HomeMy WebLinkAboutIced @ Midnight 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:.
CHRISTINE ZANIBONI
Whose place of business is:
ICED AT MIDNIGHT - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
CHRISTINE ZANIBONI
Permit Expires: July 12, 2016
License Number: T-148
Food Fee: $0.00
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: 16C"'d ------ -
2) Establishment Address
3) Establishment Mailing Address (if different)
14) Establishment Telephone No:__
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No.:
24 Hour Emergency No,:
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By: 11 ) If a corporation or partnership, give name, title, and home address of officers
0 An Association or partner.
Ll A Corporation Name Title Address
(7 An Individual
11 A Partnership
0 Other legal Entity
10 Do ^n rlirnofh/ PmQne-,ncz1h1n Pnr nni1v Onprnflon.-, (owner. nerson in charae. supervisor, manager etc.)
Name & Title:
-'-241Hour Emergency No:
Address:
Telephone No,
e), —
24 Hour Emergency No:
Q JC'�'-
S-
E-mail:
Alt E -Mail:
13t District Or Reaional Supervisor (if applicable)
Name & Title:
Address:
-'-241Hour Emergency No:
Telephone 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:
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file,
fuired as of 1WI12001 In accordance with 105 CMR 690.003
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 $25
❑ Mobile Mobile Start Date:
❑ Retail ( Sq. Ft)
[_) Milk R Cream $2
Mobile End Date:
❑ Food Service up to 100 or
❑Mobile Food & Consession $50
Mobile Comments:
up l0 10' PHF display $75
❑ Food Service up to 101 -200Manufacture
❑Mobile Food Temporary $26
Frozen Desserts/Ice Cream
i
_
21) Length of Permit:
❑ Annual
or up to 25' PHF display $100
_)
$5/1'reezer
❑ Food Service up to 201 +
❑ Pushcart $25
. -- -------------------
F Seasonal
or 25'+ PHF display $125
❑ Residential Kitchen $25
Seasonal Dates:❑
Food Service • institution
( Meals/Day)
of Pushcarts:
(� Retail Food $5
❑ Re(all Snack Food $10
❑ Temporary
Temporary Start Date:
❑ Tobacco Products No Fee
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations Deflnitionsr PHF - Potentially hazardous food (11me/temperature controls required)
Non-PHF's - non -potentially hazardous food(no (lmeHemperature controls required)
(Check all that apply): RTE - roadyto-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 He And
--------- - - Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
❑ Delivery of Packaged PHFs — Susceptible Population Facility
-- ❑ Sale of Raw Animal Foods Intended _
❑ Reheating-of Commrctaliy to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours --_ -
Customer Self -Service of Non PHF and Non- [. ( Customer Self -Service n Use of Process Requiring di Variance
Perishable Foods Only contact
and/orHACCP Plan (including bare hand
Ice Manufactured and Packaged for contact alternative, time as a public health
❑ Preparation of Non PHFs Retail Sale control)
Other Food Operations ❑ Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
❑ Offers RTE PHF In Bulk Quantities ❑ Prepares Food/Singlo 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
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 690.000 and all other applicable law. I have been Instructed by the
board of health on how to obtain . o /lets of 10 CT 580. qO and the
?fe�ydgerpi�ood Code.
24) Signature of Applicant: ���I 1 �0!%G>C� �o
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 lax returns
and paid state taxes required under law,
25) Social Security Number or Federal ID:
2.6) Signature of Individual or Corporate Name: