HomeMy WebLinkAboutMansfield Summer Camp 12/31/2021Feo- \WouUP"'
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION a �i
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(Application must be submitted at least 30 days before the planned opening date)i }' j I) w 17 20,
Establishment Name Mansfield ,s1 mr'I(r Cayy
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Establishment Address ,tp Nopt .S+Y(d, Mavis? j, MA
Establishment Mailing Address (if different)
Establishment Telephone No %-j+, 264. L 12 9
Applicant Name &Title: 3b(Vrt burn#rt j A(LYta4iok DirectUV
Applicant Address Six Pa✓K KOW MQhsftt ld. MA
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Applicant Telephone No.: 568. 851. &- g 24 Hour Emergency No.:
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Applicant Email Sg1Ayllj6K' M0.j5'fl()JK0(. COrA_
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
11 An Association
partner.
El A Corporation
Name Title Address
O An Individual
El A Partnership
❑ Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: gob 2yah - Skm.mcr Carw? 9f(Ar
Address: 110 14ppt; Si v,, }, Mavlsfit lJ, MA
Telephone No: -7' 294 W19 24 Hour Emergency No:
FAX: 1(tt► ea+iiK e maK5-he rha. to►-
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL:
No. of Food Employees:
DEP Public Water Supply No: (If applicable)
DAYS/HOURS:
Name of Person(s) In Charge Certified in
Food Protection Management:
Mary 3d)rur
Name of Person(s) In Charge Certified in
Allergen Awareness Training
MOLVY .SdItAer
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. Xl Yes
Does this establishment require a FOG permit? MI If yes, please attach
the FOG permit application.
Length of Permit:
Establishment Type:
Ly Annual
❑Retail Food $125.00
E] Mobile Food Consession
❑n Temporary
J/Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
❑ Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00
E] Pushcart $50.00 # of Pushcarts:
Temporary Time:
E] Supermarkets $400
❑ Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
Caterer $35.00
Food Operations: Definitions: PHF- Potentially
hazardous food (time4omperature controls required)
Check all that a I Non-PHFs -non-potentially hazardous food(no fime/tempereture controls required) .
t PP Y) RTE- roady-to-eat foods (Ex. sandwiches, salads, mu/fins which need no hatherprocessing) ,
Sale of Commercially Pre -Packaged Non-PHFs
`d' PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
CI Sale of Commercially Pre -Packaged PHFs
❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
El 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
El Reheating of Commercially
to be Prepared by Consumer
❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
Customer Self -Service
and/or HACCP Plan (including bare hand
El 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
Offers Raw Or Undercooked Food Of
E] Juice Manufactured and Packaged for
Animal Origin
Other Food Operations
Retail Sale
Vacuum Packaging /Cook Chill
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 IW CMR 590.000 and the federal Food Code.
Signature of Applicant: 1Ll/ YI
Pursuant to MGL Ch.62C, sec. 49A, I certi�
and paid state taxes required under law,
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns