HomeMy WebLinkAboutMansfield Rotary 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:.
COLBY BARROWS
Whose place of business is:
MANSFIELD ROTARY CLUB - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
BOB PEXIOTO, PRESIDENT
Permit Expires: J u ly 12, 2016
License Number: T-142
Food Fee: WAIVED
BOARD OF HEALTH
AichaecAcCCean, Chairman
—FOR BOARD OF HEALTH USE ONLYDate received: Date Inspected: Approved By; Permit# IssuedFMOD F-STABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 7 days prior to planned event)1)
Establishment Name:2)
Establishment Address3)
Establishment Mailing Address (if different)4)
Establishment Telephone No, 6-cr�_ Cqr, qz y3.6)
57c) 24 Hour �mergency No:
Applicant Address &-70kq7)
Applicant Telephone No.: 24 Hour Emergency No.:8)
owners Name & Title9)
Owner Address (if different from applicant):10)
Establishment Owned By: —
An Association
A Corporation
11 ) If a corporation or partnership, give name, title, and home address of officers•
or partner.•
Name Title AddressEl
An IndividualEl
Other legal Entity
Ukr
Name & Title:
Telephone No:
57c) 24 Hour �mergency No:
Alt E -Mail:
13)District OrRoniona|Supervisor (if applicable)
Name & Title:
Telephone No: 24 Hour Emergency No:
Food Establishment Information
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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.
ruired as of 101112001 in accordance with 105 CMR 590.003
Please attach copy of certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more);
20) Location: [] Permanent Location 22) Establishment Type
jjj,Moblle Mobile Start Date: 7 (D 0 Retail ( Sq. Ft)
Mobile End Date:'7 (^Z ( F„ E] Food Service up to 100 or
Moblie Comments: ` , up to 10' PHF display $75
21) Length of Permit:
❑ Annual
❑ Seasonal
Seasonal Dates:
j Temporary
Temporary Start Date:
Temporary End Dale: 7 (( i L
TemporaryTime: 5',bo
Rain Date:
Food Service up to 101 -200
or up to 25' PHF display $100
Q Food service up to 201 +
or 25'+ PHF display $125
[] Food Service - institution
( Meals/Day)
Q Caterer $25
0 Milk & Cream $2
F] Mobile Food a Consesston $50
El Mobile Food Temporary $25
Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25
Residential Kitchhen $25
Retail Food $50 of Pushcarts;
Q Retail Snack Food $10
Tobacco Products No Fee
23 Food Operations Derrnilions: PHF - Potentially hazardous food (11menemparature controls required) j
P Non-PHFs - non-pofentiaily hazardous food(no Umaltemperature controls required)
(Check all that apply): I RTE - ready -lo -eat foods (Ex. sandwiches, salads, muffins which need no furthar processing)
U Sale of Commercially Pre -Packaged Non-PHFs
[} Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Ij Reheating of Commercially
Processed Foods for Service Within 4 Hours
E] Customer Self -Service of Non PHF and Non -
Perishable Foods Only
rl Preparation of Non-PHFs
E] PHFCooked To Order
Ej Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
[] Customer Self -Service
I] ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Heid
for More Than a Single Meal Service
I] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
I] Vacuum Packaging / Cook Chill
I] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Other Food Operations i] Juice Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
S {Cv t; ��p ` Ej Offers RTE PHF in Bulk Quantities I] Prepares Food/Single Meals for
u"A.� A ma �{ Catered Events or Institutional Food Service
- \ � Retail Sale of Salvage, Out -Of -pate
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application E] waived
I, the undersigned, attest to the accuracy of the information provided In this application and affirm that the food
establishment operation will con—Ay with 105 CMR 690.000 and all other applicable law. I have been instructed by the
board of health on how to obtairry opies of jV5 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: v �—
Pursuant to MGL Ch.62C, sec, A11ortify under the penalties of perjury that I, to my best knowledge and belief, have filed ail state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name: