HomeMy WebLinkAboutKirley Masonry 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: STREET FAIR -FAMILY FUN NIGHT
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:.
ERIC STROM
Whose place of business is:
KIRLEY MASONRY AND STOVE EMPORIUM - MANSFIELD FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
ERIC STROM, OWNER
Permit Expires: July 12, 2016
License Number: T-79
Food Fee: WAIVED
BOARD OF HEALTH
MichaeCVicCCean, Chairman
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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:
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2) Establishment Address
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3) Establishment Mailing Address
(if different)
24 Hour Emergency No:
Telephone No:
4) Establishment Telephone No:
5) Applicant Name & Title:
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6) Applicant Address
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7) Applicant Telephone No.:
24 Hour Emergency No,:
8) Owners Name & Title
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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
Association
or partner.
Corporation
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Name Title Address
El An Individual
El A Partnership
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0 Other legal Entity
121 Person Directly Responsible For Daily Operations (owner, person in cnarge, supervisor, manager etc.)
Name & Title:
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Address:
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24 Hour Emergency No:
Telephone No:
FAX:
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Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
I Name & Title:
Address:
Telephone
I 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.
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: L] Permanent Location
22) Establishment Type
❑ Mobile Mobile Start Date:
❑ Retail ( Sq. Ft)
Mobile End Date:
[] Food Service up to 100 or
Mobile Comments:
up to 10' PHF display $75
21) Length of Permit:
❑ Food Service up to 101-200
❑ Annual
or up to 25' PHF display $100
❑ seasonal
❑ Food Service up to 201 +
– —
TO be completed by the Board of Health
Total Permit Fee:
Payment is due with application ❑ waived
or 25'+ PHF display $125
Seasonal Dales:
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Temporary Start Date:
Temporary End Date:
Temporary Time: �(�
Rain Date:
Ej Food Service - Institution
( Meals/Day)
❑ Caterer $25
❑ Milk & Cream $2
C7 Mobile Food & Consession $50
R. Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
❑ Pushcart $25
❑ Residential Kitchen $25
Retail Food $4 of Pushcarts;
Retail Snack Food $10
Tobacco Products No Fee
23) Food Operations Definitions; PHF -Potenftapy hazardous food (ttntellempemture controls required)
Non-PHF's - non-potentlelly hazardous food(no fima/tompomture controls required)
(Check all that apply): I RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ Sala of Commercially Pre -Packaged PHFs
❑ Delivery of Packaged PHFs
❑ Reheating of Commercially ^�
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHF and Non
Perishable Foods Only
(-1 Preoaration of Non-PHFs
Other Food Operations
M,n di
El PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly —
Susceptible Population Facility
Sale of Raw Animal Foods Intended
❑ to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (Including bare hand
contact alternative, time as a public health
control)
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
Juice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of
Animal Origin
❑ Prepares Food/Single Meats for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
[� Retail Sale of Salvage, Out -Of -Data
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. 1 have been instructed by the
board of health on how to obtain of 105 CMR 590.00y an eral Food Code\A .
24) Signature of Applicant:
Pursuant to MGL Ch.52C, sec. 49A, I certify under the p�s of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required tinder law.
2.5) Social Security Number or Federal ID: —
f 26) Signature of Individual or Corporate Name: