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Home My WebLink AboutMansfield Pop Warner 5K 10/02/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 9ermit to Operate a Food Service Establishmen 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:. MANSFIELD POP WARNER Whose place of business is: MANSFIELD POP WARNER - MONSTER DASH 5K ROAD RACE/ WALK MANSFIELD HIGH SCHOOL 250 EAST STREET PERSON(S) IN CHARGE KARA COLBY Permit Expires: October 02, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-85 BOARD OF HEALTH MichaeCMcCCean, Chairman 10/9/2016 WAIVED FOR BOARD OF HEALTH USE ONLY p Date received: Date Inspected: Approved By: Permit # Issued T-85 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submiffed at least 30 days before-tiie-planned opening date) 1) Establishment Name MANSFIELD POP WARNER - MONSTER DASH 5K ROAD RACE 2) Establishment Address r o�1a ns ��e � d N 3) Establishment Mailing Address (if different) p.0, BOX 92 MANSFIELD, MA 02048 4) Establishment Telephone No -- 5) Applicant Name & Title: KARA COLBY, BOARD OF DIRECTOR 6) Applicant Address 7) Applicant Telephone No.: 5W-331,3717 24 Hour Emergency No.: 8) Owners Name & Title MQ n S (1'6 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 An Association or partner. A Corporation Name Title Address An Individual A Partnership Other legal Entity - - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc. Name & Title: KARA COLBY Address: Telephone No: L(508) 717-5360 24 Hour Emergency No: FAX: l E-mail: KARACOLBY30VERIZON.NET Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address. Telephone No: 24 Hour Emergency No: E-mail: FAX: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) 16) No, of Food Employees: 17) DAYS/HOURS: 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 101112001 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) 20) Location: %./Permanent Location 22) Establishment Type I I I Caterer $12.50 Moblie Moblie Start Date: _I Retail ( Sq. Ft) i i Milk &Cream $5.00 Moblie End Date: i Food Service up to 100 or I i Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 , Manufacture Frozen Desserts/ice Cream $12.50/freezer 21) Length of Permit: 1 Food Service up to 101 -200 Annual or up to 25' PHF display $75.00 Pushcart $12.50 # of Pushcarts: 0 Seasonal Food Service up to 201 + j Residential Kitchen $50,00 or 25'+ PHF display $137.50 Retail Food $50.00 Seasonal Dates: Food Service Institution Retail Snack Food $12.50 v? Temporary b�2/zf7) ' Temporary Start Date: ( Meals/Day) Tobacco Products $12.50 / 2�2Dt to Temporary End Date: Temporary Time: Rain Dale: 10h 23) Food Operations Definitions: PHF - Potentially hazardous food (umeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timehemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing) Sale of Commercially Pre -Packaged Non PRFs j [ ; PHFCooked To Order L. t Hot PHF Cooked and Cooled or Hot Hei ----- ------ - _-- _ -- - - 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 ' 1. i PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs I -;<; ._ - - - - Susceptible Population Facility -; Sale of Raw Animal Foods Intended I Vacuum Packaging /Cook Chill Reheating of Commercially 1 to be Prepared by Consumer Processed Foods for Service Within 4 Hours i ! I- i 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 OnlyIce Manufactured and Packaged for ' contact alternative, time as a public health control) Preparation of Non-PHFs Retail Sale Other Food Operations 1 Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin WATER &FRUIT, DEL'S LEMONADE Prepares Food/Single Meals for r/ ; _ i Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ( , Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health !i Total Permit Fee: Payment is due with application ;vl. waived 1, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply wit 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cope of 1 5 CMR 590.00 nd the rerFoodCode.24) Signature of Applicant:Pursuani to MGL Ch.82C, sec. 49A, I certify under the penalties of perjumy best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 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. __& I &�h - * Signature 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 cupiwov. mass.govldia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY, Pie Business/Organization Name: Address: PO M City/State/Zip: 1 1 1 a 1• Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with employees (full and/ or part-time).* 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 mployces. [No workers' comp. insurance required]* 4, [U e are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req] --- -- L.,,., ,.V, o rho 37d7 Business Type (required): 5. F-1Retai1 6. Restaurant/Bar/Eating Establishment 7, F-1officeand/or Sales (incl, real estate, auto, etc.)p S. C1>0 ofit 9, ❑ Entertainment 10.[] Manufacturing I1.❑ Health Care 12,0 Other it workers' compensation policy inrormauom 'Any applicant that checks box xi muse a!so nn uuu,� �w • ,*If the corporate officers have exempted themselves, but the corporation hes other employees, a workers' compensation policy is required and such an organization should check box #i. 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 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 DIA for insurance coverage verification, I do hereby certify! r der the pains an en a�ltleopel'uiy that the information provided ab a is tr a and correct n�'1 `�1 f _ -33c] -3 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 Mansfield Board of Health We Date 01, V Food Service Permit Fee for the following reason request a waiver of the Thank you, Signature �a *1 Title `( PC