HomeMy WebLinkAboutCreative Community Center 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishment,
Type: RETAIL SNACK FOOD
In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and
Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
LESLIE MCCONAGHY
Whose place of business is:
CREATIVE COMMUNITY CENTER
270 NORTH MAIN STREET
PERSON(S) IN CHARGE:
LESLIE MCCONAGHY, OWNER
Permit Expires: December 31, 2016
License Number: S-23
Food Fee: $12.50
BOARD OF HEALTH
Michae(McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
[DateDate Inspected: Approved By: Permit # Issued
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1) Establishment Name G �eQ �I ✓e (f ok-, , UM ►
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No 7-741-
5)
-741^5) Applicant Name & Title: �� cS e
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6) Applicant Address ave V�
7) Applicant Telephone No.: 9 24 Hour Emergency No.:
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8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
0 An Association or partner.
17 A Corporation
Name Title Address
KAn Individual
• A Partnership
L Other legal Entity
l,___ •: 1--r narenn in rharae. subervisor, manager etc.)
12) Person uirecuy mespunsiuiG -,y
Name &Title: s / e C /''®n�-
Address: d(� / G�� !�� �( 0%6
Telephone No: �� o� [0 24 Hour Emergency No: WC 2 7qX
FAX:
E-mail: ('Dh G} CLQ a or-,eA- Ve Comma, � CGr►'�
Alt E-MailUS e %'Y1 CC COPY -IC--aS-1
13) District Or Regional Supervisor (if applicable)
r
me & Title:dress:
lephone No: 24 Hour Emergency No:
ACT
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL: 12'4116
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: A164
17) DAYS/HOURS: 5UA) - JAI- '74 l D P--
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file. �✓
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ A11A
20) Location: Permanent Location
Q Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
Retail (`W Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $125.00
Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
Food Service - Institution
( Meals/Day)
Caterer $25.00
Milk & Cream $10.00
Mobile Food & Consession $75.00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
0 Pushcart $25 # of Pushcarts:
Residential Kitchen $100.00
Retail Food $100.00
Retail Snack Food $25.00
Tobacco Products $25.00
Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
23
P , Non-PHF's - non -potentially hazardous food(no timeAemperature controls required)
(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
A,—aa of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Use of Process Requiring A Variance
Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only E] Ice Manufactured and Packaged for contact alternative, time as a public health
F-1 Preparation of Non-PHFs Retail Sale control)
il I E3,juice Manufactured and Packaged for F1 Offers Raw Or Undercooked Food Of
Other Food Operations NV_T Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities E]Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application L] waived
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 cypies of 105 CMR 590.0 and the federal Food Code.
24) Signature of Applicant:
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. ( ,73
25) Social Security Number or Federal ID: 0�j u 7 G
26) Signature of Individual or Corporate Name:
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.
* Signat re of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Fed era l'ldentification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'U'r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
nnlicant information Please
to
Business/Organization Name: (�y �� ' �1 ,� "
Address: .2-j® N 0y+t'
City/State/Zip: N Cha SJR t 1 j M)t NSPhone #: �'�(4"
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2. 1 am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 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.]
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.❑ Manufacturing
11.0 Health Care
12.%Other 1� 1_6
*Any applicant that checks box #1 must also till out the section oeiow snowing [noir workers' compensation policy intormanon,
**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 Nan
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic.
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 DTA for insurance coverage verification.
I do hereby certify, under the pains andpenalties ofperjury that the information provided above is true and correct
Official use only. Do not write it? 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
www.mass,gov/dia