HomeMy WebLinkAboutBerry Best Tri Town Tasting 10/4/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
permit to Operate a Food Service Establishmen,
Type: TEMPORAY 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:,
BRIAN W. JOHNSON
Whose place of business is:
BERRY BEST BRAND - 9TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @ THE
XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE
BRIAN W. JOHNSON
Permit Expires: October 04, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee:
License Number: T-158
BOARD OF HEALTH
MichaeCMcCCean, Chairman
A y - 1,
:
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening da -
/Z
1) Name }
2 Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title: --
r
7 ,911-
6) Applicant Address > l°
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title
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
I An Association or partner.
/ A Corporation Name Title Address
r An Individual4/z, '
A Partnership
I Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: r y
Telephone No: 24 Hour Emergency No:
FAX:
E-mail: -
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
14) WATER SOURCE:
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS:
Food Establishment Information
15) SEWAGE DISPOSAL:
16) No. of Food Employees:
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):
20) Location: Permanent Location 22) Establishment Type
[ ' Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
Annual
Seasonal
Sea nal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Retail ( Sq. Ft)
Food Service up to 100 or
up 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 +
or 25'+ PHF display $137.50
Food Service - Institution
( Meals/Day)
Caterer $12.50
Milk & Cream $5.00
Mobile Food & Consession $37.50
Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
Pushcart $12.50 # of Pushcarts:
Residential Kitchen $50.00
Retail Food $50.00
etail Snack Food $12.50
Tobacco Products $12.60
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)
-
ALI
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
1 Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Preparation of PHFs For Hot And
— - —
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Vacuum Packaging / Cook Chill
Use of Process Requiring A Variance
Customer Self -Service
and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for
contact alternative, time as a public health
Retail Sale---
control) - - - -- - -i
Juice Manufactured and Packaged for' Offers Raw Or Undercooked Food Of
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 r ? 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 an e ederal F d Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the
and paid state taxes required under law.
/J,25) Social Security Number or Federal ID:
1/26) Signature of Individual or Corporate Name: 4z
of perjury that I, to my best knowledge and belief, have filed all state tax returns
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 IrWilriclual 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
Business/Organization Name; l l
P
Address: 1 ✓ /ck _
City/State/Zip:.--._^- - ' Phone #: .
Are you an employer? Cheek 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 Tvue (required):
5. etail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12. ❑ Other f
*Any applicant that checks box //I must also (ill 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 H 1.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's
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 DIA for insurance coverage verification.
I do hereby certify, under the pains and pe ties of erjury that the information provided above is true and correct.
Signature' `' Date:
Phone #: ---
Official use only. Do not write in this area, to be completer) 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 Date
We, ,---'X-, A request a waiver of the
Food Service Permit Fee for the following reason
Thank you,
Signature
Title