HomeMy WebLinkAboutJuice Plus 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:.
KRISTINA MCCONNELL
Whose place of business is:
JUICE PLUS - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
KRISTINA MCCONNELL
Permit Expires: July 12, 2016
License Number: T-150
Food Fee: WAIVED
BOARD OF HEALTH
NichaeCNcCtean, Chairman
Date received:
FOR BOARD OF HEALTH USE ONLY
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: U ICE,
2) Establishment Address
Ne+_ 0296
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
5) Applicant Name & Title: �o5aqoi
6) Applicant Address RMS jr'
7) Applicant Telephone No.: 24 Hour Emergency No,:
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
El An Association
L1 A Corporation
El An Individual
VEl Partnership
Other legal Entity(6"A 61
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
H.
Alt E -Mail.
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
t f+6 Pt6' JL,
Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
H.
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:
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
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): 11
20) Location: ❑ Permanent Location
VMoblie Moblie Start Date;
Mobile End Date; �) i2 I2q te
Mobile Comments:
21) Length of Permit:
❑ Annual 4 iA,,
❑ Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Dater a
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
El Milk & Cream $2
❑ Mobile Food & Consession $50
Mobile Food Temporary $25
Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25
El Residential Kitchen $25
Retail Food $50 of Pushcarts:
Retail Snack Food $10
Tobacco Products No Fee
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
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service [] PHF and RTE Foods Prepared For Highly
❑ rY 9
Sale of Raw Animal Foods Intended Susceptible Population Facility
❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations rte, J&
t4
of i� V 0
Customer Self -Service ❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for contact alternative, time as a public health
Retail Sale control)
Juice Manufactured and Packaged for I [] Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
C � p� ,0 1 J ❑ Retail Sale of Salvage, Out -Of -Date '
Gt or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application ❑ waived
1, 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 copleh 9f105 CMR 590q.Q00 and the federald Code,
<, - — " n /IF o
24) Signature of Applicant:
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: