HomeMy WebLinkAboutFriskie Fries 10/15/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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:.
RANDE DANTUONO
Whose place of business is:
FRISKIE FRIES - 5TH ANNUAL FIRE TRUCK PULL & FOOD TRUCK FESTIVAL @ THE
XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
RANDE DANTUONO, THOMAS WRIGHT
Permit Expires: October 15, 2016
Permit Expires:
Permit Expires:
Permit Expires:
Food Fee:
License Number: T-163
BOARD OF HEALTH
MichaeCMcClean, Chairman
WAIVED
FOR BOARD OF HEALTH USE ONLY
.1te Received Date Inspected Approyed B,V Permit # 'Issued
Food Establishme,nt, PermlitApplitation
(Application'thUsi be su'bmiftedatleastW days beforelhe Planned opening dail
1)'. Esiablishment Harne:
Friskie Fries
2) EsOblishment Address:
751 Hartford Ave Johnston R1 02919
3) Establishmerit Mailing Address (if differe0t):
4) Establishniiint Teleplione. 146.
401-919-5489
5), Applicant Raine & Title:
Rande Dantuono Owner
6) Applicant Address:
7) Applicant Telephone No: 401
241 5137 24 Hour Emergency No:
8) Owner, Name & Title (if different from applicant):
9) Owner Address (it different from,appiicant):
10) Establishment Owned By:
0 An assodation
0 A corporation
• An inclivkRial
• A pamership LLC
Other le ent'
11) If a pcirpQratjon or partnership, give name, titte, and home address of
officers or'partner.
Name Title Home Address
Thomas Wright Partner 83 9th St
Providence RI
02906
.12) Person, Directly Responsible for flail rations (Owner, Person in Charge, Siq)ervisor. Manager etc.)
N.-,e&TtjeRande Dant
ono
Thomas Wright Partner
Address .
751
Hartford Ave Johnston R1 02919
Te4ephone No-
401-241-5137 Fax:
Emergency Tee No:
401-261-6978
13) District Or Regional Su Nisor if applicabk)
Name & Title:
Address:
Telephone No
Fax:
Food Establishment Information
94) Water Source:
16) Sewage disposal:
DEP Public Water Supply No.,,( if applicable)
9 8) Clays and ;Hours of Operation:
One day 10-2 1
1 t') No. of Food Employees: 2
18) Ham of Person In Ch i ge Certified in Food Protectlon Management;;
Required as of I01112flriffrr aamdanoe with 105 CMR 5$0-003641
19) Persian Trained In Anti -Choking Procedures {if 25 seats or more): 0 Yes 0 No
20) Location:
22) ; Establishment Type (check all that oppiy)
❑ Caterer
(check orae)
❑ `
Retail ( Sq. Ft):
❑ Food Delivery
❑ Permanent Structure
❑
Foot) Service - { Seats)
❑ Residential Kitchen for Retail Sale
p , Mobile
❑
Food Seraice-Ttakeont
❑ Residential Kitchen for Bed and Breakftst
x
❑
Food Service - Institution
Houle
MealslDayi
❑ Residential Kitchen for Bed and Breakftst
Establishments
Other (Describe)
Food
a Frozen Dessert Manufacturer
21) Length Of Permit,
(check arae)
truck
nAnnual
❑ seaasona Dates:
Tent1 /15 0 2
t}e&nidons.• PHF -porenriallyhazardous food(r"irpoemperaruraeeanuo%srequired)
23) Food Croeratians:More-PH
- norm-- porendaliy hazardous food
(no timeiremperaNre controls requirecq
check aff that
RTE- ready -an -ear foods (Fx sandwiches, salads." inuifns which need no ftinher'processing)
❑ Sale of Cornrmerciatiy Pre-
❑ PHF Cooked To Order
❑ Hat PHF Cooked and Cooled or Hirt Held for
Packaged ' Non-PHFs
More Than a Single l Service.
❑ Sale of Commercially Pre-
a Pr tiah'Of PHFs For Hcy And `
❑ PHF ami RTE Foods Prepared For Highly
Packaged P ff s
Cold Holding For Single Meal
XService.
Susceptible Population Facility
❑ Delivery of Packaged PHFs
❑ Sale Of Raver Animal Foods Intended
❑ Vacuum Packaging/Cook Chilt
to be Prepared by Consumer.
❑ Reheating of Conmeercially
❑ Cgston Self -Service
0 Use Of 'r Requiring Ae AndlOr
Processed Foods n=or S ce
HACCP Flan (including bare hand Contact
Xb'dz n 4 Hours..
alternative, time a8 a pWilic.health control)
❑ Customer Self -Service Of Non-
o Ice' Manufactured, and Packaged for
❑ Offers Raw Or Undercooked Food :Of Animal '
PHF and Non -Perishable Foods
Retail Sale
Origin:
Cir '
❑ Preparation Of Non-PHFs
❑ Juice Manufactured and Packaged
❑'` Prepares FoodtSMfor
ingle eals Catered
for Retail Sale
Events or. Institutional Food Service
Other (Describe):
1, the undersigned, attest to;
establishment operation wil.
24) Signature of Applicant:
Pursuant; to MGL Ch. 62C, sec.
belief, have filed all state tax ret
u �rrers rc r c ra-rr rn r3urx �rrarrrraes
To be completed , the Board ofH'ealth
❑ Rett Sale of Salvage, put -of mate or Iota) Permit Fee;
r3ioned Food Payment is due vritla application
uracy of the information, provided in this application and i affirm that the foot)
V with ltl5 CMR 590.000 and aU other applicable taw. I have been instructed by the board of
OaL 59009 and the federal Food Code.
L,1 c9rtify under the;taerialties of perjury that i, to my best knowledge and
is and paid state taxes required under law.
25) Social Security Namner or Federal ID: 9244913996
26) Signature of Individual or Corporate Name;
TAX CERTIFICATION FOR
I certify under the penalties of pei)uryi that L to my best knowledge and
belief, have filedall state tax returns and, paid all state taxes required
under law.
Signahze of h-idividual or Corporate Name
9244913996
—Social Security No. Wolunfary) or Federal
Idenf#icaion Phtmbu
By: Corporate Officer (Amdatory, if ApplimW)
*This license will not be issued unless this certification clause is, sizned
by the applicant.
YoUr social security rLumber will be ftu-nislied to the Massachusetts
De�partment of Revenue to detern-tine 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 inade under the authority of Massachusetts General Law
.Chapter..62C, section 49A.
C-1�T-Tsus',stei:i=,Deskt*,.Scolt'sDocuumti,FoodEsmblishmk-i -TemgTAX.CSR =AM.NFQKh4_&c
The Conintonwealdi qfAlassachusetts
cc
Del)a'ri?ii,�iit.ofIiiditstri,41A idents
Office of Investtigations
600 Mishh1gloli'StPeet
Briton ILA 02111
wivir.massgovIdia
NVOkers' Compens.-,ifion Insuraiice. Affida-vit: General Businesses
Applicant Information Please Print Legibly
Bus iness,,,'QraAliizat.ionNanw.- F r i s k i e Fries
Ad&e,q,.: 751 Hartford Ave
cltyr,-State1p: Johnston RI 02919 p1lone 4.
/z
,Are rota, an .employer? Check the appropriate box:
L ❑ I mna einployeiwith einployees (full ands"
lam a sole proprietor or partn,er!A,np and have no
employees wericing,for nae l any capacity.
[No wor,'kers'com- insurance re- quimd]
3. El 'We are a corporation =4 its officers have exercised
their right ofexeinption per :c. 152, 1(41)1,and we have.
4.Ej We are a 40n -profit: I
with no einployees, I
*If the Corporate offici
>n, stay ed by'volunteers.
401-919-5489
Business Type (required):
5. R Retail
6., XResta urant,'Bal:YE ating Establishin,ent
7. ❑ Mice, and/or Sales {inti. real estate,. auto, etc.)
9. ❑ EntertaWnueent
10.R manufacturing,
I I.[] Health.Qare
12. El Other
s. but thecorporazion has other employers, a wort en' compensation policy is required and such m
I ain are employer that is providing 1jW?1reA' compon satioll Hisli rail cefrsr liki, ellip1twees. Belo)r is tile Policy informatioli.
Insurance 'Coinpany Nalue: Stateline
insurer's Address: 520 North Broadway
City/State"Zip. East Providence 02914
Policy. 4 or Self -ins. Lic. 4 0141304-02 Expiration Date:
Attach a copy of the workers' compensation policy declaration.p4ge (showing the p6htnumber and exp date).
'Failure. to stcure.coverage as re-q11iieduU4k4- Section 25A of MGL c_ 152 can leadrto theimposition of critainal penalties of a
fine up to $11500.00 and/or one-year itnprisonnient, as well as civil penalties in the'forin. of a STOP 'WORK ORDER mid a fine
of bp to $250.00 a,day against the violator. Be. advised that a copy of this statement may be forwarded to the Office of
ida
ereby cern
Phone
'Official list onFy. Do norivrite in this, area, to be completed b
y city or toovi official.
Cit,
.v or Tovim: PerinitLicense 9
Is -suing Authority (circle one):.
1. Board of Health 2. Building Department I City? romm"Clerk 4. Licei'ving Board, S. Selectmtn's Office
6, Other
Contact Person- Phone
vmwmass.gov,,ma
Providence Fire Department
325 Washington Street
Providence Rhode Island 02903
(401) 243-6050
INSPECTION RECEIPT
INSPECTED PROPERTY ADDRESS me of Buildin
On this date's
/ Inspector's Signature
Inspector for the City of Providence, inspected the above referenced property in accordance
with Rhode Island General Lad's 23-28.1 et seq., entitled "Rhodylsland Fire Safety Code"
Type of Inspection: Bldg ` FA _ Pyro/Flame _ Mobilet/ Tent _ or License
4 (check one only above) —
Sprinklers _
Standpipe —
Mobile Registration #
Driver's License #
Local or MB #
Bldg Occupancies:
(List all th:d app]>)
Offrce Usq,,0, n y ..or
Owner Narne
Y/ ,)0
1 (check all that apply)
Bits. __ Liq. — Ent.
Address r+ c -.J
# of units inspected ( Total # of units in building
4-1-C
VA
In accordance"with the City of Providence Code of Ordinances, Article II of Chapter 9
entitled "Fire Prevention and Protection" an inspection fee of One Hundred ($100.00)
Dollars is due and payable prior to inspection. Said fee is payable by either Business Check or
Money Order ONLY. No personal or temporary checks accepted. All checks shall be made
payable to "Providence City Collector".
This is a receipt only for the inspection conducted at the above mentioned property. This receipt
by no means implies that the above inspected property is in compliance Nvith all applicable fire
safety codes. This receipt shall not be used to obtain a license or permit. A license or permit can
only be obtained after a letter of compliance is generated from both the Providence Fire
Prevention Bureau and the Providence Fire Alarm Division of the Providence Tire Department.
PAYMENT INFORMATION
Name on Check/Mone Order-,`-
Bank
rdel�- Phone #f%'%
} G'-<: - --- ! •
/.. �� �
Bank Name--1.,..._---�'``/_..t �t��_ Check Number
Rev 01/11
[-�C-
ceiptNEIR 2460
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BUCK NAKED FRIES asseseess$5
SIA SAIT
DUST -ED FRIES
PICK ONE: 01D MY I R I CAMN I M010 If
DRESSED FRIES
#1 FRLSKIE FRIES*
SIGNATURE BEEF CHIEI & CHEESE
2. CLUCK—U e CRISPY CHICKEN ( BUFFAEO SAUCE I BEUE CHEESE DRESSING & CRUMBEES
0 LIL PIQQIE o PUEEED PORK WASABI CUCUMBER SEAW I BARBIEVE DRIlZEE
#1 MM P01—AT-0 HEADe EOCAE SOUR CREAM I SMOKED APPEEWOOD BACON I FRESH CHIVES I SHARP CHEDDAR
#g GINN—FULDSWEEre CINNAMON -SUGAR I WHIPPED CREAM
#() SWORSOMEa MEETED CHOCOEATE I MINI MARSHMAEEOWS I GRAHAM CRACKER CRUMBS
bate Sat 10/15 10-2
*Put the name of your restaurant on first line then sign the form.
Friskie Fries
Food Service Permit Fee for the following reason:
request a waiver of the
Xfinity Center Food Truck Festival and Fire Truck Pull
to benefit Special 01yrnpics
Thank you,
Signature
Owner
TIIV.e