HomeMy WebLinkAboutMansfield School Lunch/Robinson - 12/31/20216
FOR BOARD OF HEALTH USE ONLY Permit#Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name W\Rsn �a lc1 SC�nOo� �(�v�c� t'b
Establishment Address arcs �� �} S�• ,a Cw� 1nnA o t� `lid
Establishment Mailing Address (if different)
Establishment Telephone No r"jcR , 'j..\p -) 5 t 3 x S t 3 19
Applicant Name & Title: -bow rN VVN . "-m �0 00 �w..0 I% �Y u a ✓
Applicant Address 2!5 o `_.q %y %�. VAN S1.e �a vvyq
Applicant Telephone No.: 50 %_ t q\io,) X Vs la, 4 Hour Emergency No.: S oiC• hq (OS 33
Applicant Email r
&W 9) V11`0.11�4t.t.- -X'LaolS.
(� � I'
Owner Name & Title (If different fro ap licant) —y w, yV\j,, •Y• uLL,W.
Owner Address a p� Q W W\%.'NJ o V V
Owner telephone number gyp% , SoO
Owner email:p�� VYXI In8{� �19 0 oi� . C awe
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
An Association
partner.
❑$ A Corporation
Name Title Address
El An Individual
El A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: e ` coon �.QyvtiQ 111/� trap n r
P -apt
Address: a�S t `b} si . yl(\��l L
Telephone No: 5,6 °6 • alp l 1� l3 lC 51 9j� q 24 Hour Emergency No:
FAX: rjp%. a4v �`41oj 1n 11 11
E-mail:bQyl�4yta...Po�ia..
W�.O�hSt'��olrjEhpdt5. C�
Alt E-Mail:
District Or Regional Supervisor (if applicably
_
Name&Title:�w� �• ��c1 �' on �y�wcu �t�C�a+i
Address: Aso
Telephone No:� 24IHour Emergency No:�ip . 45
�`T i a
FAX: �a�6• a�F 1
E-mail: nNAMI�
J
WATER SOURCE: 1 71+
SEWAGE DISPOSAL: Tsrry�
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
DAYS/HOURS: rn _ l- -7
Name of Person(s) In Charge Certified in Food Protection Management:
(� t� •bwc� L a l 1S m,
Name of Person(s) In Charge Certified in Allergen Awareness Training
lam �lotuu, `�a w r S4\-
,
1
Name of pest control company routinely inspecting the premises for evidence of pests A "-,b Pt4 C
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. 9 Yes
Does this establishment require a FOG permit? coo �9r y q p e.S If yes, please attach the FOG pe it applic on.
Length of Permit:
Establishment Type:
Annual
Q Retail Food $125.00 Mobile Food Consession
Q Temporary
Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Date:
FOOD TRUCKS $175.00 O 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 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 Q Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 0 Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food (timalfemperature controls required)
(Check all that apply): Nan-PHFs- non -potentially hazardous/ood(no time/temperature controls required)
RTE- ready -to -eat roods (Ex, sandwiches, salads, muffins which need no further processing)
'[] Sale of Commercially Pre -Packaged Non-PHFs El PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs b Preparation of PHFs For Hot And
Q Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
Sale of Raw Animal Foods Intended Susceptible Population Facility
Reheating of Commercially
Processed Foods for Service Within 4 Hours to be Prepared by Consumer Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Ej Customer Self -Service
y] Customer Self -Service of Non PHF and Non- contact alternative, time as a public health
Perishable Foods Only ice Manufactured and Packaged for control)
Preparation of Non-PHFs Retail Sale
p 0 Offers Raw Or Undercooked Food Of
❑t Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale 0 Vacuum Packaging / Cook Chill
Lj 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 apd the federal Food Code.
Signature of Applicant: r V A . h
Pursuant to MGL Ch.62C, sec. 49A, I certify under the
and paid stale taxes required under law.
that I, to my best knowledge and belief, have filed all state tax returns
Social Security Number or Federal ID:
Signature of Individual or Corporate Name; 04 _14lOOI 'X-In 6y'j�
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.
�q -S old
Signature of Individual or Corporate Name
O 41n _ ool • 'ao�
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory)if Apl licable)
*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:\UsenWeite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.dac
OR
R
PRI
MR'
) )
. ) |
j)(
/ a«|
a a\|
\ /{§
§ >:.
\
e=
w E)$
4 //�
2)\ V § 4-
$ t 2 {�
/ § m R}c y
# =n tee\ ƒ
�Eu
7 3 7 =
u»e
Q a)$ 2 \W » o\
v ' % \ E { 0 \ #
O 2 k \ ƒ{ /k
U % � 2\\ a
w o ®
� s ®
0
/ on UCL (
i ® \\0
m '/
U �\§
±_
_ \/S
\\
OD
ai
\®k
CL
\
r j]S
� \-
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date 101,I9 �2--
We.
Y)A LV�gl
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:
❑ 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, (--� V
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date: