HomeMy WebLinkAboutJack Conway Realtor 7/12/2016Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate----a--F--o-
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:.
SHERRELL PREFONTAINE
Whose place of business is:
JACK CONWAY REALTOR - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
SHERRELL PREFONTAINE, MANAGER
Permit Expires: July 12, 2016
License Number: T-147
Food Fee: WAIVED
BOARD OF HEALTH
AichaeclmcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at leashdays before the planned opening date)
1) Establishment Name
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No (�
5) Applicant Name & Title: 'G �- �� ✓lel
6) Applicant Address
7) Applicant Telephone No.: �24 Hour Emergency No.:
- "_ { - --
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
An Association or partner.
A Corporation Name Title Address
An Individual
A Partnership
Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title:-
1�irC',-
Address:
-
Telephone No: '0 F 9 �,l 24 Hour Emergency No:
FAX -
E -mail: r' 144-9-0-
Alt
4 Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
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.
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 22) Establishment Type Caterer $12.50
Moblie Moblie Start Date: Retail ( Sq. Ft) Milk & Cream $5.00
i
Moblie End Date: Food Service up to 100 or Mobile Food & Consession $37.50
Moblie Comments: ; up to 10' PHF display $62.50
Manufacture Frozen Desserts/Ice Cream
---
i
21) Length of Permit: Food Service up to 101 -200 $12.50/freezer
Annual or up to 25' PHF display $75.00 Pushcart $12.50 # of Pushcarts:
i
Food ood Service up to 201 + Residential Kitchen $50.00
or 25'+ PHF display $137.50
Retail Food $50.00
Seasonal Dates:
Temporary Food Service - Institution Retail Snack Food $12.50
I
Temporary Start Date: ( Meals/Day) Tobacco Products $12.50
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
(Check all that apply): 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 Commercial) Pre -Packaged PHFs Preparation of PHFs For Hot And -
Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs g - i Susceptible Population Facility
Reheating of Commercially Sale of Raw Animal Foods Intended
to be Prepared by Consumer Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
-- vicof Non PHF and Nonn - ---- Customer--- --- — - Use of Process Requiring A Variance
Customer Self SeryIce Manufactured and Packaged for and/or HACCP Plan (including bare hand
Perishable Foods Onlycontact alternative, time as a public health
Preparation of Non-PHFs Retail Sale control)
Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of
Other Food Operations
Retail Sale I Animal Origin
�o � /� �, rn�,/ Offers RTE PHF in Bulk Quantities
Prepares Food/Single Meals for
r% {° � _ __ __ Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date - -- - -
or Reconditioned Food To be completed by the Board of Health
r -
� Total Permit Fee:
.e
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 wit 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on o obtain ' s of 105 CMR 590.000 and the fed ood ode
t�24) Signature of Ap 'cant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the alties ofperjury that I, to my best knowledge arrd belief, have filed all state tax returns
and paid state taxes required under law.
f
`� 25) Social Security Number or Federal I
26) Signature of Individual or Corporate
1