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Home My WebLink AboutOrthodox Cong. Church 12/31/2016FOR BOARD OFHEALTH USE ONLY Date received'. Date Inspected: Approved By: Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must besubmitted a/least 30days before the planned opening date) 1)Establish mentName ORTHODOX CONGREGATIONAL CHURCH 2)Establishment Address 17WEST STREET 3)Establishment Mailing Address (if different) 17WEST STREET MANSFIELD, K0AO2048 4)Establishment Telephone No (508)339-4793 5\Applicant Name &Title- SHEILA A, MILLER G)Applicant Address 179 CENTRAL STREET, MANSFIELD, MA 02048 7)Applicant Telephone No.: (508) 339-6863 24Hour Emergency No.: 8) Owners Name & Title B)Owner Address (If different from applicant) Owner's telephone number ORTHODOX CONGREGATIONAL CHURCH 17 WEST STREET, MANSFIELD, MA 02048 (508) 339-4793 1O)Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. ACorporoUon Name Title Address An Individual A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (mwner, person in nho/ge, supervisor, manager etc.) =/Namn & TiUeCHAIR BOARD CJ� TRUSTEES � � '~ �J �^_� /�-�A~/ 06ex A/ ��/ ' /-EL `"0V Address: 15 IAN KEAT OR C/O ORTHODOX CONGREGATIONAL CHURCH \ Telephone No: ' FAX: (508) 339A793 CALL FIRST E-mail: AM V1 Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Nome&Title: Address. Telephone No. E-mail: 248ou/£/no/go/uy0o (781) 541-0256 24Hour Emergency No PLEASE USE THIS CHECK LIST TO BE SURE THE FOLLOWING PAPERWORK IS SUBMITTED WITH THE APPLICATION: o APPLICATION /FDOC\MILK & CREAM, TOBACCO |FREQUIRED) oSERV-SAFE AND ALLERGEN CERTIFICATES /FREQUIRED u TOBACCO APPLICATION — MUST SUBMIT CURRENT DEPARTMENT OF REVENUE CT -3T RETAIL EXCISE UNIT LICENSE WITH APPLICATION u TAX CERTIFICATION FORM n / COMPENSATION INSURANCE AFFIDAVIT AND, IF REQUIRED TO HAVE WORKERS, COMPENSATION, PLEASE INCLUDE THE WORKERS' COMPENSATION POLICY DECLARATION PAGE FROM YOU INSURANCE CARRIER WITH THE POLICY NUMBER AND EXPIRATION DATE ` n MAKE SURE ALL INFORMATION |SCORRECT ONTHE APPLICATION n PAPERWORK MUST BE RETURNED WITH ORIGINAL SIGNATURES. fe 41, Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (if applicable) 16) No. of Food Employees: 17) DAYS/HOURS: VARIES 18) Name of Person In Charge Certified in Food Protection Management: SHEILA A. MILLER If more than 3 individuals are certified, complete list is on file. Required as of 101112001 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 Moblie Moblie Start Date. Retail ( Sq. Fl) Moblie End Date Moblie Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date Temporary 'rime: Rain Date. 23) Food Operations (Check all that apply): Food Service up to 100 or Lip to 10' PHF display $62.50 Food Service up to 101 -200 or up to 25' PHF display $75.00 Food Service up to 201 f- or 25'+ PLIF display $137.50 Food Service - Institution Meals/Day) Caterer $12,50 Milk & Cream $5 00 Mobile Food & Consession $37 50 Manufacture Frozen Dessedshce Cream 512.50/freezer Pushcart $12.50 # of Pushcarts. Residential Kitchen $50.00 Retail Food $50 00 Retail Snack Food $12,50 Tobacco Products $12.50 Definitions Ptir - Potentially hazardous food (firnelletriperattife controls required) Non -Pi If -s - non -potentially hazardous food(no fiareltempetatule controls required) RTF - ready-fo-eat foods (Ex sandwiches. salads, muffins which treed no fuithet processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Retreating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF` and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations PHFCookedTo 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 Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food 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) Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events Or Institutional Food Service To be completed by the Board of Health Total Permit Fee. Payment is (Joe with application waived 1, 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 7/s 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 1, 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: 04-6004675 lr 26) Signature of Individual or Corporate Namel Town ofMansfield 7o\YY ^/'6ll"n#'"/J - Board °//leU//h G Park Row Mansfield, N1/\O2048 A�v �� '" ~ - _ ' Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on JUne 1st of each year. NAME OFBUSINESS: ORTHODOX CONGREGATIONAL CHURCH ADDRESS: 17WEST STREET TELEPHONE AT LOCATION: (508) 339-4793 OWNER 0FBUSINESS: ORTHODOX CONGREGATIONAL CHURCH TELEPHONE OF OWNER: (508) 339-4793 FEDERAL ID/SS NUMBER: 04-6004675 FEE: $5.00 PERMIT NUMBER: FS -51 SIGNATURE: I certify under the penalties of perjury that 1, 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) 14A dy-7— 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 0VT C e of Investigations 600 Washington Street Boston, AIA 02111 U. jvwminass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 0 rc 49� _t i vi.�r� �`� /C/`,®_ _� �l c,, ;� Address: 1 tom. S J Phone 8: Are you an employer? Check the appropriate box: El I air) a employer with employees (full and/ or part-time).* 2.Ej I am a sole proprietor or partnership and have no employees working for me in any capacity, [No workers' comp. insurance required] 311 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' cornp. insurance required]** 4:We are a non-profit organization, staffed by volunteers, 4 �(with no employees, [No workers'.comp. insurance req.] Olf/I 33 - L- 13 Business Type (required): 5. F] Retail G. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. E] Non-profit 9. F1 Entertainment I O.E] Manufacturing I LEJ Health Care 12.0 Other *Any applicant that checks box U I must also fill out the section below showing their workers' compensation policy information. *"If (lie corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such in organization should chuck box 81. I ani (in 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 It or Self -ins. Lic, fl 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 Investip,ations of the DIA for insurance covera2e verification, ,to hereby cerltl�fj', ider I ori and penalties of perjury that the information provided above is free and correct gnature, Date: �— one #: Official use only, Do not write in this area, to be completed by city or toren official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. cityl-rown Clerk 4. Licensing Board S. Selectmen's Office G. Other Contact Person: Phone #: www,fnass.gov/di,i PM � I v LL >' N LO � r Q� X LU CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: MATfHEWGEMIN1ANI Certificate Number: 2678349 Date of Completion: 1112912016 Date of Expiration: 11/2112021 ?he above-named person is hereby issued this cert ficate for completing an allergen awareness trainingprognam recognized by the Massachusetts Department of Public Health in accordance with 105 CMR 590.009(G)(3)(a). Diis certificate will be valid for five (5) years from date of completion. Issued By: T z mRa NATIONAL C m RESTAURANT ASSOCIATION® Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 www.restaurant.org Southborough, MA. 01772 508-303-9905 www marestaurantassoc.org Mansfield Board of Health Date % f We, J-� request a waiver of the Food Service Permit Fee for the following reason Thank you, Signature Title