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Home My WebLink AboutMansfield Youth Baseball 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 ESTABLILSHMENT 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 YOUTH BASEBALL Whose place of business is: MANSFIELD YOUTH BASEBALL 273 OTIS STREET PERSON(S) IN CHARGE: JOHN KROUSKOS Permit Expires: December 31, 2016 License Number: FS -132 Food Fee: WAIVED Milk & Cream F-/1 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: MANSFIELD YOUTH BASEBALL having a place of business at.- MANSFIELD t: MANSFIELD YOUTH BASEBALL 273 OTIS STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 12/3112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -132 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 -132 FOOD ESTABLISHMENT PERMIT APPLICATION --App-7ic�ion musT�esubmiite—o--at- Ie�3-0-aa-y�-b—eforeTFie pTnneaopening 1) Establishment Name MANSFIELD YOUTH BASEBALL 2 Establishment Address 273 OTIS STREET ---- j 3) Establishment Mailing Address (if different) 273 OTIS STREET MANSFIELD,MA 02048 4) Establishment Telephone No (508) 261-9655 5) Applicant Name & Title: JOHN KROUSKOS 6) Applicant Address 15 FARM POND PATH, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 261-9665 24 Hour Emergency No.: (781) 868-1782 8) Owners Name & Title MANSFIELD YOUTH BASEBALL 9) Owner Address (If different from applicant) Owner's telephone number 5082619655 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers W An Association or partner. ❑ A Corporation Name Title Address ❑ An Individual -- --- �❑ A Partnership - 12 Person DirectlyResponsible El Other legal Entity -- — ------------ - - p � For Daily Operations (owner, person in charge, supervisor, manager etc. Name & Title: JOHN KROUSKOS Address: 115 FARM POND PATH, MANSFIELD, MA 02048 — Telephone No: 1(508) 728-0552 24 Hour Emergency No: (781) 868-782 FAX: 1- - - - E-mail: JOHNKROUSKOS(cD-COMCAST.NET Alt E -Mail - 13) District Or Regional Supervisor (if applicable) 1 Name & Title: ICHIRS VINSON Address: 11 ROBIN CIRCLE, NORTON, MA 02766 Telephone No: (508) 269-8142 24 Hour Emergency No: (508) 269-8142 FAX E -mall: CVINS0N7@C0MCAST.NET 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: APRIL -JULY WEEKDAYS 5-8 WEEKENDS 9-5 SEPT -OCT WEEKENDS/SUNDAY ONLY 9-5 18) Name of Person In Charge Certified in Food Protection Management: CHRISTOPHER VINSON 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): ❑ iF20) Location: Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or up to 10' PHF display $62.50 Moblie Comments: 21) Length of Permit: �/❑ Annual Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: 23) Food Operations (Check all that apply): 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 ❑ Food Service - Institution ( 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 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 ❑ Sale of Commercially Pre -Packaged PHFs I ❑ Delivery of Packaged PHFs I Reheating of Commercially Processed Foods for Service Within 4 Hours 1 ❑ Customer Self -Service of Non PHF and Non - i Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations n PHFCooked To Order ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ 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) ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin -- — - ❑ Prepares Food/Single Meals for E] Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date -- - - - - — _ or Reconditioned Food I To be completed by the Board of Health Total Permit Fee: Payment is due with application W 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 CMR1590.?P0 and the federal Food Code. 24) Signature of Applicant: b t k 1 d and belief have filed all state tax returns Pursuant to MGL Ch.62see-glfff, I certiry under the penalties of perjury that I, to my es now a ge and paid state taxes required under law. a 25) Social Security Number or Federal ID: 22-2473644 26) Signature of Individual or Corporate Name: ` 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 YOUTH BASEBALL ADDRESS: 273 OTIS STREET TELEPHONE AT LOCATION: (508) 261-9655 FAX NUMBER: OWNER OF BUSINESS: MANSFIELD YOUTH BASEBALL TELEPHONE OF OWNER: 5082619655 FEDERAL ID/SS NUMBER: 22-2473644 FEE: $5.00 PERMIT NUMBER: FS -132 SIGNATURE: DATE: Ff�%� 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. * Signature of Individual or Corporate Name (Mandatory) By: orporate Officer andatory, if applicable) ** Social Security Number (Voluntary) or Federal'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. 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 Applicant Information Please Print Legibly Business/Organization Name: K�1, s Address: P . 0 ►3 a x 7 3 City/State/Zip: M S' f, z (A rt1 ✓A-- t3 -� V'9 Mone #: 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, We are a non-profit organization, staffed by volunteers, l 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 11. ❑ Health Care 12.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: Attach acopy 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, under thq pain, and penalties of perjury that the information provided above is true and correct 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: www,mass.gov/dia Phone #: Mansfield Board of Health Date W Food Service Permit Fee for the following reason Thank you, Title re request a waiver of the oration and Instructions to information compensation for their empees. Y ter l 52 requires all employers to provide workoyeers' Laws- chapter is defined as "...every person in the service of another under any contract of hire, Massachusetts General Law Pursuant to this statute, an employ express or implied, oral or written." artnership, association, corporation or other legal entity, or any two oyer,r there An employer rise, and including the legal representatives of a deceasd lliowever, the i to er is defined as an individual, p employing employees, of the foregoing engaged in a joint enterprise' al entity,ant of the receiver or trustee of an individual, partnership, association or other leg house not more than three apartments and who resides therein, or the Occup owner of a dwelling house having such employment be deemed to be an employer." ho employs persons to do maintenance, construction or repair work on such dwelling dwelling house of anotherw P or on the grounds or building appurtenant thereto shall not because o agency shall withhold the issuance or also states that "every state or local licensing g Y MGL chapter 152, §25C(6) sin the commonwealth for any uirs:d." renewal of a license or permit to operate a business or to con liancebwith tile insurance e coverage crag requi ions shall prod acceptable evidence of compor any of lits cl with the insurance applicantwho has not p 25C(7) states "Neither the commonb'ltevidence of comp Additionally, MGL chapter 152, § public work until acceptableauthority." t ble e ." enter into any contract for the performance of to the contracting requirements of this chapter have been p IApplicants the boxes that apply to your situation and, i i checking ensation affidavit completely, by one number along With a certificate of insurance. Please fill out the workers' comp an ,s name, address and p with no employees other than the members 1 our insurance comp Y ershi s LLP) ees, a policy necessary, Supply Y or Limited Liability Parte P (employconfirmation of Limited Liability Companies (LLC) workers' compensation insurance. If an LLC or LLP does have or partners, are not required to carry or town d that this affidavit may be submitted to davit. Thrtm�davit should beAreturned to the cccidents for ity is required. Be advisenot the Department of Industrial Accidentscall the Should you insurance coverage. Also be surer sign and date wensation policy, please that the application for the permit or license is beingrequested, uestions regarding the law or if you are required to obtain a workers comp have any q below. Self-insured companies should enter their self-insurance license number on the Department at the number listed appropriate line. City or Town Officials rimed legibly. The Department has provided a space at the bottom You regarding the applicant.applicant that Please be sufe that the affidavit is complete and p current the affidavit for you to fill out in the even t eOwh ch will be used as a referencetnumber. In addition, ti app i of year, need only submit one affidavit in Please be sure to fill in the permit/license lieappl n given y ed or marked by the city or town must submit multiple Permit/license applications a any ermits or licenses. Anew � mess policy information (if necessary), A copy of the affidavit that has been official y stamped P applicant as proof that a valid affidavit is on file for future P permit not related to any may be provided to the app said person is NOT required to complete this must. be filled out each year. ',Where a home owner or citizen is obtaining a license or p or commercial venture 0 e, a dog license or permit to burn leaves etc.) affidavit.ou have any questions, advance for your cooperation and should y The Office of Investigations would like,to thank you in call. please do not hesitate to give us a The Department's address, telephone a TheaCornmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 06 or 774977 -MASSA F - Fax # 61 www.mass.gov/dia Form Revised 5-26-05