HomeMy WebLinkAboutOlson Restaurant 10/4/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
'ermit to Operate a Food Service Establis
Type: TEMPORARY MOBILE FOOD TRUCK
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:.
SEAN OLSON, PRESIDENT
Whose place of business is:
OLSON RESTAURANT GROUP FOXBORO, LLC - 9TH ANNUAL TRI -TOWN CHANBER
FOOD TASTING @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE
RUBIA SOARES
Permit Expires: October 04, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee:
License Number: T -MOBILE -1 WAIVED
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
T -MOBILE -1
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name OLSON RESTAURANT GROUP FOXBORO, LLC - 9TH ANNUAL TRI -TOWN CHANB
2) Establishment Address 885 SOUTH MAIN STREET
3) Establishment Mailing Address (if different) 163 MAIN STREET SUITE 2, MEDWAY
MEDWAY, MA 02053
4) Establishment Telephone No (774) 215-5279
5) Applicant Name & Title: SEAN OLSON, PRESIDENT
6) Applicant Address 163 MAIN STREET SUITE 2, MEDWAY, MA 02053
7) Applicant Telephone No.: (508) 533-3030 24 Hour Emergency No.: (617) 592-9852 SEAN OLSON (781) 953-2687
8) Owners Name & Title SEAN OLSON, PRESIDENT
9) Owner Address (If different from applicant) 6 GOLDENROD DRIVE, MEDWAY, MA 02053
Owner's telephone number 5085333030
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
V Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: E Rura',a„ &are,s
Address: 163 MAIN STREET #2, MEDWAY, MA 02053
Telephone No:
24 Hour Emergency No: (617) 592-9852 SEAN OLSON (781) 953-
2687
FAX:
E-mail: i�C�'��la� d l S Ott r. Ciao
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title: N'0
Address:
Telephone No:
FAX: E-mail:
24 Hour Emergency No:
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS:
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees:
18) Name of Person In Charge Certified in Food Protection Management: ""KV,> Cto5likin
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): I/
20) Location: Permanent Location
22) Establishment Type
V Moblie Moblie Start Date: 10/6/2015
Retail ( Sq. Ft)
Moblie End Date: 10/6/2015
Food Service up to 100 or
Moblie Comments: FOOD TRUCK
up to 10' PHF display $62.50
21) Length of Permit:
Food Service up to 101 -200
Annual
or up to 25' PHF display $75.00
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
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: 0
Residential Kitchen $50.00
Retail Food $50.00
Retail Snack Food $12.50
Tobacco Products $12.50
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads. muffins which need no further processing)
Sale of Commercially Pre -Packaged Non -PRFs
Sale of Commercially Pre -Packaged PRFs
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
Other Food Operations
PHFCooked To 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: $25.00
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 off 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: -ice jXi��
it
Pursuant to MGL Ch.62C, sed`' 49A, 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: 46-1034534
A
26) Signature of Individual or Corporate Name: LJ itk f tl tti
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.
Sigdature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
- 1639S3�
** 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
s Boston, MA 02111
rvrvw.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
,Applicant Information Please Print Legibly
Business/Organization Name: W(iollS Sanrlwich -Shbp _
Address: '' 1 54I
City/State/Lip: N�(YtS(; e, �(Y1_1 t 6� �' Phone
Are yo un employer? Check the appropriate box:
I . am a employer with . I0employees (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' camp, 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
11.❑ Health Care
12.0 Other J_ _
*Any applioanl that checks box It I roust also till 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 M i.
I ani 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. 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 MGI, e. 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 $250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties oj'perjury that the information provided above is true and correct,
Phone #: ° 60Z -339-(35)1_3k
Official use only, Do not write in this area, to be completed by city or town official
City or Town;
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2, Building Department 3, City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person:
www.rnass.gov/dia
Phone #:
t t ?Y-VY_
)A= ;
CERTIFICATE OF LIABILITY INSURANCE Ro<' -x.1/9/2015
THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE„R$ NO RIGHTS UPON THE CERTIFICATE HKI)ff THIS
CERTIFICATE 000$ NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED SY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE GOES NOT CONSTITUTE A CONTRACT SETWEEN TWE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, ANI? THE CERTIFICAT15 HOLDER.
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Mansfield Board of Health
We,
Food Service Permit Fee for the following reason
`-d E Tri -Tow n
Thank you,
Title
attire
Date
request a waiver of the