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Home My WebLink AboutMansfield School Lunch/Jordan Jackson - 12/31/2021q FOR BOARD OF HEALTH USE ONLY Permit # Issued If FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name O�S oo t@ J � '� WVnnST� tL.� Establishment Address aSs Establishment Mailing Address (if different) Establishment Telephone No Ljp� • 'd� `, S ac3 X 4 `�-� Applicant Name & Title: ��-poWn Applicant Address a1�0 E(�4) ��N S Qlcy Applicant Telephone No.: 'rjt% •�� )• 1`}� Jia�4 Hour No.:CSO U -W4 • 4Ska ,Emergency Applicant Email YI e YV�GrnS��4 Owner Name & Title (If different frnom applic nt) \ Owner Address �, ��( 4 ") , �,,,,, 6 V\-�\A Owner telephone number 50'6 • a�D 1• "16CO Owner email: ��lljtMc+p �� VV�bMSt�l�lStoo�S CSC Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. 0 A Corporation Name Title Address 11 An Individual 0, A Partnership 'S Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: �p� . a �`,15^a 44t a-1 24 Hour Emergency No: FAX: C3p$ . a�A tdSC�oo��, Cr�r_ E-mail: �ooao . CuB�rovL @ W�DN`Sf�u Alt E-Mail: District Or Regional Supervisor (if applicable) �^ JV4 l S Name & Title: Address: 'ac30 T 0 Y 2S 1' o `'� Telephone No: �q%. a�1.1�0�3�Ial 24 Hour Emergency No: Sa� �to(0 ' TSIo`l i FAX: S 0% . 2Ac k- 1 i 13 E-mail: n V) - LXV4wt-e_ rn�t s_t d Sc��ol e • c ' , Food Establishment Information WATER SOURCE: 6vw. SEWAGE DISPOSAL: 6w� DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: M — �__ �', �O - -Name of offPPers\on(s) IIn1 Charge Certified in Food Protection Management: Name of off Person(s) In Charge Certified in Allergen Awareness Training lJb C4%%" V'L Name of pest control company routinely inspecting the premises for evidence of pests A -Q %4 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. Y9 Yes Does this establishment require a FOG permit?_ If yes, please attach the FO permit application. Length of Permit: Establishment Type: Annual ❑ Retail Food $125.00 Mobile Food Consession [ 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 l0 201 + $300.00 0 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: Delinillons:PHF - Potentially hazardous food(timeRemperature controls required) (Check all that apply): Nan-PHF's- non -potentially hazardous/ood(no lime/temperature controls required) RTE - ready -to -eat roods (Ex, sandwiches, salads, mus ns which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs"*:] PHFCooked To Order �N Hot PHF Cooked and Cooled or Hot Held E] Sale of Commercially Pre -Packaged PHFs 'tS Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly 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 contact alternative, time as a public health Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Ice Manufactured and Packaged for control) of Non-PHFs Preparation Retail Sale P i] Offers Raw Or Undercooked Food Of 0 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale E] Vacuum Packaging / Cook Chill i] Offers RTE PHF in Bulk Quantities b 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 1105 CM 590.000 a the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, 1 certify under the penalties oil and paid state taxes required under law. 1 q Social Security Number or Federal ID: o 4 - \4 Signature of Individual or Corporate Name: I, to my best knowledge and belief, have fled all state tax returns ��001 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 -7-- , sb W� S � L� -Shoo( � vv , Signature of Individual or Corporate Name Z)qo . oo I • � "Social Security No. (Voluntanj) or Federal Identification Number Corporate Officer (Mandatory, if *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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc �•J (D U 0 U w N O N N W I .P ®rl 0 —o Mansfield Board of Health Request for Fee Waiver for Food Permit Date t o 3� $" We, organization ) request a waiver of the Food Service Permit Fee for the following reason: 19 This is a request from a town department. 1_ Please list the department: [��o4 ❑ 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 l *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: 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. 1 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. C__'�_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. Applicant Signature,, r V'\��`^ v`�� Date: Lt Applicant Name (please print clearly) L �AwN L-4 N 6L e 0 0 c O LL 0 `0 • 'E o- v O `v w m 0 cc < N C ry 'A�r' V Z .J I mg N 0 N N 0 0 h s