy� _ (0 •, L5 _ a
Name off Person(s) In Charge Certified in Food Protection Management:
(
t" & it vv'_�A�—
Name of Person(s) In Charge Certified in Allergen Awareness Training
r2n �rvn.o_a K,\—
Name of pest control company routinely inspecting the premises for evidence of pests A• b a4 Uwvt�
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. L�Yes
Does this establishment require a FOG permit? If yes, please attach
,,on ono
the FOO permit application.
Length of Permit:
Establishment Type:
�r] Annual
M Retail Food $125.00
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
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
0 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400
®Residential Kitchen $100.00
Rain Date;
Milk &Cream $10.00
Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required)
(Check all that apply): Non-PHFs- non-potenflally hazardous food(no fime/temperature controls required)
RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no
further processing)
`E] Sale of Commercially Pre -Packaged Non-PHFs IN PHFCooked To Order
'R Hot PHF Cooked and Cooled or Hot Held
[j Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And
for More Than a Single Meal Service
E] Delivery of Packaged PHFs Cold Holding For Single Meal Service
l PHF and RTE Foods Prepared For Highly
0 Sale of Raw Animal Foods Intended
'[ Reheating of Commercially
Susceptible Population Facility
to be Prepared by Consumer
Processed Foods for Service Within 4 Hours
Q Use of Process Requiring A Variance
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)
�F] Preparation of Non-PHFs Retail Sale
� Offers Raw Or Undercooked Food Of
Q Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Q Offers RTE PHF in Bulk Quantities
Prepares Food/Single Meals for
Q 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 CMR 590.000 sold the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of berlury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law. 1 t h
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: —�
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: Corporate Officer (Mandatory, if A li ble)
(04lo- C) O 1 . ao q
*"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:\Usen\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 i o 1 t q `.1,
We, U ���o�,� SCkZx:ots (restaurant/ 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: Lac..(, �Ckvs Vv��c�d
❑ 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,
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature:
Date: