HomeMy WebLinkAboutFancheezical @ xfinity 10/31/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: TEMPORARY FOOD PERMIT
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:.
NATHANIEL BROWN
Whose place of business is:
FANCHEEZICAL - THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
NATHANIEL BROWN
Permit Expires: October 31, 2016
License Number: FS -28
Food Fee: $125.00
BOARD OF HEALTH
MichaeCvicCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS -28
FOOD ESTABLISHMENT PERMIT APPLICATIUN
--- - ---(�rpp ica ►on mus esu m— tte—d-a eas ays e ore e p an�open►ng--c-fa-Ve) l
1) Establishment Name FANCHEEZICAL - THE XFINITY CENTER
Establishment Address
.2) 885 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 85 MILL STREET
NEW BEDFORD, MA 02740
4) Establishment Telephone No (214) 518-9994
Applicant Name & Title: NATHANIEL BROWN
�5)
6) Applicant Address 85 MILL STREET, NEW BEDFORD, MA 02740
7) Applicant Telephone No.: (214)5 18-9994 24 Hour Emergency No.: j
I
8) Owners Name & Title NATHANIEL BROWN j
9) Owner Address (If different from applicant)
�i Owner's telephone number 2145189994
p i
i10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
❑ A Corporation
Name Title Address
V An Individual
-
❑ A Partnership
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:TATHANIEL
BROWN
j Address: �85
MILL STREET, NEW BEDFORD, MA 02740 j
Telephone No:
(214) 518-9994 24 Hour Emergency No:
FAX:
�- E-mail:
NATHANBROWN72(cD-GMAIL.COM -_
Alt E -Mail:
13) District Or Regional
Supervisor (if applicable)
Name & Title:
'Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
14 WATER SOURCE: TOWN
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees:
DEP Public Water Supply No: (If applicable)
117) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management: NATHANIEL S. BROWN
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): ❑
III
20) Location: ❑ Permanent Location
�IklvlF1oblie Moblie Start Date:
22) Establishment Type
Retail ( Sq. Ft)
❑ Caterer $12.50
E]Milk & Cream $5.00
Moblie End Date: ` y
Fv] Food Service up to 100 or
❑ Mobile Food & Consession $37.50
Moblie Comments: 1 /
--- — —
2- 1) Length of Permit:
up to 10' PHF display $62.50
F-1Food Service up to 101 -200
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
Annual
or up to 25' PHF display $75.00
❑ Pushcart $12.50 # of Pushcarts: 0
❑Seasonal -
Seasonal Dates:
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
[:]Food Service - Institution
F1Retail Snack Food $12.50
❑ Temporary
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $12.50
Temporary End Date:
Temporary Time:
Rain Date:
J
23) Food Operations Definitions: PHF - Potentially
Non-PHFs
I(Check all that apply): RTE - ready
hazardous food (time/temperature controls
- non -potentially hazardous food(no time/temperature
-to -eat foods (Ex. sandwiches, salads, muffins which
required)
controls required)
need no further processing)
Sale of Commercially Pre -Packaged Non -PRFs
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
J
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs -
❑ rY g
--
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
_
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
- -
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
-
-
Reheating of Commercially
Processed Foods for Service Within 4 Hours
-- - ---
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
___ _
❑ Customer Self -Service of Non PHF and Non-
[J Customer Self -Service
--
Perishable Foods Only
_ _ _
�❑ Preparation of Non-PHFs
contact alternative, time as a public health
control) )
— _-
❑ Ice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of
Animal OriginFoo{
Other Food Operations
E]Juice Manufactured and Packaged for
Retail Sale
for
[JC teraed res Events ngle olr Insti ut olnal Food Service
-
❑ Offers RTE PHF in Bulk Quantities
❑ Retail Sale of Salvage, Out -Of -Date
L_7Reconditioned Food
---
To be completed by the Board of Health
Total Permit Fee: $125.00
Payment is due with application ❑ waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply w'th 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain pg5,gs of 105 CMR 590.000 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.
25) Social Security Number or Federal ID: 450-35-6385n
26) Signature of Individual or Corporate Name: U
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.
*
Signalure of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification 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
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address:
t�'toQ
City/State/Zip: ((� 2 ✓�lV4 07 T Phone
Are you an employer? Check the appropriate box:
1. aI am a employer with T1 employees (full and/
or part-time).*
2. ❑ I 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. ❑ Health Care
12, El Other
*Any applicant that checks box # l 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 ant an employer that is providing workers' co�nsadon insurance for employees. Below is the policy information.
Insurance Company Name: ,., )h 31 �d S (� 0 t2 1'
Insurer's Address
I
City/State/Zip: \I � Cy -9 �f i
Policy # or Self -ins. Lia # 0 (02 2-0 3 1 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
Investil;ations of the DIA for insurance coverage verification,
6
0 ��?
I do hereby certify, der the pai s andpenalties of perjury that the information provided above is true and correct
Signature: lA1/( Date: 13J moi.
2,P 1p
Phone
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 #:
www.mass.gov/dia
Bank #
Pkt#
TOWN OF MANSFIELD
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER
Department: BOARD OF HELATH Date: JUNE 14, 2016
Schedule:
From Whom Account Number Amount
FANCHEEZICAL NATHANIEL BROWN 01512-445006 $ 125.00
Cash $ 125.00
Checks $
Total $ 125.00
Online or Wire Receipt $
TOTAL: $ 125.00
Mansfield, MA JUNE 14, 2016
To The Officer Making the Payments:
The above is a detailed list of moneys collected by me, amounting in the aggregate to:
$ 125.00 for the period ending JUNE 14 2016
which I have paid to the Town Treasurer whose receipt I hold therefor.
Employee or Det Head
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
applicantwho 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 sufe 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
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 bum 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
Form Revised 5-26-05