HomeMy WebLinkAboutSt. Mary's Septemberfest - 12/31/2021FOR BOARD OF HEALTH USE 0 n P9
Date Received Permit Fee Approved U AUG 6 2021 it # Issued
Re Z
Temporary Food Establishment Permit Applica i n
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name:
Saint Mary Parish SeptemberFest
Establishment Address:
330 Pratt Street, Mansfield MA 02048
Establishment Mailing Address (if different):
Establishment Telephone No:
508-339-2981
2) Applicant/Owner Name & Title:
Rev. Michael K. McManus, Pastor
Applicant/Owner Address:
330 Pratt Street, Mansfield MA 02048
Applicant/Owner Telephone No:
508-339-2981
Applicant/Owner Email address:
office@stmarymansschool.org
3) Person In Charge of Onsite Operations & Title: Rev. Michael K.McManus, Pastor
PIC Address:
330 Pratt Street, Mansfield MA 02048
PIC Telephone No:
508-339-2981 Emergency/onsite Telephone No:
PIC Email Address:
office@stmarymansschool.org
4) Event Attending:
Parish SeptemberFest
Date(s):
September 12, 2021
Event Name:
Saint Mary Parish SeptemberFest
Event Location:
330 Pratt Street, Mansfield MA 02048
Event time:
11:00 a.m. to 4:00 p.m.
5) Check one
ID Food Truck
o Caterer
o Other:
6) Solid waste disposal plan:
7) Water Source:
8) Sewage disposal plan:
9 ) Please give a brief description of the food to be served:
10 ) Food will be prepared:
EM Onsite for immediate consumption
0 Onsite and held at proper hot/ cold holding temperatures
E] Offsite and held at proper hot/ cold holding temperatures
o Offsite, cooled and reheated on site
o Other:
11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Manager: Cameron Symonds
Allergen Awareness: Cameron Symonds
12) Please describe on site hand washing facilities that will be utilized:
We have multiple handwashing facilities readily available in the Rose Garde, in the
mobile concession trailer, and in the Parish Center.
13) Please list all sanitizing solutions that will be on site:
Approved sanitizers containing chlorine or quats will be available for use on site in
spray bottles and single —use wipes (Sans —wipes)
14) If applicable, please describe your FOG management plan or attach the written plan:
15) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the Base of Operations
or Commissary permit:
I, the undersigned, attest to the accuracy of the information provided in this application and I 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 cop
('}��so�f 105 CMR 5 0.000 and the federal Food Code.
19) Signature of Applicant: ' �� 4" , 7"
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.
20) Social Security Number or Federal ID: 04-210-6666
21) Signature of Individual or Corporate Name:
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 Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
04-210-6666
'Social Security No. (Volnntay) or Federal
Identification Nannber
*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.
ILC l Ur/LL/lull WCHCL/L Vf lIl HJJ[[LIL HJCL[J
d9u\ Department of lndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
rvww.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Saint Mary Parish SeptemberFest
330 Pratt Street
City/State/Zip: Mansfield MA 02048 Phone #: 508-339-2981
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2.0
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.
8. ® 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]**
11 ❑ Health Care
4.®
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
12.❑ Other
*Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
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 hereby certify, under the pains anti penalties ofperjury that the infornutdot provider) above is true and correct
Official use only. Do not write in this area, to be completed by city or town official.
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 Person: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or hnplied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permiUlicense number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
(A'
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date August 10, 2021
We, Saint Mary Parish SeptemberFest (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.
❑X We are a religious organization.
❑ Other:
Thank you, 77
Signature
Pastor
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
Food Protection Questionnaire for Catered Events
Date of Event: 9/12/2021 Event Time: 11:00 a.m. to 4:00 p.m.
Location of Event: Parish
List all foods that you will be chilling, holding, cooking, and/or re -heating at the event location:
On ice/Refrigerated Cooking Reheating
assorted beverages hamburgers fried dough
ice cream hot dogs chicken fingers
french fries lasagna
pulled pork apple pie
Food Manager Certification Person Trained On Site? M Yes o No
Allergen Awareness Menu Label Present? M Yes o No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
hamburgers > 1550 ice cream < 320
hot dogs > 155°
pulled pork "s 1600
chicken fingers % 1600
List the required temperature for each food as it leaves your preparation site:
beverages 400
ice cream 320
hot dogs i 1400
hamburgers > 1400
chicken fingers 7 1400
pulled pork ? 140.
french fries y 1400
lasagna 1400
How will the PHF be kept at or below 41°F? refrigeratots / freezers / coolers
How will the PHF be kept at or above 140°F? fryers / grilles / smoker / cambros / ovens
TimeofPHF?Setup 10:00 a.mServed Removed
Please describe hand washing and sanitizing supplies that will be provided on site:
We have multiple handwashing facilities readily available in the Rose Garden,
in the mobile concession trailer, and in the Parish Center. Aproved sanitizers
containing chlorine or quals will be available for use on site in spray bottles
and single -use wipes Sani-wipes .
List all equipment that will be supplied for an event, including but not limited to food
thermometers, cleaning wipes, utensils, non -latex gloves, heating utensils, ice etc.
Thermapen
gloves
wipes
various utensils
Ice
cookers
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