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Home My WebLink AboutOpen Season Catering 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:. DAVID LIVESEY Whose place of business is: OPEN SEASON CATERING LLC - 5TH ANNUAL FIRE TRUCK PULL & FOOD TRUCK FESTIVAL @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE. - DAVID LIVESEY, OWNER Permit Expires: October 15, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-152 BOARD OF HEALTH Michael-mcClean, Chairman WAIVED Date Received Date Inspected Approved By Pennit # Issued Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening dat] 1) Establishment Hame: C 2) Establishment Address: 16 MC, 5-"'C LIA-Ie- 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 6Y 0 �';2 I 5) Applicant Name & Title: 31 6U-) 6) Applicant Address: 13S�120C%jr-7 oz V 7) Applicant Telephone No: L(, 24 Hour Emergency No: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: 0 An association • A corporation • Ail 0 Other L-pl entiti 11) tf a corporation or partnership, give name, title, and home address of officers or partner. Nan -re Title Home Address ILAt-'Ct?, <��) ( dA,4 /1' aww--t- r-S114- &41d'eldlb 0 12) Person Directly Responsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager etc.) Nan -ve & Title-. :pnod c 1, Uxe-se, --7 � A.P--.-- Address: 146-�- 1-44'j. f r - Telephone No: L G9,2 (a - 1-7 X Z Fax: k' 'o Emergency T No - 13) District Or Regional Su4rvisof if applicable) Ran-* & Title: Address: Telephone No: Fax: Tuagracatmr-Ta I Food Establishment Information 14) Water Source: JC) y;C (_ -AI-k 16) Sewage disposal: I(- , xc DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: Vee -"t ) 17) No. of Food Employees: 2- 18) Name of Person In Charge Certified in Food Protection Management: "DA Required as of 10/l/2001in accordance ,*nth 105 CUR 590.003(A) 119) Person Trained In Anti -Choking Procedures (if 25 seats or more): KYes 0 No 20) Location: 22) Establishment Type(check all that apply) -")( Caterer (check on--) 0 Retail ( Sq. Ft) 0 Food Delivery 0 Permanept Structure 0 Food Service - ( seats) 3 Residential Kitchen for Retail Sale Mobile ri Food Service - Takeout :I Residential Kitchen for Bed and Breakfast 0 Food Service - Institution Home MeaWDay) 0 Residential Kitchen for Bed and Breakfast Establishments 0 Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) 0 Annual C3 Season"Dates: ry YN Tern tes�lffTf E0 tt 5021 & Definitions: PHF- potentially hazardous food(rimeAemperature controls required) 23) Food Operations: Jqon-PHFs - non- potentially hazardous food (no timeltemperature controls required) (check all that RTE - ready -m -eat foods (Ex. sandwiches, salads. muffins which need no further processing) • Sale of Commercially Pre- PHF Cooked To Order 0 Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service, • Sale of Commercially Pre- o Preparation Of PHFs For Hot And C) PHF and RTE Foods Prepared For Highly Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility Service. • Delivery of Packaged PHFs 0 Sale Of Raw Animal Foods Intended a Vacuum Packaging/Cook CNII to be Prepared by Consumer. [3 Reheating of Con 'ally 0 Custom Self -Service 0 Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. a-tternative, time as a public health control) 0 Customer Self -Service Of Non- 0 lee Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of Animal PHF and Non -Penis hable Foods Retail Sale 06gin, Only. Preparation Of Non-PHFs 1:1 Juice Manufactured and Packaged Prepares FoodlSingle Meals for Catered I for Retail Sate 11A Events or Institutional Food Service utters K i t Fmt- in bUlK UU3nEMe$ Other (Describe): To be completed by the Board of Health 0 Retail Sale of Salvage, Out -of Date or Total Pei -mit Fee: Rened Food Payment is due mith application 1, the undersigned, attest to the accuracy of the information provided o5%is application and I affirm that the food establishment operation will comp MR 590.000 and a 4 � ��,Licable law. I have been instructed by the board of V health on how to obtain copiejs7�05 MR § '000 3nd the fe 4 Foo - e. 24) Signature of Applicant: —J --n Pursuant to MGL Ch. 62C, I belief, have filed all state tax returns 25) Social Security Number or Federal 10: Eder the.penalties of perjury that 1, to my best knowledge and state taxes required under law. "1-7 - S -'J 1 19;Z I-( 2- 26) Signature of Individual or Corporate Name: nl��K eg Vo �-1 '12V I "U TAX CERTIFICATION; FORM I certih- udder the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes requirk solder law. or Corporate rause "Social Seccuity No. or Fe&-T(z] Iderif -cation Ivri mhe-r B;': Cory}orate Officer (-Ury lrtory.r-11pptieabteI This license will not be issued unless this certification clause is signets by the applicant. " Your social security number will be furnishers to the Massachusetts Department of Revenue to determine whether you have met tax filiulg or tax payment obligations. Licensees who fail to correct their non -filing or delinqueney Swill be subject to license suspension or revocation. This request is made tinter the authority of Massachusetts General Law Chapter 62C, section 49A. C:`.Lrsers sldte Desk -top `toes Oats r. Food Establisha>=ars- Tenp T_4 C CERTIF A'7iON FOR.\ikx The Commoitirealth of _ lassaehitsetts Deharnnent of Industrial Accidents Office ofbivestigations IF 600 iTashingion .Sweet Boston, JL4 02111 t x11'1 c.fnas s.govIdta Workers' Compensation insurance AffidaA it: General Businesses Applicant Information Please Print Ledbly BusiuesslOrgaiuzation Name: ,,v5 1I C-. Address: �'� Phone * (�� ® i� 2• ( - C'tS.State!'Zip. MJF rte c l� - Z �— :ire %-on an employer^ Check 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 eapacim- [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. [oto workers' comp. insurance required]* 4. ❑ We are a non-profit organization. staffed by volunteer s. with no employees. [Ivo wrorker%i comp, insurance req.] Business Type (required): 5. ❑ Retail 6. Restaurant BaVEatina Establishment ❑ Office and`or Sales (incl. real estate. auto. etc.) S. ❑ Non-profit 9. ❑ Entertainment 10.1-1 Manufacturing 11.❑ Health Care 12.V3 Other — 40 % " 5 - 'Any applicant that checks hes =l must also fill wit the section below showing thea worker,* worke' compensation policy ►nfermation. °If the corporate officer have exempted themselves. but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I alit all en►plot•er that is providing +corkers' contpensatiot► fit sit rance for• fit 1� eatplgyees. Belo+r is die polio' iitfort►tntion. Insurance Company Name: Insurer's Address: (!!>de f3e_4C0c'U Ce.�) +tire. City:State Zip: ®2 5r,3,C - 13-79' Policy T or Self -ins. Lic. # �C�C3C�� Expiration Date: 17 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 25 A of iv1GL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 S250.00 a day against the violator. Be advised t at a copy of this statement may be forwarded to the Office of Investigation of the DLA for insurance coverage v 'tion. I do Iterebr and pen es of t;r that the ill o2 provided N 9-M-OMEWINE Official it se oil ty. Do not 11'rite in this area, to be eo►t►pleted bY cit(' or town official_ Citi- or Town: Permit,License 9 trite and correct. '10116 Issuing Authority (circle one): 1. Board of Health ?. Building Department 3. City,,Tow'n Clerk 4. Licensing Board Selectmen's Office 6. Other C ontaet Person: mit,-sr.mass.goc dta Phone gt ExagtForm NO- 10387 Cort. No. 11797690 CIRTIFICAT1®N DAVID J LiVESEY To .. Si._.._•L f. `�3'i 9� lv, bi ' �c�.:�iu: �.:.� � � •�. the Date of Examination: 12/111 ua of Expiration- 12/1112019 f d Lctal laws avvb•Chedc wilh your loc+l raga. fKaUonrequttntents, " EF). All rights $1014 National Rostaumnl Association "der license by.NaUonal —'L is a mgisleredtmd S—s fe isa lmdemark of ,�r. Assodation 5oiulk. a] I � 1U.- 1��-;M' � U 7, � 1 �MA 0 �U� � n � 1 Date *Put the name of your restaurant on first line then sign the form. We, request a waiver of the Food Service Permit Fee for the following reason: Thank you, Xfinity Center Food Truck Festival and Fire Truck Pull to benefit Special Olympics 0 C.6 A/,e- %Z -- Title