HomeMy WebLinkAboutMemorial Park Ice Cream Social 06/04/2016Commonwealth 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:.
Whose place of business is:
MEMORIAL PARK - ICE CREAM SOCIAL
111 HOPE STREET
PERSON(S) IN CHARGE:
KRISTEN READ
Permit Expires: June 04, 2016
License Number: T-106
Food Fee: $0.00
BOARD OF HEALTH
MichaeCMcCtean, Chairman
FOR BOARD OF HEALTH ,USE ONLY
Date Received Date Inspected Approved By Permit # Issued
Town of Mansfield Limited Product
Temporary Food Establishment Permit Application
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Food Establishment Information
14) Water Source: Town [17)
Sewage disposal: Town
DEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation:
No. of Food Employees: NIA
18) Name of Person In Charge Certified in Food Protection Management: Not appliccable
RPauired as of 101112001in accordance with 105 CMR 590.003 A Plea,eaBschco of—iH ale.
19) Person Trained In Anti -Choking
Procedures (if 25 seats or more): *Yes
❑ No
Type(check all that apply)
❑
Caterer
20) Location:
(check one)
Sq. Ft)Seats
)❑
❑
❑
Food Delivery
Residential Kitchen for Retail Sale
❑ Permanent Structure
vice - (
vice - Takeout
Residential Kitchen for Bed and Breakfast
❑ Mobile
FEstablishment
vice - Institutioneals/Day)
❑
Home
Residential Kitchen for Bed and Breakfast
Memorial
Establishments
park
❑
Frozen Dessert Manufacturer
21) Length Of Permit: Other (Describe)
(check one)
❑ Annual Snack
❑ Seasonal/Dates:
❑ XTemporary/Dates/Time:
Definitions: PHF- potentially hazardous rooa(umeicemperalu•
23) Food Operations: Non-PHFs — non- potentially hazardous food (no time/temperature controls required)
RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
check all that a 1 ❑
❑ Distribution of Commercially Pre -
Packaged candy or bottled drinks Ice cream party
❑ Preparation and distribution of ❑
popcorn, cotton candy, open hot
and cold drinks. ❑
❑ Distribution of foods that are cut ❑
u and served . ❑
Ll ❑
❑ ❑
❑
❑ ❑
❑ Layment
mpleted by the Board of Health
Other (Describe):
ermit Fee:
❑ is due with application
I, the undersigned, attest to the accuracy of the information provided in this appl
1111111 Uldt tilt: 1VUU
establishment operation will comply with110�5�CMR 590.000 and all other applicable law. I have been instructed by the board of
health on how to obtain copies of 1 / MR 5 0.0 a the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 49A,1 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.
i
26) Signature of Individual or Corporate Name:
Mansfield Board of Health
6/2/16
Date
We, _Mass Premier Courts Volleyball request a waiver of the
Food Service Permit Fee for the following reason
community Service
Thank you, l
Signature
!)('re d MA K�
Title