HomeMy WebLinkAboutTravelin' Bones Xfinity - 12/31/2021C6 �'
FOR BOARD OF HEALTH USE ONLY
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PermitFee I�lA proved By Permit # Ipsued�l
If
Mobile Food Establishment (MFE) Permit Application t
(Application must be submitted at least 14 business days before the planned opening date)
1) MFE
2) Applicant(Owner Name & Title: , )
ApplicanyOwner Address:
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Applloant/Owner Telephone No: &6
Applicant/Owner Email address: r +
3) Person in Charge: of Onsite Operations & Till e. U o y.j
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PIC Address:
6
PICTelephone. No: Emergency/onsite Telephone No:
PIC-Email. Address:
4) Location of Service:�rt�.t�,
Date(s) if applicable: S /j— 2 /S— O
Event Name if applicable: n
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Event/_Service Locations Cii-4T
Event! Service time:
5) Length of Permit:
6) Solid wastedisposal plan:
dAnnual
o Temporary
Dates:
7). Water Source:
5) Sewage disposal plan:
I.
9) Food will be prepared:
o Onsite for immediate consumption
r--] _Onsiteandheld at proper hots cold holding temperatures
dOffsite and held at hot] holding
proper cold temperatures
O Offsite; cooledand reheated on site
o Other,
10) Please attach a menu or a website link to the menu or give a brief description of the food to be served:
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11) If P:isbeinghe Person who has completed the following ttaining5 andattachappropflat0
cer'� /n�_��l_t—oa p12) Please desconseand washing facilities that will be utilized:
4,. 'L 'LIe S I S J\ k R
13) Please list all sanitizing solutions that will be on site:
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14) Do you havepropane, fryolators and/or hoods on your truck? �S
If yes, you must first be Inspected and approved by the Mansfield Fire Department. Phone number:608-261-7321
Fire Department Signature of Approval:
15) If applicable, please describe your FOG management plan or attach the written plan:
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16) Location of Base of Operations or Commissary:
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Please attach copies of Base of Operations. or Commissary Permit,
17) Please list additional communities where a food permit is held:
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I, the undersigned, attest tothe -accuracy of the information provided in this application and I affirm that the food
establishment operation will comply y4th 105 CMR 000 and all other applicable law. I have haen instructed by
the board of health on how to obta, copil R 590.000. andthefederal Food Code.
18)Signature of Applicant:.
Pursuant to MGL Ch'62 sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all statdtax returns and paid state taxes required under law.
19) Social Security Number or Federal ID: —
20) Signature of individual or Corporate
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.
Le
Signature of Individual or Corporate Name 'W , orp rate officer (Mandatonj, if Applicable)
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"Social Security No. (Voluntary) or Federal
Identification. Number
*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:\Usmrs leite\Owktop\Scotes Documents\Food Estnblisliments-Tomp\TAX CERTIFICATION FORMAw
The Commonwealth of Massachusetts
UTDepartment qfIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02III
www.mass.govIdia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
City/State/Zip:
Are you an employer? Check the appropriate boa:
L❑ lama employer with employees (full and/
or part-time).*
2. ❑ [am a sole proprietor or partnership and have no
employees working for mein any capacity,
3.Wo workers' comp, insurance required]
e are a corporation and its officers have exercised
their right of exemption per e. 152, §1(4), and we have
no employees. [No workers' comp. insurance required]*
4. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone
Business Type (required):
5. Retail
6. Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. ❑Entertainment
10-n Manufacturing
I I Health Care
12.Q Other
'Any applicant (lint checks box #1 riiust. also till curt die section below showing their workers' compensation policy information.
°ll'the corporate officelsitave exempted themselves, but die corporation hasother employees; a workeis' Compensation policy is required and such an
organization should check box 41..
lam mt employer tizatis providing workers' compensation insurance, for my employees. Below is the policy illformatfon.
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. #
Expiration
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 tine
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 verifintinn
I do hereby certi�, a er thews anzl penalties ofpetJuiy ttia[ the information provide[[ aGoue is true qnd correek
Official use only, Do not Ivrite in this area, to lye completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www.nnass,gov/dia
Phone
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.
'�c' 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. 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.
"lV" I have received 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.
✓� 4�d 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
Applicant Name(please print clearly) V� t
The Worcester Coanty F®od Truck Center
Woo?rucks is a division of Dogfather Vending, !6G
67 Main St, Boylston, MA 01505
Website: www.wootrucks.com Email: wootrucks0gmall.com Phone: 508 6124583
Town of Boylston Permit Number 2021-2
06/07/2021
To Whom It May Concern,
This letter is to serve as notice that Travelin•Bones has authorization to use our
facility for the purposes of cleaning and sanitizing equipment, emptying
wastewater, food prep, cooking, food storage, potable water, and other uses to
be determined, to comply with the State of Massachusetts ordinances for proper
food truck operations.
This authorization expires on 12/31/2021, or before, upon notice by either party
of termination.
Mark Gallant
Owner
For more information about our center, and to see the last time this truck used
our facilities, please access our scheduling calendar at www.wootrucks.com
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