HomeMy WebLinkAboutJackson Effie Coffee Cabin Xfinity -12/31/2021FOR BOARD OF HEALTH USE ONLY
Date Received Permit Fee Approved By Permit # Issued
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Mobile Food Establishment (MFE) Permit Application
(Application must be submitted at least 14 business days before the planned opening date)
1) MFE Name: JA(V-W-) I (% CJOKEE Qk) iJ M (-C
2) Applicant/Owner Name & Title: /ia i� f ) �
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Applicant/Owner Address: 1/5- fJ
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Applicant/Owner Telephone No: J- Cy
Applicant/Owner Email address: d , 0 doyreA
3) Person In Charge of Onsite Operati ns & Title: 1 I%YtLa
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PIC Address: 11 i 1 vl � r e_ . LV
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PIC Telephone No: / ( $S
E�mlergency/onsiteTelephone No: OT ((d4a
PIC Email Address: S(xbC7(lGtI�nQ C
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4) Location of Service:
Date(s) if applicable: �r S (g g ?A gq 9 1 9/23
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Event Name if applicable:
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Event/ Service Location:
Event/ Service time:
6) Length of Permit:
6) Solid waste disposal plan:
o Annual
Isa Temporary q
Dates: 4 �l
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7) Water Source:
8) Sewage disposal plan:
9) Food will be prepared:
10 Onsite for immediate consumption
C3 Onsite and held at proper hot/ cold holding temperatures
o Offsite and held at proper hot/ cold holding temperatures
ED Offsite, cooled and reheated on site
E3 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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' �f C, U k�¢�
11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Managei-A)MY\ I olL. O'-C-S�00
Allergen Awareness: \k ft)w"- CC-. CAI eS po
12) Please describe on site hand washing facilities that will be utilized: �1 ®
aJL aA 514e— �%� �C)r:O1Q I hW> of
13) Please list all sanitizing solutions that will be on site:
3�ec-" " tK3gA— n
14) Do you have propane, fryolators and/or hoods on your truck?
If yes, you must first be inspected and approved by the Mansfield Fire Department. Phone number: 608-261-7321
Fire Department Signature of Approval:
16) If applicable, please describe your FOG management plan or attach the written plan:
16) Location of Base of Operations or Commissary:
Pleasebe'ttach copies of Base of Opera ons or Commissary Permit.
17) Please list additional communities where a food permit is held:
U4l +Dn
I, the undersigned, attest to the
establishment operation will cc
the board of health on how to o
18)Signature of
of the info ion provided in his application and I affirm that the food
106 CMR,j� 000 and all of f� applicable law. I have been instructed by
as of 1e6 R 590.000 *e federal Food Code.
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of per,
have filed all state tax returns and paid state taxes required under law.
19) Social Security Number or Federal ID: w `fq, 6
20) Signature of Individual or Corporate
mgbest kpdwledgeand belief,
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.
of Individual or Corporate Name
�/ , 111 m
"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.
C:\Users\sleite\Desktop\Scott's Docutnents\Food Establislunents- Ternp\TAX CERTIFICATION FORM.doc
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office ofInvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
o1
Phone #: 611 b ti r r �'
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
2.1( 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.
[No workers' comp. insurance required] 8. ❑ Non-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
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, 1 LE] Health Care
with no employees. [No workers' comp. insurance req.] 12.® Other C2-20 �1Cv
*.any applicant that checks box #1 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 #l.
I am 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
fore up to $1,500.00 and/or one-year im risonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a dA against the violVor. Be advised that a copy of this statement may be forwarded to the Office of
I do hereby e9{ify, under the pyjits aril penJi/nes of perjury that the
-7117
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermittLiceuse #
is true and correct.
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
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 implied, 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 permit/license number which will be used as a reference number. In addition, an applicant that
roust 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
Foam Revised 5-26-05
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.
(�
l" 1 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.
t
v j I 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,
sI ry,;frozen, semi -frozen, or other forms of beverages to the public for consumption.
I have received a copy of the Plas1
responsibility to ensure hat this bylaw is
violations of this bylaw ill result in fines
Applicant
Applicant Name (please print clearly)
)ylaw. 1 understand my
food establishment. I understand
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