HomeMy WebLinkAboutUxbridge 1st Holiday Nite 10/15/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
®ermit 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:.
TOM BELLACQUA
Whose place of business is:
UXBRIDGE IST HOLIDAY NIGHT COMM;- 5TH ANNUAL FIRE TRUCK PULL & FOOD
TRUCK FESTI @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE
BOB AMBROSINO
Permit Expires: October 15, 2016
Permit Expires:
Permit Expires:l
Permit Expires:
Food Fee:
License Number: T-159
BOARD OF HEALTH
MichaeCNcCCean, Chairman
WAIVED
I
IM61:47-NMI S MAO= 1413
Date Received Date Inspected Approved By Permit # Issued
Food Establishment Permit Application
(Application n7ast be submitted at least 30 days, before the planned opening d
1) Establishment Name; ric 'k HO i jP bli q
/c�j
2) Establishment Address: 1"63 61"'1) LC()L1(zkA,4idU
444, OLZ�
3) Establishment Mailing Address (if different): V
4) Establishment Telephone No; f/1
5) Applicant flame & Title:
C/O UID
6) Applicant Address: A f a-121
7) Applicant Telephone flo:
24 Hotff Emergency No: Z�A
8) Owner I -Jame & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Cywned By;
* A.P. association
41!1 A cowffation
iD) An :ndlivvdual
iDj A Wnership
kv Othef le�p! entity
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
Name tie,Honie Address
12) Person Directly Res, onsble For Daily OpSrations jOwner, Person in Charge, S!!pervisor, Manager etc.
Nlame & Tte:_
Address:
_741,
Telegtxxie Nor
302,
Enx-rgency Tel-eptroie No:
3
13) istrict Or R-Vitanal Supervisoi (if applicable)
VO,me- & Title-,
Addrew:
Telephone No-,
Fax:
a
v_auo! ao'_
14) Water Source: �'j V,
15) Sewage disposal:
.
J
DEP Public Water Supply No: (if applicable)
b! l
16) Days and Hours of Operation:
17) No. of Food Employees.,
18) t4ame of Person In Charge Certified in food Protection Management:
Retied a,� of ILI'llt' OCI,xirc,. arse
ve165 CAI,-; 'i-9-0,003jAJ
19) Person Trained In Anti-C-hoking Procedures (it 25 seats or more): 0 Yes 0 110
20) Location:
22)
Establishment Typetcheck oil Mit apply?
D Caterer
'cpfeck one)
D
'Retail f 'Sq. Ft)
D Food Delivery
Pernnanert Stpictire
,7j
Food Service - ( Seats;
:3 Residential Kitchen for Retail See
I;)--
Food S;e��ice - Takeout
:1 Residential Kitchen for Bed and Breakfast
`a
Food SeNce -!nWVtutco,,
Home
meaWDay)
0 Residential Kitchen for Bed and Breakfast
Establishments
Other (Describe)
,3 Frozen Cies sett tlanu-factver
21) Length Of Permit,
(chneck orej
Arnuat
0 sea&C-0-alt0ates:
7
i Temporary,,, Dat/Ttme:
Definitions: PHF- potentially hazardous food(rime,'remperarure controls required)
23) Food Operations:
14on-PHFs - norr- porentially hazardous food
(no rimelzeraperacure con roil required ' )
RTE - ready-ro-ear foods (Ex. sandwiches,
salads. muffins which need no fu,7zher processing)
eck w/tholl :
�ch-.PWY,,
• Safe of Coninierciafly Pre-
Z' PHF Cooked To Order
3 Hot PHF Cooked and Coded cc Hot He"d for
Hot
Packaged No -PHFs
More Than a Single WN, Service,
ix
• Sale of Caninx-rcially Pre-
'3 Preparation Of PHFs Ff-- Hot And
3 PHF and RTI= Foods Prepared Fof Highly
Packaced PHFs
Coid HL -1 -ling For Single Meal
SusceptiAe PcqXation Fadity
Service.
• Deiiqery of Packaged PHF,,
:3 S Of Raw Animal Foods Intended
'13" - ging/Cook ChT
_"n' Packa
to be prepared by C-onsinier.
Reheatirm of Con-niercially
D C%,istom-- Self -Service
o Use Of Process Requirng AVariance And!Or
,0-
Processed Foods For Service
HACCP Plan (including bare hap,! cortact
Withi.ri 4 How,-
afternatkre, time as a public heafth control.)
ri customer Seif-Service Of noir-
3 lee Manulactured and Packaged for
o Offers Raw Cr Underwaked Food Cif AnM,31
PHF ard Non-Petishal.,Ae Foods
Retail Sale
€nly.
i
I
Plop-PHFs
z) Juice Mianufa-c-1wred and Packaged
0 Prepares FoodSjng�-- Meals for Catered
for Retail Sale
Events or InstoAcnal Food Service
Other (Describe): Offers K -It MTV- in WK Quantitie
s To he complered b.i rhe Board of Healrh
Retail Sale of Salvage, Out -;i Date or Total Perinit Fee:
Reconatoned FPii-ment ia due nith ippUcitiou
ood
1, the undersigned, attest to tile accuracy of the information provided in this application and I affirm that the food
establishment operation will Comply 'th 105 CMR 590,000 and all other applicable law. I have been instructed by the board of
health on how to obtain copies of MR 590.000 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch. 62Ct sec, 49A, I certify unde the penalties of perjury that 1, 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:
26) Signature of Individual or Corporate Narne,
TAX CERTIFICATION FORM
I certify trader the penalties of perjury that 1, to nab, best knowledge and
belief, have filed all state tax i:eturrts uid paid all state taxes required
under law.
Sigtaftire of Indi%,W-,,1Tob--o/rate 1�—mie By: Corporate Officer
—Sod,d 5eauity No. 64'�477oWz) tv Federal
'This license will not be issued unless this certification clause is signed
by the applicant.
Your social securit-y; nuiviber will be furnished to the Massachusetts
Department of Revenue to determine ivhether you have niet 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 imder the auti-toritv of Massachusetts General Law
Chapter 62C, section 49A.
C: V-;�Us DXWJ-'km-mTxd CUMCAUION FOP2AIdor
FROM :POSTAL CENTER USA FAX NO. :508 234 4861 Oct. 06 2016 12:32PM P1
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Exam Fora No. 4719 NATIONAL �<< v � RESTAIIRANi
t� Cert. No. 90WW2 ASSOCIATION, l
ry afe ' Certif cation
TO R013ERT C AMBROSIN
for successfully completing the standards set forth by the National Restaurant Association Educational
r
Foundation for the Serv$afe& food Protection Managei Unification Examination.
Date of Examination- 05/02/2012
Date of Expiration: 05/02/2017--
Local laws apply. Check with your local royulatory agency for recertification requirements.
CZi72010 National Restaurant Association Educational Foundation. All rights reserved. ri0G55
L,) *,-\0 yz,
FROM :POSTAL CENTER USA
FAX NO. :508 234 4861 Oct. 06 2016 12:32PM P2
CERTIFICATE OF
ALLERGEN AWARENESS `T'RAi IN
Name of Recipient ROBCR'I AMBROSINO
CeTtif cats NeifIabcr 24Y8:i12
Bate 13f Cntnpleeim.
Date ofT'.qdntlow Bl19I2o21
7iir aAaurr„o>'nrclm, •is hercl�r dsrued ibla rrrtifriyi/p
fnrro�y/rting unnilet�b uu�wmaors trainin(,�pro�mm�
r� /9b�hized Gy +`.beeMwssarhNnYfi 17fpar!>~jtrvt a, f Pitlrhr.Heallb
'if t7rf01 awre with 105 CM)Z 590 ti09(G7(7)(aJ
his P-Piifrrate sudll &Wjjdfm Etre (5) yecra fYBm dale pfconrpletiptt,
IA$nfA By:
M:u chuf4mA"t-wantA dorlon
M,765.7122
a'i.7 liimpi6 R-1, Sv9M im
5ovthhulwgl,,MA ai'772
1%'VAX exhenn,lttOcy
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FROM :POSTAL CENTER USA FAX NO. 508 2,34 4861 Oct.
,u06Y2016 12:34PM P4�
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ose dor sale arbat
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merchandise; etVares 'arpYbf1
ar ':indlwnre tags.
ficial' �ovver8° ... .:• ,.. b,�., ��
e 19� not vale. after tlie.l censers
lias.ettdorsed l s
until
Z`ititi,'litett e d the lfcen�a i�..;d'ated, and8iazre�+�ti':,v�,%�.;tl��:,;�iicfi�rl:,"�ii�p or'
provided iii thpa niargln' hei6d, an
Signature of the Director, T}i ' ppartian of the license indicating the hee�iae nt �; ie nsee Haase' . ,
and the date of expiration nttset be worn itl;a �tiosble and eonspicunt�8. aianYt on rioter el6thing,
otherwise he will be liable to the game pcnalt6y as ' #i he bnd t no license:
THIS LICENSE IS t40T TRANSFERASLE ...::
FROM :POSTAL CENTER USA FAX NO. :508 234 4861 Oct. 06 2016 12:35PM P5
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.Qk The Continowrealth of -11as sachuseils
Deparnnent of Industrifil Accidents
Qffice qf hivestigations
600 Mashingion Sn-eei
Boston, L4 02111
IV 11,11-ps.111ass'gol"'Win
Worker -s" Compensation Insurance Affidavit: General Businesses
Bustness.i0r( pnization Name:
Addfess,: /'p3 0 Afw64'
Are you in employer? C'heck- the appropriate box:
1, Fj I am a employer with _ employees (full and
or part-time)
I am a sole proprietor or p3rurerihip and hive no
emplo,,-ee,, v,-orizing for me in any capacirr
(No, workefs . cenT- insivance required]
3. El We are a corporation and its officer: have exercised
their right of exemption per c. 1552, 1(4t and we have
employees. [No worker=' comp. insurance reqniiedl*
4, Ir e are a non-profit organization, staffed by volnuteeti.
Awith no employees- [No work-evC ccwip, insutance %eq.]
WIMBEIMMIM
Btr;iness Type (required):
5, [_1 Retail
6, Ej Re-�tauraiitiBar,Eatirlg Establishment
7. 0 Office andor Sales (incl. real estate, itito, etc.)
S. 6(Non-proftt
9, Fj Entertainment
10-R NL-utufactiirinL7
I 10 Health care
12" El other
'Aay apphCaut rb-at checks K -o„ =1 -U'i* 01,10 fill Out ;hr '.'Acrtc-z belaw 5hcwme (mea worLen' com:pauaea policy Lufonustiou.
.+Ifzhe zorp'nn-'e Officer- bLz,.-e exempted t;Ut :he Corpoz'3°soy!VI4 other eMDICA leei. 2 Worker 'come sarion F lzcsn. lequi-ed a --d iuch m
OTPU-Mlwa, s:iould check box # I .
I flin all elflplo�yer Mot is Providing 1i orkers ' conlPen5alfoll in5i'll-ancefor ))III- elliployees. Below is the POUCY infortflatioll.
lw.urauce Company Narue:
Insurer's Addzes:
Policy # or Self-m�- Lic. #1
Expiration Date,
Attach -.1 copy of the workers' compensation policy declaration page (shoiiing the policy number and expiration date).
Failure to secure coverage as required under Section -25A of)NML c, 1-5-2carr lead to the tinposition, of crimiam penalties of a
fine tip to $1,500.00 and,'or one-year imprksonmelit, as well a> civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day agam,,4t theviolator. Be a&ised that a copy of this -mtement may be for.varded to the Office of
Investizatious of the bLA for insurm-ice coverage verification.
Ido Iter ;1 cer-9n rinder the pains and porabies ofperjitty that the inforination provided abiove is true and correct.
Official n se only. Do notwi-fre in this area, to be coinpleted b), citt, or town offrcial
City or Town:
Permit,"License #
Lsiting Autborin• (circle one);
1. Board of Health 2. Building Department 3. (Aty7own Clerk 4. Licensing Board 55. Selectmen's Office
6. Other
C'ontact Person
v, ww. m Ai S. f 0V & a
Phone 114:
M0 #
E32�-
# # # #- -
Date/C'
*Put the name of your restaurant on first line then sign the form.
we, ►f request a waiver of the
Food Service Permit Fee for the fol wing reason
Thank you,
XfinitCenter Food Truck Festival and Fire Truck Pull
to benefit Special Olympics