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FOR BOARD OF HEALTH USE ONLr4 Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
420
Establishment Named
Establishment Address �� W
Establishment Mailing Address (if different)
Establishment Telephone No
Applicant Name & Title: `` \\.
-s 1V
Applicant Address
Applicant Telephone No.- 24 Hour Emergency No.: `30$V 2;--!>9 _ a5cli
Applicant Email
4_0_\MA'j . lh� ---
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number :5oa-
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
El An Association
partner.
El A Corporation
Name Title Address
El An Individual
El A Partnership
I Other legal Entity
Person Directly Responsible For Daily Operations (o ner, person in charge, supervisor, �manager et .)
Name &QX1 U�
Address:Sa e< OI
Telephone No: S'z5S c:)Sci•f 24 Hour Emergency No: -a
FAX:
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable) -�
Name & Title:;Rvk`�
Address:
Telephone No:24 Hour Emergency No' c� G�3� , SO�
FAX:
/
E-mail: t
f
Food Establishment Information
WATER SOURCE: I
SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) J
No. of Food Employees: (�
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Vilergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests AAA Pe Sy 6o Afro
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. El Yes
Does this establishment require a FOG permit? !7 If yes, please attach the FOG permit application.
L ngth of Permit:Type:
—Esttablishment
Retail Food
Annual Ley $125.00 Mobile Food Consession
[i Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 0 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date: f� Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
0 Food Service up to 201 + $300.00 jr Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 n Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 Q Caterer $35.00 -!J
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Food Operations: Definitions. PHF- Potentially hazardous food (time/temperature controls requited)
(Check all that apply): Non-PHF's -non-potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
N((����
[] Sale of Commercially Pfb-P ckaged Non-PHFs [i PHFCooked To Order E] Hot PHF Cooked and Cooled or Hot Held
0 Sale of Commercially Pre -Packaged PHFs U Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service E] 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
E] Customer Self -Service of Non PHF and Non- contact alternative, time as a public health
Perishable Foods Only E] 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 [,J 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 viQpies of 105 CMR 590.000 and thg federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, 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 ID: '54- Ic� ;;rlV 4I
Signature of Individual or Corporate Name:
Date
We,
Mansfield Board of Health
Request for Fee Waiver for Food Permit
urant/ 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.
4 We are a religious organization.
❑ Other:
Thank you, I
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Ojfice of Investigations
600 Washington Street
Boston, MA 02111
W-7 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Address:
City/State/Zip:
#:� 5t)�--1�s4
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7. ELOffice and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• on -profit
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
o employees. [No workers' comp. insurance required]*
4. We are a non-profit organization, staffed by volunteers, 11.❑Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but ttre corporation has other employees, a workers' compensation policy is required and such an
organization should check box 41.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereb erd on er the pgips and
Si nature: �\
Phone #: ,1� oL Z1 �
llOfficial use only. Do not write in thi:
City or Town:
ofpeijuty that the information provided above is true and correct.
to be completed by city or town official.
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
Phone
www.mass.gov/dia
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 taxe equired
under law. k 0 ) 04,v �U�
111 �vvl � � y
llloL �
Signature of Individual or Corporate Name
**Social Secu_riittyl No. (Voluntary) or Federal
Identification Number
By Corpo
Off'�
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\Scott's Documents\Food Establisbments- Temp\TAX CERTIFICATION FORM.doe
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.
Y/A I 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. 1 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.
I have received a copy of the Polystyrene Container Reduction bylaw. 1 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
Applicant Name (please print clearly)
§ 180-16
ARTICLE III
Plastic Waste Reduction
[Added 4-10-2018 ATM by Art. 451
§ 180-16. Purpose.
§ 180-17
The purpose of this bylaw is to protect the Town's natural beauty and
irreplaceable natural resources by reducing the number of single -use
plastic check-out bags that are distributed and used in the Town of
Mansfield and to promote the use of reusable bags.
§ 180-17. Definitions.
The following words shall, unless the context clearly requires
otherwise, have the following meanings:
CHECK-OUT BAG — A bag provided by a store to a customer at
the point of sale. Check-out bags shall not include bags, whether
plastic or not, in which loose produce or products are placed by the
consumer to deliver such items to the point of sale or check-out area
of the store.
DEPARTMENT — The Mansfield Health Department.
HEALTH AGENT — The Health Agent for the Mansfield Board of
Health or their designee.
RECYCLABLE PAPER BAG — A paper bag that is 100% recyclable and
contains at least 40% post -consumer recycled content, and displays
in a visible manner on the outside of the bag the word "recyclable"
or a symbol identifying the bag as recyclable and a label identifying
the bag as being made from post -consumer recycled content and the
percentage of post -consumer recycled content in the bag.
RETAIL ESTABLISHMENT - Any business facility that sells goods
directly to the consumer, whether for or not for profit, including,
but not limited to, retail stores, restaurants, pharmacies, convenience
and grocery stores, liquor stores, seasonal and temporary businesses.
REUSABLE CHECK-OUT BAG — A sewn bag with stitched handles
that is specifically designed for multiple reuse and that:
A. Can carry 25 pounds over a distance of 300 feet;
B. Is machine washable; and
C. Is either:
(1) Made of natural fibers (such as cotton or linen); or
11