HomeMy WebLinkAboutNo Coast Kitchen - 12/31/2021Date Re eived Permit Fee Approved By Permit # Issued
t ' �`16) kY 103 (.5
Mobile Food Establishment (MFE) Permit Application
(Application must be submitted at least 14 business days before the planned opening date)
1) MFE Name: 6 CV00J' IG '�R A LU,
2) Applicant/Owner Name & Title: ` wdr CL (ai V-ek-
ApplicanVOwner Address: 5 (ZtiOl,�o U 2,v aA iKk k Ol 6-o2
ApplicanVOwner Telephone No: ) 1� ( 3tLj - U7 pp
Applicant/Owner Email address: Y�0 C OgS��G��C�nQf!\1, L 1/VLGu C cat�1
3) Person In Charge of Onsite Operations & Title:
PIC Address: '5 2.k( 1Vb`,r Wa-CAA-e W\A mkoc)`Z
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PIC Telephone No: C� IL6 31 q - 01 a-) Emergency/onsite Telephone No:
PIC Email Address: y�0 C p 01A 1Q 6&(.c l,L(E CA
4) Location of Service: Koyk�C_Qy,_JAy
Date(s) if applicable: \fOJ• axsA JLL�e�s \h $ 2A al,-1 (2( S g2_11 2/
Event Name if applicable: \ ojy't &t>
Event/ Service Location: gl-v� luti-cV
Event/ Service time: 5jn1,A — ik'ioM
5) Length of Permit:
6) Solid waste disposal plan:
Annual
TYAS�f�OlJ�S
o Temporary
Dates:
7) Water Source: ((
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8) Sewage disposal plan: �/ r
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9) Food will be prepared:
o Onsite for immediate consumption
o Onsite and held at proper hot/ cold holding temperatures
E3 Mite and held at proper hoV cold holding temperatures
r W Offsite, cooled and reheated on site
o Other:
10) Please attach a menu or a�werblsite link to the menu or give a brief description of the be served:
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11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Manager: ayv\t
Allergen Awareness: �IJ U. Cuy-&
12) Please describe on site hand washing facilities that will be utilized:
13) Please list all sanitizing solutions that will be on site:
T� � S(ru,i.E;1 50/50 \,oU-c.c.JA 4c 1
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14) Do you have propane, fryolators and/or hoods on your truck? _-
If yes, you must first be inspected and approved by the Mansfield tFire Department Phone number: 508-261-7321
Fire Department Signature of Approval: Vas —7 Z\ 1
15) If applicable, please describe your FOG management plan or attach the written plan:
16) Location of Base of Operations or Commissary:
w00`--L4cy-C.
Please attach copies of Base of Operations or Commissary Permit.
17) Ple a list a dRi nal communities where a food permit is held:
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.1 have been instructed by
the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code.
18)Signature of
Pursuant to MGL Ch. 62C, sec.49A, I certify under the
have filed all state tax returns and paid state taxes regi
19) Social Security Number or FederalID:
20) Signature of Individual or Corporate
Ides of perjury that I, to my best knowledge and belief,
under law.
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The Worcester County Food Truck Center
WooTrucks is a division of Dogfather Vending, LLC
67 Main St, Boylston, MA 01505
Website: www.wootrucks.com Email: wootrucks@gmail.com Phone: 508 612 4583
Town of Boylston Permit Number 2021-2
07/01/2021
To Whom It May Concern,
This letter is to serve as notice that No Coast Kitchen LLC 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
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.
&6i�_ UL
Signature of Individual or Corporate Name
� 3 ,4 g7
**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.
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A.DDlicant Information Please Print LegiUly
Business/Orgmiiwtion Name:- N 0--� �`5'f — ` `—� �e>" LL C =----------- —_
Addmss: S 9,0�\Oo u a�
City/State/Zip:_ w M ) 6►6�LPhone
Are you anerrgrloya? Check the appropriatebax:
1.❑ I ama employer with employees (fulland/
2.1rpart-time).*
ama sole proprietor orpamlership andhaveno
employees worldng forme in any capacity.
[No workers' comp. insrnance required]
In We are a corporation and its officers have exercised
theirlight of exemption per c.152, §1(4), and we have
no employees. [No wuxrkas' comp. insrnance retlrm�edl'
4.n We are anon -profit organi7.atiorl, staffed by volunteers,
with no employees. [No workers' comp. inamce req.]
,4�3ty - 01no
Business Type (remm'e f:
S. Q Retail
6. E�Kestainant/Bar/Eating Establislm> att
7. Office and/or Sales (incl. teal estate, auto, etc.)
8. Q Non-profit
9. QEntettairmrent
10.n Manufacturing
11.Q Health Care
12.0 Other
-Any appliomt tint check box 41 [Host also fill out the section below showing theirworim' wtnpermnonpolicyinfonnation
**If the capotateofficers haveexanptedfliamelves, but the corporationhasothaemployees,awodc 'con xmfianpolicyisrecnritedandsuchan
otg mintion should check box #1.
I [artmr er{rloy+a tiYot isp►wtrlorgxal+�s' mrgre rliar utslemu e fot my ar�laytees Bebv is the polky brfatrr ffar.
Insurance Company Nine:
City/State/Zip:
Policy # or Se)f-ins. Lic. # Expiration
Attach a copy of the workers' carlgn mflon policy declaration page (dmingihepolicy manber ande:ph'ation date).
Failure to secure coverage as reWh-edrnrder Section 25A of MGL c.152 can lead to the imposition of cranial penalties of a
fine up to $1,500.00 and/or one-year unlaisommrt, 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 data copy of this statement maybe forwarded to the Office of
Investieations of the DIA for instuarrce coverage verification
I
City or Town:
L}' I over
I.' 111 ::1 1 (
Perndt/Lio nse#
Lsslmlg Authority (circle ease):
1. Board of Health 2. Building Department 3. City/Tom Clerk 4. Licensing Board 5. Selectmen's Oice
6. Odw
Phone #:
contact
www.nvas.gov/dia
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.
�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.
R�/ 1 have received a 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.
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.
Vz:Applicant Signature Date:
Applicant Name (please print clearly)