HomeMy WebLinkAboutBoy Scouts #51 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:.
CATHERINE DEMASSI
Whose place of business is:
BOY SCOUTS TROOP 51 - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
CATHERINE A. DEMASSI
Permit Expires: July 12, 2016
License Number: T-138
Food Fee:
BOARD OF HEALTH
MichaeCMcCCean, Chairman
I -D Ob—
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit# Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 7 days prior to planned event)
1) Establishment Name,
2) Establishment Address
Address:
3) Establishment Mailing Address (if different)
Telephone No:
4) Establishment Telephone No:
FAX:
5) Applicant Name & Title:
A "b
6) Applicant Address
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4
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7) Applicant Telephone No.:
24 Hour Emergency No.:
t5o`�6_ - S 3,;1- - 14914
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
PKAn Association
11) If a corporation
or partner.
or partnership, give name, title, and home address of officers
Ll A Corporation
Name
Title Address
11 An Individual
11 A Partnership
Ll Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:-'
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Address:
I
61--o e- LIQ
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS:
V, �.� c� t I r Jtl- _ w::1,11 �r� \vein _Vt�� .(,r_
18) Name of Person In Charge Certified In Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: ❑ Permanent Location
❑ Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
21) Length of Permit:
❑ Annual
❑ Seasonal
Seasonal Dates:
Temporary Start Date: -7 t 12 11 �,
Temporary End Date: t 7—
Temporary Time:
Rain Date:
22) Establishment Type
Retail ( Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $75
Food Service up to 101 -200
or up to 25' PHF display $100
Food Service up to 201 +
or 25'+ PHF display $125
Food Service - Institution
Meals/Day)
Caterer $25
❑ Milk & Cream $2
❑ Mobile Food & Consession $50
Mobile Food Temporary $25
Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25
Residential Kitchen $25
Retail Food $50 of Pushcarts:
❑ Retail Snack Food $10
❑ Tobacco Products No Fee
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23) Food Operations
(Check all that apply):
Definitions: PHF- Potentially hazardous food (timeltemperature controls required)
Non-PHF's - non -potentially hazardous food(no timellemperalure controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ Sale of Commercially Pre -Packaged PHFs
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
❑ ry g
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Vacuum Packaging / Cook Chill
El Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
E] Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
Preparation of Non-PHFs
Other Food Operations
❑ Juice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of
Animal Oriain
❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Dake
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application ❑ waived
I, the undersigned, attest t e ccuracy of the information provided in this application and affirm that the food
establishment operation 111 com ly with 105 CMR 59 . nd all other applicable law. I have been instructed by the
board of health on how t obtain c pi s of 105 Clvl"R.000 and the federal Food Code,
24) Signature of Applicant.,- C
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:
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