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HomeMy WebLinkAboutSE Regional School 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 Establishmen 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:. LUIS LOPES, SUPERINTENTENT Whose place of business is: SOUTHEASTERN REGIONAL SCHOOL DISTRICT - 9TH ANNUALTRI-TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE DAVID DEGAN Permit Expires: October 04, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-132 BOARD OF HEALTH michaeCMcCCean, Chairman WAIVED FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued Food Establishment Permit Applicati©i (Application must be submitted at least 30 days before the planned 1) Establishment Name: SOC Y �QGz E Uri �C r (CretI GUS l 2) Establishment Address: �rz �"1-�Vv' �_ 11 <j1 , C) l S�7N1 j~l 3) Establishment Melling Address (if different): t ` 4) Establishment Telephone No: j 6 J-2- -2 -6) 6)Applicant Name & Title: ��l i 6) Applicant Address: �a V"L G S C- U �? 7) Applicant Telephone No: 3 24 Hour Emergency No: S� ? "� S 8) Owner Name & Title (if different from applicant): �V 1 -e c v- r Vc) cj �1 9) Owner Address (if different from applicant): Saw e- & S C"- � 10) Establishment Owned By: m An association • A corporation G An individual m A partnership i • Other legal entity C> 11) if a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address 12 Person Directly Responsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager etc.) Name & Title: ,- C a r`) Address: .c -f d Telephone No:3d ,, Fax; 50 9- — a Emergency Telephone No: -7 -?-S- 13 DistrictOr Regional Supervisor (if applicable Name & Title: Address: Telephone No: Fax: 59Uapphcahonb-2.406 Gnnri Gc4ahlichmonf Infnrmnfinn 14) Water Source: \ 16) Sewage disposal: r\ DEP Public Water Supply No: (h`applicable) 0 C), 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: Required as of 10111200 lin accordance with 105 CMR 590.003(A) Pkase apace co orce lffwfe. 19) Person Trained in Anti -Choking Procedures (If 25 seats or more): m Yes m No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer / (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery rg Permanent Structure ❑ Food Service - ( Seats) ❑ Residential Kitchen for Retail Sale ❑ Mobile ❑/Food Service -Takeout ❑ Residential Kitchen for Bed and Breakfast 0 Food Service - Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length 0f Permit: (check one) ❑ Annual ❑ SeasonaVDates: ❑ Temporary/Dates/Time: Definitions: PHF- potentially hazardous food(time/temperature controls required) 23) Food Operations: Non -PRFs - non- potentially hazardous food (no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 6qh52k all that a / : Sale of Commercially Pre- ❑ PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non -PRFs More Than a Single Meal Service. ❑ Sale of Commercially Pre- ❑ Preparation Of PRFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PH Fs Cold Holding For Single Meal Susceptible Population Facility Service. ❑ Deliveryof Packaged PHFs ❑ Sale Of Raw Animal Foods Intended ❑ Vacuum Packaging/Cook Chill to be Prepared by Consumer. ❑ Reheating of Commercially ❑ Customer Self -Service ❑ Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative time as a public health control ❑ Customer Self -Service Of Non- ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin. Only. Q Preparalion Of Non•PHFs ❑ Juice Manufactured and Packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale I Events or Institutional Food Service u utters K, C rnr In CiulK %.tuanu❑eS Other (Describe): ❑ Retail Sale of Salvage, Out -of Date or Reconditioned Food 1, the undersigned, attest to the accuracy of the informatloell jdC establishment operation will comply with 105 CMR 690,00health on how to obtain copies of 105 CMR 590.000 and t 24) Signature of Applicant: Pursuantto MGL Ch. 62C, set;. 49A, I certify under the pboafties of perjui belief, havefiled all state tax returns and paid state taxes required under be completed by the Board of Health tal Permit Fee: yment is due with application tion and I affirm that the food law. l have been instructed by the board of 25) Social Security Number or Federal ID: 2 3 _( --7 2 26) Signature of Individual or Corporate Name: I, to my best knowledge and TAX CERTIFICATION FORM Y certify under the penalties of perjury that 1, to my best knowledge and belief, have fired all state tax returns and paid all state taxes required under law. ature oiVdividual or Corporate Name 177) **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. C:\Userslsleitc\Desktop\ScotVs DOCnments%Food Establishments. Temp1TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Aeeidetnts Office pf Investigations 600 Washington Street Boston, MA 02111 kq)� www. mass.gov1dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly �� Business/Organization Name: �S`�c� �u'�E-� ( (, C J Address: ':), '� City/State/zip: Phone #: a',— . 30-- 116 C Are you an employer? Check the appropriate box: 1. W --I am a employer with 3CR employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for the 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 10.0 Manufacturing 11.[:] Health Care �- 12AOther J b I t S U -D ( lS' \ �- *Any applicant that checks box #1 mast also fill out the section below showing their workers' compensation policy tntbnnation. **If the corporate officers have exempted themselves, but the corporation rias other employees, a workers' compensation policy is required and such an organization should check box # 1. 1 am an employer that is providing workers' compensatiot�r, insurance for my emplglwes. Below is the policy information. Insurance Company Name: i x Y Insurer's Address: , v (2 City/State/Zip: Policy # or Self -ins. Lie. # 0 Expiration Date: L,90- 1-7 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. Ido hereby certifi,, under t1 ains ant ties of perjury that the information provided above is true and correct. Signature: Date: Phone #: S Offlcial use only. Do not write in this area, to be completer/41) 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: Phone #: m w.inass.gov/diu Insurance Proposal Workers' Compensation Southeastern Regional School District Insurance Company: Atlantic Charter Insurance Company A M Best Rating A Policy Term: 07/01/2016 to 07/01/2017 Location Schedule 250 Foundry Street , South Easton , MA 02375 Bodily Injury by Accident: Each Accident $100,000 Bodily Injury by Disease Per Policy _ _ $500,000 Bodily_lnjury by Disease Each Employee �^ $100,000 Workers Compensation Statutory Benefit OTHER STATES: Refer to policy Forms, Conditions and Exclusions: • Loss Ratio Dividend Plan • Refer to Policy *This Workers' Compensation policy is subject to an annual audit, The final premium is determined after the audit has been completed, MARSH & MCLENNAN AGENCY, LLC 32 W LO in W z z W m z Q U c� z z U w L 0 1 Z LU m Z � (0 o M N 0 M `�- d-a Q� O a � o � 0 U 0 W 0 z U Q Q p � �ZQ N O N o<() nd iu) it0 zw< a 0 1 til V .H Q Q a Mansfield Board of Health Waiver 2016 for Food Permit Date � b -2-)1 ' *Put the name of your restaurant on first line then sign the form. We, Sr�Aq a SU,r-(a 1 Sb request a waiver o the Food Service Permit Fee for the following reason: 6C) Taste of Tri -Town Food Festival on 10/4/16 located at the Xfinity Cer Thank you, C Title