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Home My WebLink AboutOur Daily Bread 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' l Type: FOOD ESTABLISHMENT 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:. CONGREGATIONAL CHURCH Whose place of business is: OUR DAILY BREAD - MANSFIELD'S COMMUNITY FOOD PANTRY 15 WEST STREET PERSON(S) IN CHARGE RICHARD KELSAY, DISTRIBUTION COORDINATOR Permit Expires: December 31, 2016 License Number: FS -129 Food Fee: WAIVED BOARD OF HEALTH AichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -129 FOOD ESTABLISHMENT PERMIT APPLICATION - (,�pplica ion must 5e su m� - ifted at least �refore� d opening a e 1) Establishment Name OUR DAILY BREAD - MANSFIELD'S COMMUNITY FOOD PANTRY 2) Establishment Address 15 WEST STREET 3) Establishment Mailing Address (if different) 15 WEST STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-1343 5) Applicant Name & Title: DEBBIE CHAMBERS 6) Applicant Address 3 NOREEN ROAD, MANSFIELD, MA 02048 J 7) Applicant Telephone No.: (774) 719-2276 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 24 Hour Emergency No. CONGREGATIONAL CHURCH 5083394793 (847) 372-0027 (508) 339-2504 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 W Other legal Entity --- - — 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: RICHARD KELSAY, DISTRIBUTION COORDINATOR Address: 52 STEARNS AVENUE, MANSFIELD, MA 02048 Telephone No: (508) 339-2504 24 Hour Emergency No: (847) 372-0027 (508) 339-2504 FAX: E-mail: DEBBIE(cD-CHAMBERS - FAMILY.NET Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title. RICHARD KELSAY, DISTRIBUTION COORDINATOR Address: 52 STEARNS AVENUE, MANSFIELD, MA 02046 Telephone No: (508) 339 2504 FAX: E-mail: 24 Hour Emergency No: (847) 372-0027 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) �16)No. of Food Employees: ALL VOLUNTE 17) DAYS/HOURS: SATURDAYS 8:30-11:30 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): ❑ qj 20) Location: Permanent Location 22) Establishment Type �❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $5.00 Moblie End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 up to 10' PHF display $62.50 Moblie Comments: ❑ Manufacture Frozen Desserts/Ice Cream 21) Length of Permit: ❑ Food Service up to 101 -200 $12.50/freezer 0 Annual or up to 25' PHF display $75.00 ❑ Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) ;Check all that apply): i 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 And 1 ____- - -- - ---- -- - Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly E]Delivery of Packaged PHFs -- -_ -_. _— -- - Susceptible Population Facility ---- -- - - -- F1 Sale of Raw Animal Foods Intended ❑ 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 Perishable Foods Only E] Ice Manufactured and Packaged for contact alternative, time as a public health L]Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin OffersRTE -- PHF in -13- .ulk - 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 - J 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 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: 34-1927041.1 t 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. `US, * Signature of Individual or Corporate Name (Mandatory) By: 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: C) . W M F City/State/Ztp:k. A Phone #: i :3 ` _ L - 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. ❑ 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 7. [�, Office and/or Sales (incl, real estate, auto, etc.) 8. Non-profit 9, Entertainment 10. ❑ Manufacturing I E ❑ 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 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 &frtify, under the pains and penalties of perjury that the information provided above is true and correct. Phone#• i) - 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 W Food Service Permit Fee for the following reason Thank you, Signature :11M Title Date Iq- request a waiver of the