HomeMy WebLinkAboutMansfield Animal Shelter 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 FOOOD 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:.
JEFF COLLINS
Whose place of business is:
MANSFIELD ANIMAL SHELTER - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE
ANIMAL CONTROL OFFICER - JEFF COLLINS
Permit Expires: J u ly 12, 2016
License Number: T-141
Food Fee: WAIVED
BOARD OF HEALTH
MichaeC-g4cCCean, 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: Mansfield Animal Shelter
2) Establishment Address 175 Fruit Street, Mansfield, MA 02048
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: (508) 272-1084
5) Applicant Name & Title: Volunteer and president of Mansfield Shelter Friends
6) Applicant Address 5 Kemp Farm Way, Mansfield, MA
7) Applicant Telephone No.: 508-337-6325 24 Hour Emergency No.:
8) Owners Name & Title this is the Town of Mansfield Animal Shelter
Alt E -Mail:
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
O An Association
or partner,
D A Corporation
Name Title Address
11 An Individual
❑ A Partnership
Cl Other legal Entity
121 Person Directly Responsible For Daily Operations (owner, person in cnarge, supervisor, manager eic.)
Name & Title:
Animal Control Officer - Jeff Collins
Address:
Mansfield Animal Shelter 175 Fruit Street, Mansfield, MA
Telephone No:
(508) 261-7339 24 Hour Emergency No:
FAX:
msf@mansfieldshelter.org / ana.villella@verizon.net
E-mail:
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. WE ARE JUST GIVING OUT CANDY.
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
❑ 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:
❑ Annual
❑ Seasonal
Seasonal Dates:
J Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
❑ 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
❑ Milk & Cream $2
❑ Mobile Food & Consesslon $50
❑ Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25
❑ Residential Kitchen $25
❑ Retail Food $5p of Pushcarts:
❑ Retail Snack Food $10
❑ Tobacco Products No Fee
23) Food Operations
(Check all that apply):
Definitions. PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/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
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
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HAGCP 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
Preparation of Non-PHFs
Other Food Operations( E]Juice Manufactured and Packaged for I El 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
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: 'A�1 vim"" &a, _
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: