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Home My WebLink AboutMansfield Schools 12/31/2016Commonwealth 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: FOOD ESTABLISLHMENT 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ ROBINSON SCHOOL 245 EAST STREET PERSON(S) IN CHARGE: BARBARA PALIE, FOOD SERVICE MANAGER Permit Expires: December 31, 2016 License Number: FS -45 Food Fee: WAIVED Milk & Cream 0 BOARD OF HEALTH AichaeCMcCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: TOWN OF MANSFIELD - SCHOOL DEPARTMENT having a place of business at. Town of Mansfield 6 Park Row Mansfield, MA 02048 MANSFIELD SCHOOL LUNCH @ ROBINSON SCHOOL 245 EAST STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -45 Scott Leite, Heaah ,Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred --------------- FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -45 FOOD ESTABLISHMENT PERMIT APPLICA I IUN pp , ,ion mus esu mi e a eas ays e ore e p anne opening a e 1) Establishment Name MANSFIELD SCHOOL LUNCH @ ROBINSON SCHOOL 2) Establishment Address 245 EAST STREET 3) Establishment Mailing Address (if different) 245 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No 508-261-7513 x51319 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR I 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 — -- —_� 7) Applicant Telephone No.: (508) 261-7400 X33124 24 Hour Emergency No,: (508) 339.6633 8) Owners Name & Title TOWN OF MANSFIELD - SCHOOL DEPARTMENT - 9) Owner Address (If different from applicant) 2 PARK ROW, MANSFIELD, MA 02048 — — Owner's telephone number 10) Establishment Owned By: ❑ An Association ❑ A Corporation ❑ An Individual--------- ❑ A Partnership W Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address E-mail: dawn.langtry@mansfieldschools.com _ 1')1 Darenn nimmnlv RP-,nnnsihle For Daily Operations (owner, person In cnarge, supeivisVi, uianayci va .j Name & Title: i BARBARA PALIE, FOOD SERVICE MANAGER i ------------------ �Address: — 245 EAST STREET, MANSFIELD, MA 02048 – — – -- — — — No: (508) 261-7513 x51319 24 Hour Emergency No: (508) 339-6533 (508) 261-7413 rTelephone FAX: E-mail: ----- —----� Alt E -Mail: _ _ -- --- -- ------ ---- — -- --- 13) District Or Regional Supervisor (if applicable) Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR A—ddress: 250 EAST STREET, MANSFIELD, MA 02048 Emergency No: (508) 866-4512 Telephone No: (508) 261-7400 X33124 24 Hour E-mail: dawn.langtry@mansfieldschools.com FAX: (508) 261-7413 _--_—_ Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 4 17) DAYS/HOURS: M -F 7:00 AM - 3 PM -- -- -- -- 18) Name of Person In Charge Certified in Food Protection Management: BARBARA PALIE 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 DAWN M. LANGTRY certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: 91 Permanent Location 22) Establishment Type ❑ Caterer $12.50 e Moblie Start Date: ❑ Mobile ❑Retail ( Sq. Ft) Milk & Cream $5.00 � � Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 F1Food Service up to 101 -200 Manufacture Frozen Desserts/Ice Cream El $12.50/freezer 21) Length of Permit: n Annual or up to 25' PHF display $75.00 i- Food Service up to 201 + ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Seasonal or 25'+ PHF display $137.50 E]Retail Food $50.00 Seasonal Dates: Food Service - Institution ❑ Retail Snack Food $12.50 ❑ Temporary Temporary Start Date: A0 Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: �— Rain Date: �3) Definitions: PHF -Potentially hazardous food (fimeftemperature controls required) Food Operations Non-PHF's - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non -PRFs F-/] PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held F� _ for More Than a Single Meal Service —, ---- ❑ Sale of Commercially Pre -Packaged PRFs 0 Preparation of PRFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility ---- ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer 91 Reheating of Commercially ❑ Vacuum Packaging / Cook Chill — ----- —) 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- Customer Self -Service Perishable Foods Only❑Ice contact alternative, time as a public health control)_ ❑ Offers Raw Or Undercooked Food Of Manufactured and Packaged for Retail Sale _ -- _ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for Other Food Operations Retail Sale Animal Origin 91 Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities J ❑ 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 W waived 1, 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 copies of 105 CMR 590.000 and tl;e federal Food Code, 24) Signature of Applicant: 14:2n, ry t, L Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-6001209 26) Signature of Individual or Corporate Name: W-1-1 that I, to my best knowledge and belief, have filed all state tax returns - SGloo Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: MANSFIELD SCHOOL LUNCH @ ROBINSON SCHOOL ADDRESS: 245 EAST STREET TELEPHONE AT LOCATION: 508-261-7513 x51319 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: 04-6001209 FEE: $5.00 PERMIT NUMBER: FS -45 SIGNATURE: DATE: S l------- § k , ƒ « « « »O « ? :. « \p L § \ / ƒ a \ L ƒ / 00 2� L, ƒ� $ $ � \ � 1*0 a I :^ 3 'C' � % f 3 .q E m � V �7It- i r � . ƒ \ o �\ 00 o/ ƒ 2\¥ § k 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. * Signature of Individuai-or Corporate Name (Mandatory) By, Corporate Officer (Mandatory, if applicable) o q — (Doo/'109 ** Social Security Number (Voluntary) or Fed eral'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. 11 Mansfield Board of Health We, M AM& w -'w Food Service Permit Fee for the following reason Thank you, Date 6TI16 request a waiver of the '--� V%" Signature Title Commonwealth 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: FOOD ESTABLISHMENT 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ QUALTERS MIDDLE SCHOOL 240 EAST STREET PERSON(S) IN CHARGE: BRENDA CORMIER, FOOD SERVICE MANAGER Permit Expires: December 31, 2016 License Number: FS -47 Food Fee: WAIVED Milk & Cream V BOARD OF HEALTH MichaeCNcClean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: TOWN OF MANSFIELD - SCHOOL DEPARTMENT having a place of business at.- MANSFIELD t: MANSFIELD SCHOOL LUNCH @ QUALTERS MIDDLE SCHOOL 240 EAST STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -47 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY p Date received: Date Inspected: Approved By: Permit# Issued FS -47 FOOD ESTABLISHMENT PERMIT APPLICATION pp ►ca ion mus esu mi e a eas ays e ore e p anne opening a e 1) Establishment Name MANSFIELD SCHOOL LUNCH @ QUALTERS MIDDLE SCHOOL 2) Establishment Address 240 EAST STREET __ ---- -- - - 3) Establishment Mailing Address (if different) 240 EAST STREET MANSFIELD, MA 02048 - 4) Establishment Telephone No - 508-261-7530 X23108_________- 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 - 261-7400 x33124 24 Hour Emergency No.- (508) 339-7618 7) Applicant Telephone No.: (508 ) 8) Owners Name & Title TOWN OF MANSFIELD - SCHOOL DEPARTMENT MA 02048 MANSFIELD, , - 9) Owner Address (If different from applicant) 2 PARK _ ---- --- 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. Name Title Address El Corporation I - - ❑ An Individual _------ - -- -- ❑ A Partnership __ ---- - -- -- 91 Other legal Entity I ---------- -- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) -_ -_-___--_____.------------- Name & Title: BOO BRENDA CORMIER, FD SERVICE MANAGER - - Address: 240 EAST STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-7530 X23108 24 Hour Emergency No: (508) 339-7618 -- - -- FAX: (508) 261-7413 --- - --- - - ----------- --------- ------- E-mail: BRENDA.CORMIER(cD_MANSFIELDSCHOOLS_CO - - Alt E -Mail: _ _ -- ------------------ - - -- --- - 13) District Or Regional Supervisor (if applicable) __- Name & Title: DAWN M. LANGTRY, FOOD SERVICE DIRECTOR Address: 250 EAST STREET, MANSFIELD, MA 02048 — _-- - -_ Telephone No: (508) 261-7400 X33124 24 Hour Emergency No: (508) 866-4512 - - -- FAX: (508) 261-7413 �E-mail: DAWN.LANGTRY@MANSFIELDSCHOOLS.COM Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 8 DEP Public Water Supply No: (If applicable) -- 17) DAYS/HOURS M -F 6:30 AM - 2 PM 18) Name of Person In Charge Certified in Food Protection Management: BRENDA L. CORMIER 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 DAWN M. LANGTRY certificate — ---- 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location I 22) Establishment Type ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: Mobile Comments: 21) Length of Permit: 91 Annual ❑ Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 0 Food Service up to 201 + or 25'+ PHF display $137.50 F./I Food Service - Institution 4(,0 Meals/Day) ❑ Caterer $12.50 W Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) _ -- Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged Non -PRFs �l Sale of Commercially Pre -Packaged PRFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations W PHFCooked To Order Preparation of PHFs For Hot And Service —For Highly Foods ❑ Cold Holding For Single Meal Susceptible Population Facility ] Sale of Raw Animal Foods Intended Consumer Vacuum Packaging / Cook Chill - to be Prepared by - ❑ Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand time as a public health ❑ Ice Manufactured and Packaged for contact alternative, control) — Retail Sale _ --_ Packaged for _ - ❑ Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Animal Origin — — Retail Sale Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or In Food Service ��®r ail Sale of Salvage, Out -Of -Date ] econditioned Food To be completed by the Board of Health Total Permit Fee. Payment is due with application _ waived J 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 copies 590 OOr 0 and thifederal Food Code. 24) Signature of Applicant: \ I Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-6001209._,�v� 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: MANSFIELD SCHOOL LUNCH @ QUALTERS MIDDLE SCHOOL ADDRESS: 240 EAST STREET TELEPHONE AT LOCATION: 508-261-7530 X23108 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: FEDERAL IDISS NUMBER: 04-6001209 FEE: $5.00 PERMIT NUMBER: FS -47 SIGNATURE: , DATE: 0 E Z 0 0 v 0 w 0 m 0 O O �_ m m qC u n O .� d 4" 3 ,P c cs Commonwealth 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: FOOD ESTABLISHMENT 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL 250 EAST STREET PERSON(S) IN CHARGE: CAROL D'AMBRA, FOOD SERVICE MANAGER Permit Expires: December 31, 2016 License Number: FS -44 Food Fee: WAIVED Milk & Cream W BOARD OF HEALTH MichaeCvicCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: TOWN OF MANSFIELD - SCHOOL DEPARTMENT having a place of business at: Town of Mansfield 6 Park Row Mansfield, MA 02048 MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL 250 EAST STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 12/31/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -44 Scott Leite, Heaah ,.gent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -44 FOOD ESTABLISHMENT PERMIT APPLICATION pp ica ion mus esu mi e a eas ays ��7annecTopenin a e CAROL D'AMBRA, FOOD SERVICE MANAGER 1) Establishment Name MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL Address: 2) Establishment Address 250 EAST STREET 3) Establishment Mailing Address (if different) 250 EAST STREET (508) 261-7400 x33142 24 Hour Emergency No: (508) 339-3241 (508) 261-7413mail MANSFIELD, MA 02048 4) Establishment Telephone No 508-261-7400 x33124 : 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR CAROL.D'AMBRA(c�MANSFIELDSCHOOLS.COM _ — -- Alt E -Mail: 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 F7)Applicant Telephone No.: (508) 251.7400 x33124 24 Hour Emergency No.: (508) 339-3241ners Supervisor (if applicable) Name & Title TOWN OF MANSFIELD - SCHOOL DEPARTMENT _- -- -- 9) Owner Address (If different from applicant) 2 PARK ROW, MANSFIELD, MA 02048 Owner's telephone number Address: 250 EAST STREET, MANSFIELD, MA 02048 — —-------- - (508) 261-7400 X33124 24 Hour Emergency No: (508) 886-4512 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. El Corporation Name Title Address ❑ An Individual _ -- ---- --- - --- I ❑ A Partnership j W Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person In charge, supervisor, manager ac,) Name & Title: CAROL D'AMBRA, FOOD SERVICE MANAGER Address: 250 EAST STREET, MANSFIELD MA 02048 Telephone No: (508) 261-7400 x33142 24 Hour Emergency No: (508) 339-3241 (508) 261-7413mail : 7E- CAROL.D'AMBRA(c�MANSFIELDSCHOOLS.COM _ — -- Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: DAWN M. LANGTRY, FOOD SERVICE DIRECTOR Address: 250 EAST STREET, MANSFIELD, MA 02048 — —-------- - (508) 261-7400 X33124 24 Hour Emergency No: (508) 886-4512 Telephone No: E -mall: dawn. Iangtry@mansfieldschools.com FAX: (508) 261-7413 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: M -F 6:30 AM - 2 PM Food Establishment'Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 10 18) Name of Person In Charge Certified in Food Protection Management: CAROL D'AMBRA 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 DAWN M. LANGTRY certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑� J 20) Location: 0 Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: n Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 Food Service up to 201 + or 25'+ PHF display $137.50 91 Food Service - Institution 450 Meals/Day) ❑ Caterer $12.50 0 Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 23) Food Operations I (Check all that apply): Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) - — - - - Sale of Commercially Pre -Packaged Non-PHFs FV� PHFCooked To Order Yj Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs FV� Preparation of PHFs For Hot And Cold Holding For Single Meal Service — -------- ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility - ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill — ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only Q Customer Self -Service ❑Ice Manufactured and Packaged for Retail Sale —_ —_ n Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities i. 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 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 copies of 105 CMR 594.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-E 26) Signature of Individual or Corporate Name: that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL ADDRESS: 250 EAST STREET TELEPHONE AT LOCATION: 508-261-7400 x33124 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: 04-6001209 FEE: $6.00 PERMIT NUMBER: FS -44 SIGNATURE: "—�\rv, DATE: 1GI j F-,- q L-2 w 1§ Commonwealth 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: FOOD ESTABLISHMENT 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:. TOWN OF MANSFIELD - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON 255 EAST STREET PERSON(S) IN CHARGE: DIANE PENNELLATORE, FOOD SERVICE MANAGER Permit Expires: December 31, 2016 License Number: FS -46 Food Fee: WAIVED Milk & Cream W BOARD OF HEALTH MichaeCvicCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: TOWN OF MANSFIELD - SCHOOL DEPARTMENT having a place of business at: Town of Mansfield 6 Park Row Mansfield, MA 02048 MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON 255 EAST STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 12/31/2016 unless previous to that time is suspended or revoked. Expires 12/31/2016 License No.: FS -46 Scott Leite, 9--!'ealth .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD'OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -46 FOOD ESTABLISHMENT PERMIT APPLICATIUN -- pp ica ion mus esu mi e a eas ays ire e p anne opening a�—--� 1) Establishment Name MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON �2Establishment Address 255 EAST STREET - — — _ i 3) Establishment Mailing Address (if different) 255 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No 508-261-7525 x44127 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR i 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 17) Applicant Telephone No.: (508) 261-7400 X33124 24 Hour Emergency No.: (508) 339-3670 i �8) Owners Name & Title TOWN OF MANSFIELD - SCHOOL DEPARTMENT 9) Owner Address (If different from applicant) 2 PARK ROW, MANSFIELD, MA 02048 Owner's telephone number 5082617525 --- 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 — - ------ _ -- --- ---- - - --- -- �W Other legal Entity ---- 12) Person Directly Responsible [-or Ually uperaiions kowner, person m cndi ye, suNCi vlavi , i nai iayvi U "q ----------------------- ------------------------------------------------ - Name & Title: DIANE PENNELLATORE, FOOD SERVICE MANAGER Address: 255 EAST STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-7525 x44127 24 Hour Emergency No: (508) 339-3570 FAX: --- (508) 261-7413 — --_— -- -�— ---- - E-mail: -- — — — EAt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: DAWN M. LANGTRY, FOOD SERVICE DIRECTOR Address: 250 EAST STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-7400 X33124 24 Hour Emergency No: (508) 866-4512 FAX: (508) 261-7413 E-mail: dawn.langtry@mansfieldschools.com Food Establlis'hmEnt Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 8 1 17) DAYS/HOURS: M -F 6:30 AM - 2:30 PM 18) Name of Person In Charge Certified in Food Protection Management: DIANE M PENNELLATORE 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 DAWN M. LANGTRY Lcertificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): � _— — 1 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Milk & Cream $5.00 j Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 ❑ $12.50/freezer j i 21 Length of Permit: g n Annual or up to 25' PHF display $75.00 � Food Service up to 201 + ❑ Pushcart $12.50 # of Pushcarts: E] Residential Kitchen $50.00 ❑ Seasonal or 25'+ PHF display $137.50 ❑ Retail Food $50.00 Seasonal Dates: Food Service - Institution ❑ Retail Snack Food $12.50 ❑ Temporary Temporary Start Date: 400 Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: _ 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no timeRemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs F-/] PHFCooked To Order ❑d Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs n Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer 0 Reheating of Commercially -------- ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ----------- ------- - ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand n Customer Self -Service of Non PHF and Non- Customer Self -Service Foods Only contact alternative, time as a public health control) E] Ice Manufactured and Packaged for Retail Sale _— _ �Perishable _ Q Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Other Food Operations Retail Sale Animal Origin V Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ 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 F,/] 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 o twin copies 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 penaltim of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-6001209 26) Signature of Individual or Corporate Name: G1t� ury that I, to my best knowledge and belief, have filed all state tax returns r Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON ADDRESS: 255 EAST STREET TELEPHONE AT LOCATION: 508-261-7525 x44127 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: 5082617525 FEDERAL ID/SS NUMBER: 04-6001209 FEE: $5.00 PERMIT NUMBER: FS -46 SIGNATURE: DATE:----- P - z LL Q' W cR z� cn � o c .4 0 -0 Z o c za Lim z I= a W g W W z u a �' ® v'i V 2 o � P - z t o k u Mansfield Food Service List of Staff ServSafe Certified School Year 2016-2017 Dawn M. Langtry— Food Service Director Mansfield High School Carol D'Ambra — Food Service Manager Thea Pesce —Senior Cook Deb Harney Carol Otto Krissy Schleicher Deb Cosgrove Qualters Middle School Brenda Cormier— Food Service Manager Anne Murphy—Senior Cook Geraldine Curtin Patricia McLoughlin Mary Peirce Jordan Jackson Diane Pennellatore — Food Service Manager Robin Nunes —Senior Cook Paula Tully Stacey Gallagher Cynthia Duarte Robinson Barbara Palie — Food Service Manager Sheila DePalma —Senior Cook Marcie Jones Lisa Allen