HomeMy WebLinkAboutAJ Bruno Conc 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: PUSHCART
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:.
ANTHONY J. & SHANNON BRUNO
Whose place of business is:
A. J. BRUNO CONCESSIONS LLC
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
ANTHONY BRUNO
Permit Expires: December 31, 2016
License Number: P-94
Food Fee: $250.00
Milk & Cream V
BOARD OF HEALTH
MichaeCvicClean, 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:
ANTHONY J. & SHANNON BRUNO
having a place of business at:
A. J. BRUNO CONCESSIONS LLC
885 SOUTH MAIN 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.: P-94
Scott Leite, H-leaah .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
P-94
FOOD ESTABLISHMENT PERMIT APPLICATION
pp ica ion mus esu m► e a eas ays e ore e;p anne opening a e
1) Establishment Name BRUNO CONCESSIONS yry`
2) Establishment Address 100 SOUTH MAIN STREET a �6 C�kr IeS S rre I
3) Establishment Mailing Address (if different) 100 SOUTH MAIN STREET C4 q6 Ckw,- ►,eS S,Zr=aef
MANSFIELD, MA 02048 A f ry v+ M Ge e
4) Establishment Telephone No (508) 962-9985 sots - qe),- 01q � �{
��"
5) Applicant Name & Title: ROBERT J. BRUNO & ANTHONY J. BRUNO At
ihun T� igrv^eJ
6) Applicant Address 100 SOUTH MAIN STREET, MANSFIELD, MA 02048 C06 (A'/,5 5f,
7) Applicant Telephone No.: (508)962-998a esolm 24 Hour Emergency No.: ss $�rG-A6J®� q(e(
8) Owners Name & Title , ANTHONY J. & SHANNON BRUNO
9) Owner Address (If different from applicant) 8
Owner's telephone number 5089629984
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
[,IQ A Corporation
Name Title Address
An Individual
, �ti , Dtuner i�t6 Cf,,,� fes �� . e
❑ A Partnership
�-
Other legal Entity
191 Parson nirectly Resnonsible For Dailv Operations (owner, person in cnarge, supervisor, manager etc.
�i
a,� day
7dcl.tj
Name & Title:
ANTHONY BRUNO
Address:
1 I® -.,..mom -SWI AN�Yr ^7
1�`�g,^�A®:R. �-�T���- n��k r� — � 48 ( � w� feS S���ti� Al p
iY✓
Telephone No:
(508) 962-9984 24 Hour Emergency No: (508) 261-7198
FAX:
E-mail:
r _ teastA3et Q f v�u (� G Mti `/. Co>✓)
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
SHANNON BRUNO
Address:
100 SOUTH MAIN STREET, MANSFIELD, MA 02048
Telephone No:
(774) 244-1089 24 Hour Emergency No:
E-mail:
%CC_
Jgv`1
Food Establishment Information
14) WATER SOURCE: MOBILE
15) SEWAGE DISPOSAL: MOBILE
16) No. of Food Employees: 1
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: SEASONAL
18) Name of Person In Charge Certified in Food Protection Management: ANTHONY J. BRUNO
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
22) Establishment Type
❑ Caterer $12.50
n Moblie Moblie Start Date:
❑ Retail ( Sq. Ft)
0 Milk & Cream $5.00
Moblie End Date:
❑ Food Service up to 100 or
❑ Mobile Food & Consession $37.50
Moblie Comments: 10 PUSHCARTS
up to 10' PHF display $62.50
❑ Food Service up to 101 -200
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
21) Length of Permit:
r--/] Annual
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
Pushcart $4 # of Pushcarts: 10
❑ Residential Kitchen $50.00
E]Retail Food $50.00
FV1 Seasonal
Seasonal Dates: CONCERT DATES
❑ Food Service - Institution
❑ Retail Snack Food $12.50
❑ Temporary
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $12.50
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
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)
❑ Sale of Commercially Pre -Packaged Non-PHFs
FV] 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 And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
❑ rY 9
F] Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ 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
❑ Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
control)
❑ Ice Manufactured and Packaged for
Retail Sale
❑ Preparation of Non-PHFs
❑ Offers Raw Or Undercooked Food Of
Animal Origin
Other Food Operations
❑ Juice Manufactured and Packaged for
Retail Sale
❑ 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: $250.00
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 590.000 and the federal Food Code.
24) Signature of Applicant: )
Pursuant to MGL Ch.62C, sec. 49A, I 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.
25) Social Security Number or Federal ID: - , ice— tj �� 6 J1
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 1 st of each year.
NAME OF BUSINESSAJ. BRUNO CONCESSIONS
S09
ADDRESS: 100 %GUTS �vii�ii� "�'- (I K) 9 C c6 f�
TELEPHONE AT LOCATION: (-F�6 - 986 S 0 ,- - Ct
FAX NUMBER:
OWNER OF BUSINESS: R ., ANTHONY J. & SHANNON BRUNO
TELEPHONE OF OWNER: 5089629984
FEDERAL ID/SS NUMBER: 011-54-6117
FEE: $5.00
PERMIT NUMBER: P-94
SIGNATURE: a
A4-04V37
v
DATE: '� -( y - 1 -�'
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 -W ividual or
Corporate Name (Mandatory)
Chi
By: Corporat6 Officer
(Mandatory, if applicable)
� n 'l
** Social Security NumberrWoluntary) 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
Applicant Information Please Print Legibly
Business/Organization Name: 11. j tp i'a WAoeS S,`0n S
Address: q q 6 ft ct,, les I mo;t�ca ---C—
City/State/Zip: v; A-rnc Q Phone #: t b r,-, ®14C1 ---19 f 1-1
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3.40 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,
with no employees. [No workers'_comp. insurance req.]
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
*Any applicant that checks boxfl 1 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 Hl.
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 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 DTA for insurance coverage verification.
I do hereby certify, under the pains andpenalties ofperjury that the information provided above is true and correct.
Signature Date: S - N
Phone #: Z§0 qt q eI
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
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