HomeMy WebLinkAboutIndustrial Dev. Com. 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:.
NANCY WALL
Whose place of business is:
INDUSTRIAL DEVELOPMENT COMMISSION - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
NANCY WALL
Permit Expires: July 12, 2016
License Number: T-146
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
pp (ca ion mus e submitted at leastays berore the planned opening date)
1) Establishment Name�(U ®'»'twit SSi il�U �Y10. � 0,0 L/C�VYI-C q � (G 61
2) Establishment Address
3) Establishment Mailing Address (if different)
Address:
4) Establishment Telephone No
Telephone No:
5) Applicant Name & Title:
FAX:
E-mail:
6) Applicant Address
Alt E -Mail:
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:
❑ An Association
O A Corporation
❑ An Individual
❑ A Partnership
El Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
_
191 Parsnn nirectiv Responsible For Dally UDeratlons (owner. person in cnarge, supervisor, manager etc.
fkjlq
Name & Title:
AMV16y tj,� I ,
Address:
CJQS
Telephone No:
90 cI. 0&6 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: _ 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
F1 9) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no Bme/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
20) Location: ❑ Permanent Location
22) Establishment Type
❑ Caterer $25.00
❑ Moblie Moblie Start Date:
❑ Retail ( Sq. Ft)
❑ Milk & Cream $10.00
Moblie End Date:
❑ Food Service up to 100 or
❑ Mobile Food & Consession $75.00
Moblie Comments:
up to 10' PHF display $125.00
❑Food Service up to 101 -200
❑ Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
21 Length of Permit:
g
Annual
or up to 25' PHF display $150.00
F] Food Service up to 201 +
❑ Pushcart $25 # of Pushcarts:
E] Residential Kitchen $100.00
E] Seasonal
or 25'+ PHF display $275.00
❑ Retail Food $100.00
Seasonal Dates:
E]Food Service - Institution
❑ Retail Snack Food $25.00
E] Temporary
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $25.00
Temporary End Date:
1
Temporary Time:
Rain Date:
23) Food Operations
;Check all that apply):
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no Bme/temperature 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
❑ Vacuum Packaging / Cook Chill
Delivery of Packaged PHFs
rY 9
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
-- -
❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
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
❑ Customer Self -Service
❑ Ice Manufactured and Packaged for
Retail Sale
f-1 Preoaration of Non-PHFs
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
,t��I Retail Sale Animal Origin
N d ( vl � C-1-( I �t j GU %c( 1"n 00 ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
l A Cf ❑ 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 590.000 and all other applicable law. I have been instructed by the
/board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code.
�" 24) Signature of Applicant: �::71 aaz � l��
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: l
rel A o It 4 U 'v'1 f 1,