HomeMy WebLinkAboutFriends of Memorial Park 09/01/2016Commonwealth 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:.
FRIENDS OF MEMORIAL PARK
Whose place of business is:
FRIENDS OF MEMORIAL PARK
MEMORIAL PARK
PERSON(S) IN CHARGE
MEGAN GONZALEZ
Permit Expires: September 01, 2016
License Number: T-125
Food Fee: WAIVED
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Ereceived: Date Inspected: Approved By., Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 7 days prior to planned event)
1) Establishment Name: -0
--Cstatiiish�Fe�t
Address VC)
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
5) Applicant Name & Title:
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
U An Association
or partner.
El A Corporation
Name Title Address
0 An Individual
iV Other legal Enlity
12)P*monDkooVyResponoUdoForDaUy0pomUonu�wno�pomun|nohmAe'oupon�n�nnxnngern�.)
'-----' ----------------'-------
Name &Title: | /\'Ve
Telephone No: 24 Hour Emergency No:
13) District Or Regional SupervAor (if applicable) J
Name &Title:
Address:
Telephone No:
-----
24 Hour
Food Establishment information
14) WATER SOURCE: 7)
DEP Public Water Supply No: (If applicable) Tv
17) DAYWHOURS:
15) SEWAGE DISPOSAL.:
16) No. of Food Employees:
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 Individuals are certified, complete list Is on file.
as of 10/9/2001 In accordance with 105 CMR
Please attach copy of certificate
19) Person Trained In Anii-Choking Procodures (Il 25 Seals or more):
20) Location: ❑Permanent Localion 22) Establishment Type
❑ Mobile Mobtie Start Date; Caterer $25
[] Retail ( 5 Ft)
ale of Commerclaily Pro -Packaged Non•PHFs
h
q.
❑ Milk & Cream $2
Mobile End Date:
❑ Food Service up to 100 or
Mobile Food Consessfon $50
Moblie Comments:
up to 10' AHF display $75
[) PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Reheating of Commercially
❑ Food Service up to 101 -200
or up to 25' PHF display $100
❑ Mobile Food Temporary $25
0 Manufacture Frozen Desserls/ice Cream
$5/freezer
21) Length of Permit: n ;
t
(] Annual
ElFood Service up to 201 +
❑Pushcart $25
F]Seasonal , pV
//
or 25'+ PHF display $125
❑ Residential Kitchen $25
Seasonal Dates:of
(] Food Service - Institution
Pushcarts:
E) Retail Food $5
—
❑Temporary
Temporary Start Date:
( Meals/Day)
l] Retail Snack Food $10
❑ Tobacco products No Fee
Temporary End Date:
Temporary Time:
Rain Date:
23) Food OperationsDaCni!ions:
PHF . Polon!rally hazardous food (6morlemperaivre controls required)
Non-PHF's - non-polvallafty hazardous food(no rimeRemperafura contrors regulred)
Check all that apply):
RTE - ready-lo•aef foods (Ex, sanolnchos, salads, muffins which need ra furthor processing)
ale of Commerclaily Pro -Packaged Non•PHFs
h
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
❑ Salo of Commercially Pro•Packaged PHFs
❑Preparation of PHFs For Hot And
for more Than a 3ingie Meal Service
Delivery of Packaged PHFs
rY 9
Cold Holding For Single Meal Service
[) PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Reheating of Commercially
El Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑Vacuum Packaging / Cock Chill
Processed Foods for Service Within 4 Hours
[l Use of Process Requiring A Variance
❑ Customer Self -Service of Non PHF and Non-
P' bl
[] Customer Self-service
and/or HACCP Plan (including bare hand
Lor s a a oo s n y ❑ Ice Manufactured and Packaged for contact alternative, time as a public health
Preparation of NOn•PHF3 Retail Sale control)
Other Food Operations Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF In Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Dale
or Reconditioned Food To be completed by the Board of Health
-^ - Total Permit Fee:
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 with 105 CMR 590.000 and ail other applicable law, I have boon instructed by the
board of health on how to obtain copWs of 105 C/M�R/590,000 and the federal Food Code.
24) Signature of Applicant:.
i
Pursuant to MGL Ch.62C, sec. 49A, eriify under the penalties of perjury That I, to my best knowledge and belief, have filed all state tax returns
and paid slate taxes required under law. 4
25) Social Security Numberor Federal ID; 1't11 -4
26) Signature of Individual or Corporate Name;L3-
I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all State tax returns and paid all State taxes required under law,
Si ature of Individual or ^T
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 ofMassachusetts
Department of Industrial Accidents
Office of Investigations
Ur 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A1212licant Information Please Print Legibly
Business/Organization N
C!
Address: --Po 9'M
City/State/Zip:. MA'nC1 Q Id IM Phone #:�- 2& _ (Ptj j
Are you an employer? Check the appropriate box:
1. [j I am a employer with 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'.eomp, insurance rcq,]
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.[] Other
*Any applicant that checks box N I most also fill out the section below showing their workers' compensation policy information.
**If the corporate otiicats have exempted thomsolves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box Nl.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information,
Insurance Company Name;
Insurer's Address
City/State/Zip:
Policy # or Self -ins. Liu. # 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 MGT, 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, u
nder the pans an penalties ofperjury that the information proviled above is true and correct,
c: or„raJ/ l/l.{ dillTj M n.,.. h �n
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2, Building Department
6. Other
Contact Person:
Permit/License h
3. City/Town Clerk 4, Licensing Board 5. Selectmen's Office
www.mass,gov/dia
Phone #:
INTERNAL REVENUE SERVICE
P. O. BOX 2508
CINCINNATI, OH 45201
Date: F E 9 20 2-015
FRIENDS OF MEMORIAL PARK INC
127 SHAWMUT AVE
MANSFIELD, MA 02048-2334
Dear Applicant:
DEPARTMENT OF TRU TREAsVRy
Employer Identification Number:
47-1486162
DLN:
17053021340025
Contact Person:
JERRY FIERRO ID# 31119
Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:
December 31
Public Charity Status:
170 (b) (1) (A) (vi)
Form 990 Required;
Yes
Effective Date of Exemption:
January 1, 2014
Contribution Deductibility:
Yes
Addendum Applies:
No
We are pleased to inform you that upon review of your application for tax
exempt status we have determined that you are exempt from Federal income tax
under section 501(c)(3) of the Internal Revenue Code. Contributions to you are
deductible under section 170 of the Code. You are also qualified to receive
tax deductible bequests, devises, transfers or gifts under section 2055, 2106
or 2522 of the Code. Because this letter could help resolve any questions
regarding your exempt status, you should keep it in your permanent records.
Organizations exempt under section 501(c)(3) of the Code are further classified
as either public charities or private foundations. We determined that you are
a public charity under the Code section(s) listed in the heading of this
letter.
For important information about your responsibilities as a tax-exempt
organization, go to www.irs.gov/charities. Enter 114221-PCII in the search bar
to view Publication 4221 -PC, Compliance Guide for 501(0)(3) Public charities,
which describes your recordkeeping, reporting, and disclosure requirements.
Sincerely,
Director, Exempt Organizations
Letter 947