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Home My WebLink AboutSt. Mary's Catholic School - 12/31/2021rr `IV t Qe W 1 FOR BOARD OF HEALTH USE ONLY i Permit # Issued/ `° l , FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 5t•h�arvJs CawOtnG $f(Ool Establishment Address 330 Qra{%( $kYl.6� I`AW;4W4 , Mpf 0ti0c1$ Establishment Mailing Address (if different) E Establishment Telephone No y0B.3b2) . $00 Applicant Name & Title: Rw Ri GhAbi K . M�wlawu5 Applicant Address 330 bra Sky"+ fvAAGf((Ad' MA "0KS Applicant Telephone No.: 150 9. 530, Aft0 24 Hour Emergency No.: Applicant Email Owner Name & Title (If different from applicant) S} , MttM 5 C(XKQ td 6 66lnoa i Owner Address J Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. O A Corporation Name Title Address El An Individual El A Partnership d Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: PANlr. navy f\. Vokrsvtf/ 1 ?rivt.gaQ, Address: 330 QrO &4r-,tF NVMS�Wd Telephone No: Ij0q • ?;51A'�00 24 Hour Emergency No: FAX: So g . 33-1. so 62) E-mail: v�lyOtifC�ylQ @ Ski vv%-avxs66L�0°1.0 n Alt E-Mail: d: Zov\,® Si; fV%"y1AAA✓t 5 r> ok 00I.1i! rAM.lw�Pi DIZO✓1�Tj✓�.A ✓t(,f� �"c( District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Vi01 Food Establishment Information WATER SOURCE: I'oWv\- SEWAGE DISPOSAL: TOW w DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS:Move A !t(*idtti r , flip Name of Person(s) In Charge Certified in Food Protection Management: Gath� eth N L llA+c( Name of Person(s) In Charge Certified in Allergen Awareness Training Cam [JUGN Fi, tu641 Name of pest control company routinely inspecting the premises for evidence of pests 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. .LEI Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: (N Annual Retail Food $125.00 El Mobile Food Consession 0 Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175,00 it Manufacture Frozen Dessertslice Cream Temporary Start Date: (] Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: dFood Service up to 201 * $300.00 E] Pushcart $50.00 # of Pushcarts: s Temporary Time: E] Supermarkets $400❑ Residential Kitchen $100.00 Rein Date: / ( 5 Milk & Cream $10.00 i] Caterer $35.00 Food Operations: Oeffnfdons: PHF- Potentlallyhazardous hwd (fimaRemparatum controls required) Check all that Nan-PHFs- non-potenifelly hazardous fwd(no tlmertemperature controls requlrsd) t PPIY) RTE-ready-taeat foods, (Ex. sariMiches,salads, muffins which used no fudherpnwessing) [] Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order E] Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meat Service Delivery of Packaged PHFs Cold Holding For Single Meal Service [F] PHF and RTE Foods Prepared For Highly F] Sale of Raw Animal Foods Intended Susceptible Population Facility Ej Reheating of Commercially to be Prepared by Consumer El Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer self-serviceand/or alternative, time as a public health 0 Customer Self -Service of Non PHF and Non- ❑ g control Perishable Foods Only Ice Manufactured and Packaged for ) 1; Preparation of Non-PHFs Retail Sale ❑Offers Raw Or Undercooked Food Of E] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale �/ [] Vacuum Packaging I Cook Chill IdOffers, RTE PHF in Bulk Quantities Ej Prepares Food/Single Meals for E] 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 applloation and affirm that the food establishment operation will comply with 105 CMR 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant:" fl?� Pursuant to MGL Ch.52C, sec. 49A, i certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal to: T Signature of Individual or Corporate Name: f - r 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 IndMduaf or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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\Desktep\Scotrs Documeats\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Department oflndustrial Accidents Office of Investigations 9 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:T 6t . M�S Ck• WM o &rAQ 0 Address: 330 $ a,4 VA City/State/Zip: MaMt�tb(d Phone#�NS 5n8.33q, 4rs�Q Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail Ln I am a employer with employees (full and/ 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. g• ❑Non-profit [No workers' comp. insurance required] 3.❑ 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 no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, I Ln Health Care with no employees. [No workers' comp. insurance req.] 12.00ther Any applicant that checks box #1 must also fill out the section below showing thew workers' compensation policy information. *ffthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an rganization should check box #1. "am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. nsurance Company nsmer's Address: ;ity/State/Zip: 'olicy # or Self -ins. Lic. Expiration Wach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ,ailme to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to $1,500.00 and/or one -yew imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of under ciao 'fSR "4 rr n.) that the information provided above is true and correct Date: IlAt6 PLO Official use only. Do not write iu this area, to be completed by city or town ofciat City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact acoKo® CERTIFICATE OF LIABILITY INSURANCE oA e(M uoorcvw) 03/31/20 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder is an ADDITIONAL INSURED, the policy(las) must have ADDITIONAL INSURED provisions or he endorsed. N SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s). PRODUCER Massachusetts Catholic Self Insurance Group 66 Brooks Drive CONTACT NAME - PHONTEe_ 617-7465742 Nn 617-779-4572 ADDRESS: lossmntrol@masswtholic.org WSURER6 AFFORWNG COVERAGE NAWO INSURER At Massachusetts Catholic Self Insurance Grou Braintree MA 02184 INSURED INSURER B: DISURERC; Diocese of Fall River, MA INSURER D: Once of The Chancery INSURERE: 450 Highland Avenue INSURERF: Fall River MA 02722 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L R IYPEOFiNSURANCE POLICY NUMBER MNIDDCDYn POLICY MMNY EW _ LIMBS COMMERCIALGENERALLIABILRY CLAIMSMADE ❑ OCCUR .EACH OCCURRENCE $ 'R PREMISES PPEMISES(Ea En $ MEDEXP(A,ryonew,san) $ GENLAGGREGATELIMITAPPUESPER PERSONAL&ADVINJURY $ POLICY❑JJECT LOC OTHER: GENERAL AGGREGATE $ PRODUCTS-COMP/OPAGG $ S AUIOMOBILELU181DiY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON.OVMED AUTOS ONLY HAUTOS ONLY 'Ea acaJEaO L LIMIT $ BODILY RLIURY(Per maroon) S BODILY INJURY (Per accMant) S PROPERTYW GE Per aaiEen 8 $ UMBREUAUAB EXCESSLMS, OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE E DEB I I RETENTION$ $ A WORKERSCOMPENSAHON ANO EMPLOYERS'LUIBWTY YIN ANVPROPRICTOIWARTNEPIEXECUtIVE ❑ OFFICERIMEMBEREXCLUDED? (MARNPtaryia NH) Dyes tlU'DONOFO DE., rIes ON OFOPERATIONS bolo+i NIA Certificateof Approvat Commonwealth of Massachusetts 3000001012020 03/31/20 03/31/21 X STAIIJtE ER EL. PCHACCIDENT $ 1,000,0()0 E.LDISEASE-EAEMPLOYEB $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,0w DESCRIPNON OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 1 W, ANtllUonal Remarks Schedule, maybe aaadred Hmsre spew la requlmd) Re:046-0 / 046-3 St Marys Parish & School 330 Pratt Street Mansfield, MA 02048 Evidence of Workers Compensation Insurance Town of Mansfield, MA 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Mansfield Board of Health Request for Fee Waiver for Food Permit Date tY. is • 201.0 We, 5H. M e "Lk wkselnoo � �""1i 0" (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: ❑ 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, 0, j Signature Trf Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: v ti F [t� T� Y"M Q ^• w.. R ^ 4 W 4 L�� h y� ppc 4 py p ippt Polk C O Illivill