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HomeMy WebLinkAboutBonez Bros BBQ 09/07/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishmenj 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:. TODD C. NOON, PRESIDENT Whose place of business is: 30 CHAUNCY STREET PERSON(S) IN CHARGE TODD C. NOON Permit Expires: September 07, 2016 License Number: FS -12 Food Fee: $75.00 BOARD OF HEALTH micliaecNcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establis/amen 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:. TODD C. NOON, PRESIDENT Whose place of business is: BONEZ BROTHER'S BBQ 30 CHAUNCY STREET PERSON(S) IN CHARGE TODD C. NOON Permit Expires: September 14, 2016 License Number: FS -12 Food Fee: $75.00 BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 9ermit 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:. TODD C. NOON, PRESIDENT Whose place of business is: BONEZ BROTHER'S BBQ 30 CHAUNCY STREET PERSON(S) IN CHARGE TODD C. NOON Permit Expires: September 21, 2016 License Number: FS -12 Food Fee: $75.00 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued tZ_ FOOD ESTABLISHMENT PERMIT APPLICATION - pp ica ion mus esu mi e a eas ays e ore ffie p1annecf opening aaTeT - 1) Establishment Name n 71 C z �+ 2) Establishment Address 3) Establishment Mailing Address (if different) 4) Establishment Telephone No / — 5) Applicant Name & Title: 6) Applicant Address 7) Applicant Telephone No.: 24 Hour Emev6ency No.: y,5,-"2 J " j3 — - ---- - 8) Owners Name & Title Aj 9) 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. WA Corporation An Individual An Name Title Address APartnership d,�_,�Ca�--- Other legal Entity 171 Person Directly Responsible For Dailv Operations (owner, person in cnarge, supervisor, manager etc. Name & Title: A4 J Address: I Telephone No:24 Hoof Emergency No: FAX: E-mail— Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name &Title: Address: Telephone No: FAX: E-mail: 24 Hour En PAID UG 3- 1 2016 Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: 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): Hot PHF Cooked and Cooled or Hot Held 20) Location: Permanent Location 22) Establishment Type4 Caterer $25.00 Moblie Moblie Start Date: C1 _7,/ rRetail j �� ~ /� ( Sq. Ft) Milk &Cream $10.00 Moblie End Date: '', Food Service up to 100 or Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream "' Food Service up to 101 -200 $25.00/freezer 21) Length of Permit: Annual or up to 25' PHF display $150.D0 Food Service up to 201 + Pushcart $25 # of Pushcarts: Residential Kitchen $100.00 Seasonal -- or 25'+ PHF display $275.00 Retail Food $100.00 Seasonal Dates: Customer Self -Service of Non PHF and Non- + Lj Customer Self -Service and/or HACCP Plan (including bare hand r , Food Service - Institution Retail Snack Food $25.00 l Temporary Temporary Start Date: ( Meals/Day) ;; Tobacco Products $25.00 Temporary End Date: Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Temporary Time: Retail Sale Animal Origin Rain Date: Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for F23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs -non-potentially hazardous food(no timeRemperaturo controls required) eck 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 r Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs rY g — Susceptible Population Facility �"-_', Sale of Raw Animal Foods Intended Reheating of Commercial) 9 y 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- + Lj Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only ] Ice Manufactured and Packaged for contact alternative, time as a public health _ Preparation of Non-PHFs Retail Sale control) ---- Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of 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 establishment operation will comply W1 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain c " s of 105 CMR 590.000 and the federal Eaad-eode" ­ 24) Signature of Applicant: Pursuant to MGL Ch.62C, c. 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 rel ed under law. 25) Social Security Number or Federal ID: 5'V– © 26) Signature of Individual or Corporate Name: % 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. * nature of Individual or Corporate Name (Mandatory) B : Corporate Officer (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 Applicant Information Please Print Legibly Business/Organization Name; Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2 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, with no employees. [No workers' comp. insurance req.] Phone #: — ­-2j,�' U Business Type (required): 5. ❑ Retail 6. estaurant/Bar/Eating Establishment 7. n Office and/or Sales (incl. real estate, auto, etc.) 8. R Non-profit 9. ❑ Entertainment I0.❑ Manufacturing IL F1 Health Care 12, F-1 Other *Any applicant that checks box N 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 t11. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. #_ 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 DIA for insurance coverage verification, I do hereby cer ' , under the pains and penalties Phone #• / 2>� 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 #: ANSI ACCRUING PROGRAM Amakan wUmN sd weaPW Pk h em mecoerrc+xew,cxcvm a CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: TODD NOON Certificate Number: 2463632 Date of Completion:8/3/2016 Date of Expiration; . 8/3/2021 r ?he above-named person is hereby issued this certificate for completing an allergen awareness trainingprogram recognized by the Alassachusetts Department of Public Health in accordance with 105 CNIR 590.009(G)(3)(a). ?Isis certi6cate will be valid for five (5) years from date ofcoinpletion. Issued By: Massachusetts Restaurant Association 333 Turnpike Road, Suite 102 Southborough, MA 01772 508-303-9905 www.marestaurantassoc.org NATIONAL RESTAURANT ASSOCIATION® 800.765,2122 w Yrestaurant.org JA Bank # Pkt# TOWN OF MANSFIELD SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER DPnartmPnt I BOH Date: 18/31/2016 BONER BROTHER'S BBQ 1 01512-445006 1 1 $ 75.00 1 TOTAL: Mansfield, MA 8/31/2016 To The Officer Making the Payments: The above is a detailed list of moneys collected by me, amounting in the aggregate to: $75.00 Ifor the period ending 8/31/2016 which I have paid to the Town Treasurer whose receipt I hold therefor. or Dept Head Jane Doucette From: toddnoon@gmail.com Sent: Friday, September 02, 2016 11:33 AM To: Jane Doucette Subject: Re: Mansfield Food Permit Jane, Here is the address 41 Highland ave. Cohasset 02025, Thanks Todd Bonez Brothers BBQ Sent from my Sprint Phone. ------ Original message ------ From: Jane Doucette Date: Thu, Sep 1, 2016 2:28 PM To: 'toddnoon(cr)tmail.com'; Subject: Mansfield Food Permit Hi Todd just wanted to remind you I still need the address for the location of the mobile unit. Thanks, Jane The information contained in this comrnunication frond the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action it) relation of the contents of this infori-ration is strictly prohibited and may be unlawful. This ernail has been scanned for viruses and malware, and n'iay have been autornatically archived by Mirnecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for- your human generated data. Specializing in; Security, archiving and cornpliance. To find out more Click Here. Jane Doucette From: Amy Donovan -Palmer Sent: Wednesday, September 07, 2016 9:02 AM To: Jane Doucette Subject: FW: Follow up with Bonez Brothers Food Truck From: Sarni, Susan [mailto:ssarni@cohassetma.org] Sent: Thursday, September 01, 2016 10:07 AM To: Amy Donovan -Palmer Subject: RE: Follow up with Bonez Brothers Food Truck Hi Amy, Thank you so much for all your help. When Bonez Brothers obtains the Food Service Permit please forward a copy. Just odd that no one else asked for a permit of an inspection in Massachusetts. Thanks, Susan Susan Sarni, SE, MPH Director of Public Health TOWN OF COHASSET Office: 781,383.4116x119 Mobile: 781.424.3058 From: Amy Donovan -Palmer [mailto:adpalmer mansfieldma.com] Sent: Thursday, September 01, 2016 8:29 AM To: Sarni, Susan <ssarni@cohassetma.org> Subject: Follow up with Bonez Brothers Food Truck Hello Susan, I wanted to follow up with you about Bonez Brothers BBQ. Right now, they are in the process of obtaining temporary food service license in Mansfield to prepare food at a local restaurant, the Fresh Catch. The additional permit is so that the two businesses (Bonez Brothers and The Fresh Catch) are separate so if one has some kind of issue, the other wouldn't be held legally responsible. According to Todd, he will be preparing all of his food at the Fresh Catch and then transporting it in his truck at hot holding temps. In our conversation, he mentioned that he's up here from Florida because of a granddaughter, which seems to make things a little more legitimate in my head- like why he's here from Florida and why he's at the campground for the summer. Todd mentioned that he is planning on coming back up next summer but I'm not absolutely sure if he'll be working out of any of the restaurants in Mansfield. He mentioned possibly going to North Attleboro. I figure we'll deal with that next summer if he does come back to Mansfield. Thanks for reaching out to me to square things away here. If you have any other questions or if you have other concerns about the food prep here in Mansfield, please let me know and we can work together to get anything straightened up. Amy ***************** Amy Donovan -Palmer, MPH Health Agent Town of Mansfield 6 Park Row Mansfield, MA 02048 508-261-7366 Disclaimer Tile information contained in this conimunication from the Town of Mansfield is confidential. It is int:ended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclos(jre, copying, ;iistribtrtic,n car taking action in relation of the contents of this inforrriation is strictly prohibited end n)ay be unlawful, tri_, ernn :. l }'t...• been for vir,ises and maivvare, ::end may have been aLitomatically �irchived by Mimecast ltd, an innovator in Soft4ware s a Service (SaaS) for business. Providing a safer and more useful place for your hurnar generated rata. Sped�flhzmg in; SeCLIIA,y,-Vc-10ving and onipliance. To find out rnore Click Here. Please be advised that the Massachusetts Attorney General has determined that email is a public record unless the content of the email falls with one of the stated exemptions under the Massachusetts Public Records Laws, IMPORTANT NOTICE: This e-mail message is intended to be received only by persons entitled to receive the confidential information it may contain. E-mail messages may contain information that is confidential and legally privileged. Please do not read, copy, forward, or store this message unless you are an intended recipient. If you have received this message in error, please forward it to the sender and delete it completely from your computer system. 2 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".-every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant -who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/]icense applications in any given year, need only submit one affidavit indicating current policy information (if necessary), A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e, a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05