HomeMy WebLinkAboutMMAS 5K Run for Arts 09/18/2018. ' Commonwealth of Massachusetts
Town of Mansfield
' Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
'ermit 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:.
BRIAN C. JOHNSON, RACE DIRECTOR
Whose place of business is:
MMAS 5K RUN FOR THE ARTS
377 NORTH MAIN STREET
PERSON(S) IN CHARGE.
BRIAN C. JOHNSON, RACE DIRECTOR
Permit Expires: September 18, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee:
License Number: T-151
BOARD OF HEALTH
MichaeCMcCCean, Chairman
WAIVED
Date received:
rnnn F:.qTARI ISHMFNT PERMIT APPLICATION
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By
Permit # Issued
_JY -afTe—asT3Fd-ays�e-fo—re-ffi-e--pTdn-n—ed-o--cT-fel------
r,,,,TUe suVm eW pening, a
1) Establishment Name
2) Establishment Address AV",
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title:
6) Applicant Address e,
24 Hour Emergency No.: _5�vl(
7) Applicant Telephone No. -.57, 2 7
8) Owners Name & Title
------------
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
k o cimprviqnr manager etc.)
12) Person Uirectly Nesponswit ru, ucilly lap- w— W- r -
Name & Title:
Address: 6 ',It
24 Hour Emergency No:
Telephone No:
FAX:
E - mail ji IL c j c
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
24 Hour Emergency NO:
E-mail:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOS
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 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): _ --
20) Location: Permanent Location
Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit
Annual
Seasonal
asonal Dates:
22) Establishment Type
Retail ( Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $125.00
Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
--- - -- - --- ' Food Service - Institution
Temporary ��
Temporary Start Date: ( Meals/Day)
Temporary End Date:��i
TemporaryTimer _—
Rain Date: 4� 1//
Caterer $25.00
Milk & Cream $10.00
Mobile Food & Consession $75.00
Manufacture Frozen Desserts/lee Cream
$25.00/freezer
Pushcart $25 # of Pushcarts:
Residential Kitchen $100.00
Retail Food $100.00
Retail Snack Food $25.00
Tobacco Products $25.00
- -
erations Definitions: PHF - Potentially hazardous food (timertemperature controls re
23 Food Oquire )
P Non-PHFs - non -potentially hazardous food(no timeltemperature 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
PHFCooked To Order
'Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre Packaged PHFs
----- ---
Preparation of PHFs For Hot An _-_---_------------
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs
---------; - - --
Sale of Raw Animal Foods Intended
Susceptible Population act i y
-_ _ . ----------- -- ---
Reheating of Commercially
to be Prepared by Consumer
Vacuum Packaging /Cook Chill
Processed Foods for Service Within 4 Hours
Use of Process Requiring A Variance
Customer Self -Service of Non PHF and Non-
Customer Self -Service
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Perishable Foods Only
_-_ ---
Ice Manufactured and Packaged for
control)_____
- - - ---
Preparation of Non-PHFs
----------
Retail Sale
--------------
-
!Offers Raw Or Undercookedo0 d Of
- ----
'Juice Manufactured and Packaged for
Other Food Operations
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 -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
105 CMR 590.000 and all other applicable law. I have been instructed by the
establishment operation will comply with
board of health on how to ojAuin-copies ofc1g5 CMR 599100 and the federal Food Code.
24) Signature of Applicant: -
Pursuant to MGL Ch.62C, sec. 49A, I certify un er 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. C tri
r1✓ 25) Social Security Number or Federal ID: l
26) Signature of Individual or Corporate Name:
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 Individual or
Corporate Name (Mandatory)
By: Corporate fficer
(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:
City/State/Zip: 1 L J r ji done #: ? ''
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2. ❑ 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 employees, [No workers' comp, insurance required]*
4. F1. 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
1111 Health Care
12.❑ Other
*Any applicant that checks box H 1 must also fill out the section below showing their workers' compensation policy tntormatron,
**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 til.
1 ant an employer that is providing workers' compensation insurance far my employees. Below is the policy information.
insurance Company
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic, # 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
t„ve.diontions of the DIA for insurance coverage verification.
do hereby®cect jiy, under painsyytd penalties of perjury that the information provided above is true and correct.
_/� z t:�/ %
I1VllG M.
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 A. Licensing Board 5. Selectmen's Office
6. Other
Contact Person
Phone #:
www.mass.gov/dia
Mansfield Board of Health
We,
Food Service Permit Fee for the following reason
Thank you,
Date
request a waiver of the
l
Title
June 1, 2016
Brian Johnson
28 Ephraim Drive
Mansfield, MA 02048
Dear Mr. Johnson:
Town of Mansfield
6 Pack Row, Mansfield, Massachusetts 02048
Board of Selectmen
At its meeting on April 13, 2016 the Board of Selectmen approved a Road Race Permit for the
MMAS 5K Run For The Arts, scheduled for September 18, 2016 from 9:00am — 1:00pm, as
referenced by the map presented.
The Board has approved the permit subject to the following conditions:
• Organizers must contact Lieutenant Tracy Juda at the Mansfield Police Department to
ensure proper safety detail a minimum of two weeks in advance of this event. Lieutenant
Juda can be reached at 508-261-7301.
• Race organizers must provide means of communication for the reporting of emergencies
throughout the course. Mansfield Fire Department is the sole transporting agent. The use
of propane will also require a permit through the Fire Department. Mansfield Fire can
be reached at 508-261-7318.
• The Board of Health requires that any distribution of food or drink requires a permit at
least five days prior to the event. Please contact the Board of Health at 508-261-7366.
• Please contact the Building Department to properly permit the use of tents. The Building
Department can be reached at 508-261-7360.
The Board asks that if there are any changes to the event that this office be notified immediately.
The Board of Selectmen wishes race organizers and all racers great success with the event. As
always, if we can be of any assistance, please contact us at 508-261-7372.
Sincerely,
;II _
Tracey Whalen
Executive Secretary, Board of Selectmen
cc: Police Chief, Ron Sellon
Fire Chief, Neal Boldrighini
Scott Leite, Board of Health
Ron Blackman, Building Inspector