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Home My WebLink AboutRelay for Life 06/18/2016Commonwealth 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: 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:. TINA SEILER Whose place of business is: RELAY FOR LIFE OF MANSFIELD 250 EAST STREET PERSON(S) IN CHARGE Permit Expires: June 18, 2016 License Number: T-135 Food Fee: WAIVED Milk & Cream V BOARD OF HEALTH Catherine .inn Memory, Chairperson Date received: FOR BOARD OF HEALTH USE ONLY Date Inspected: Approved By: Permit# Issued T-133 FOOD ESTABLISHMENT PERMIT APPLICATION -�pTica tion -m us_T�e_s u-b-m-ifted a -t -le a -s -t -30 -days b 6 fdreff e --p- ranned opening -daTe)- 1) Establishment Name RELAY FOR LIFE OF MANSFIELD 2) Establishment Address 250 EAST STREET 3) Establishment Mailing Address (if different) 1324 BELMONT STREET, SUITE 204 BROCKTON, MA 02301 L4) Establishment Telephone No (508) 897-4329 5) Applicant Name & Title: TINA SEILER 6) Applicant Address 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title TINA SEILER 91 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 F] An Association or partner. F-1 A Corporation Name Title Address 1:1 An Individual El A Partnership F-1 Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title, Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: TGSEILER(cD_COMCAST.NET Alt E -Mail: L 13) District Or Regional Supervisor (if applicable) Name & Title: Address Telephone 24 Hour Emergency No: FAX: E-mail: Food Establishment Information i 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 Pe Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑Retail ( Sq. Ft) Moblie End Date: ❑ Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: ❑ Food Service up to 101 -200 ❑ Annual or up to 25' PHF display $150.00 ❑ Seasonal ❑ Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: Temporary ❑ Food Service - Institution Temporary Start Date: 6/17/2016 ( Meals/Day) Temporary End Date: 6/18/2016 Temporary Time: 6:00 PM -12:00 PM ❑ Caterer $25.00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Rain Date: 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): 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 j ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held - -for ❑ Preparation of PHFs For Hot And More Than a Single Meal Service 1 -_ Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly -- - --- - - ---- -- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility to be Prepared by Consumer li ❑ Vacuum Packaging / Cook Chill - ---- I ❑ Use of Process Requiring A Variance ❑ Customer Self -Service j and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) Other Food Operations F1Juice Manufactured and Packaged for 1 ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _ WATER, CANDY, CHIPS, BROWNIES, - - - ❑ Prepares Food/Single Meals for COOKIES, MEAT BALLS, CHILI ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Salvage,❑ Sale of - - - -- 1 oreRelcondit Reconditioned Food Out -Of -Date To be completed by the Board of Health Total Permit Fee: Payment is due with application Fvlf 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 24 Signature of Applicant: p f 5,MR 590Q00 and thelffed I Food Code. board g f health onpp w to obtain copies �� C:" 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: 131788491 - 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. * 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 pOicant Information _ _ _ Please Business/Organization Name: C4 -V Address: joj City/State/Zip: ' Phone #i: 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, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. 0 Restaurant/Bar/Eating Establishment 7. r] Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11. [ 1 Health Care 12,[D -Other Lh' *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy intormanon, **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: L�J -kms ' f Insurer's Address:' -3 Lt ° -- City/State/Zip; `""' Policy # or Self -ins. Lic. #, 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. Expiration Date: I do hereby p and penalties of perjury that the information provided abov is true and correct. do heree by certify, nder the pains m Date: Phone #: 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): I. 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 We. ,z .. request a waiver of the 4- Food Service Permit Fee for the following reason Thank you, Signature Title At