HomeMy WebLinkAboutBarrows Ins. 7/12/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
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:.
JAY BARROWS
Whose place of business is:
BARROWS INSURANCE AGENCY - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
JAY BARROWS
Permit Expires: July 12, 2016
License Number: T-149
Food Fee: WAIVED
BOARD OF HEALTH
AichaeCAcCCean, Chairman
- -- -------
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit ft Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 7 days prior to planned event)
1) Establishment Name:
2) Establishment Address
Address:
6-A C\
3) Establishment Mailing Address (if different)
24 Hour Emergency No:
FAX:
4) Establishment Telephone No:
E -mal):
5) Applicant Name & Title:
ynh,
r) >
6) Applicant Address
7) Applicant Telephone No.:
24 Hour Emergency No.:
8) owners Name & Title
9) owner Address (If different from
applicant):
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
10) Establishment Owned By:
11 An Association
BSA Corporation
0 An Individual
El A Partnership
0 other legal Entity
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Name & Title:
Address:
6-A C\
Telephone No:
24 Hour Emergency No:
FAX:
E -mal):
Alt E -Mai.
'\)
13) District Or Regional Supervisor (if applicable)
Name &Title:
Address:
Telephone No:
FAX:
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 Individuals are certified, complete list is on file,
wlred as of 10/112001 in accordance with 105 CMR 590,003(A) Please attach
of certificate
19) Person Trained In Anti -Choking Procedures (if 25 Seats or more); ❑ f C� )
_-
20) Location: ❑ Permanent Location
22) Establishment Type
❑ Caterer $25
❑ Mobile Mobile Start Date:
❑ Retail ( Sq, Ft)
Milk & Cream $2
Mobile End Date:
[] Food Service up to 100 or
E] Mobile Food s Consession $50
Mobile Comments:
up to 10' PHF display $75
❑ Food Service up to 101 -200
❑ Mobile Food Temporary $25
Manufacture Frozen Desserts/Ice Cream
21) Length of Permit:
❑ Annual
or up to 25' PHF display $100
$5/freezer
--
E]Food Service up to 201 +
or 25'+ PHF display $125
Pushcart $25
❑
❑ Residential Kitchen $26
__
E]..Seasonal
Seasonal Dates:
n Food Service - Institution
( Meals/Day)
E] Retail Food $50 of Pushcarts:
❑ Retail Snack Food $10
j�Temporary
Temporary Start Date: 7' �c� I %
❑ Tobacco Products No Fee
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Definitions: PHF - Potentially hazardous food (flme/lemperature controls required)
Non -PRFs • non-polentiolly hazardous tood(no (lmeltomporafuro controls roquired)
(Check all that apply):
RTE -
ready-to-eal foods (Ex, sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pro -Packaged Non-PHFs
n PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hol Heid
❑ Sale of Commercially Pre -Packaged PHFs
—
❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
El Delivery of Packaged PHFs
Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
F1 Use of Process Requiring A Variance
Customer Self Service of Non PHF and Non-
(I Customer Self -Service
and/or HACCP Plan (including bare hand
Perishable Foods Only
F] Ice Manufactured and Packaged for
contact alternative, time as a public health
_ _ _
r Preparation of Non-PHFs
_ Retail Sale J �J
control
_ _) —__-- -- —
Other Food Operations
❑ Juice Manufactured and Packaged for
I Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
❑ Offers RTE PHF in Bulk Quantities
❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be completed by the Board of Health
T—
Total Permit Fee:
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 oblafrn copiep of 105 CMRAO,OYO
and the federAF9�ude.
24) Signature of Applicant: '-i u v ' ' J
Pursuant to MGL Ch.62C, sec. 49A, I 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:
26) Signature of Individual or Corporate Name: t'