HomeMy WebLinkAboutFriends of Memorial Park 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:.
MEGAN CROTTY
Whose place of business is:
FRIENDS OF MEMORIAL PARK - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
MEGAN CROTTY
Permit Expires: J u ly 12, 2016
License Number: T-145
Food Fee: WAIVED
BOARD OF HEALTH
MichaeCMcCCean, Chairman
. ..... ....
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: (?�N ovCk
2) Establishment Address RD ------
3) Establishment Mailing Address (if different)
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4) Establishment Telephone No: as) — lbw
5) Applicant Name & Title: CYZ4 +tA T�10 r Ph
6) Applicant Address z: --b -e (C�
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name &Title SCly-yle
9) owner Address (if different from applicant): Say"
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
11 An Association
or partner.
Name Title Address
11 A Corporation
0- An Individual
0 A Partnership
W Other legal Entity
Name & Title:
........ . .
Ck n CY-0�
Address:
Telephone No:
Telephone NO:
24 Hour Emergency No:
FAX;
E-mail:
Alt F -Mall:
0/')Cnq0)6'A1 ?o
1 qi niqtrinf Or Renional Suoervisor (if aoolicable)
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) DAYSIHOURS:
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 �J
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
20) location: ❑ Permanent Location
C] Mobile Mobile Start Date:( t2
Mobile End Date: 4l l
Mobile Comments:
21) Length of Permit:
❑ Annual
❑ Seasonal
Seasonal Dales;
0 Temporary
Temporary Start Date: k 1 Z
Temporary End Date: 4
Temporary Time: � _S- Pm
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 $26
❑ 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:
F] Retail Snack Food $10
❑ Tobacco Products No Fee
23) Food Operations
[______Deffni1ion_s:'pHF • Polentially hazardous food (time/temperature controls required)
Non-PHF'S • non -potentially hazardous food(no (ime/temperature controls required)
Check at$ that apply): RTE - roadyfo•oal 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
YN__ for More Than a single Meal Service
Sale of Commercially Pre -Packaged PHFs j ]Preparation of PHFs For Hot And
❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service E] PHF and RTE Foods Prepared For Highly
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
❑ Use of Process Requiring A Variance
❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Onlycontact alternative, time as a public health
F]Ice Manufactured and Packaged for
❑ eparation of Non-PHFs Retail Sale control)
Pr
Other Food Operations y❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
WO -f -f (%44% G n(A ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -pate
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application ❑ walved
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 obtpin,copies of 1o5 CW 590.900 and the federal Food Code,
24) Signature of Applicant:n
Pursuant to MGL Ch.62C, sec. 49A, I ertify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid slate taxes required under law,
25) Social Security Number or Federal to:
26) Signature of individual or Corporate Name: (�