HomeMy WebLinkAboutMetro PCS 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 NITS
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:.
JULIANA DESOUZA
Whose place of business is:
METRO PCS - MANSFIELD FAMILY FUN NITE
NORTH MAIN STREET
PERSON(S) IN CHARGE:
JULIANA DESOUZA
Permit Expires: July 12, 2016
License Number: T-120
Food Fee: WAIVED
BOARD OF HEALTH
.%ichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
T-120
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name METRO PCS - MANSFIELD FAMILY FUN NITE
2) Establishment Address NORTH MAIN STREET
3) Establishment Mailing Address (if different) 234 NORTH MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-8300
5) Applicant Name & Title: JULIANA DESOUZA, MANAGER
6) Applicant Address
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title JULIANA DESOUZA
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
An Association or partner.
A Corporation Name Title Address
An Individual
A Partnership
Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: ,JULIANA DESOUZA
Address:
Telephone No: �, 2�- 24 Hour Emergency No:
FAX:
E-mail: �J til /k C�r�
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address.-
Telephone
ddress:
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: -fi,
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 101112001 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 2 22) Establishment Type
Moblie Moblie Start Date: Retail ( Sq. Ft)
Moblie End Date: Food Service up to 100 or
Moblie Comments up to 10' PHF display $62.50
21) Length of Permit:
Food Service up to 101 -200
Annual
or up to 25' PHF display $75.00
Seasonal
Food Service up to 201 +
PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
or 25'+ PHF display $137.50
Seasonal Dates:
Sale of Commercially Pre -Packaged PRFs
Temporary
Food Service - Institution
Temporary Start Date: 7/1*201*5-
( Meals/Day)
Temporary End Date: -7144/20t5
Temporary Time: 1 2 l 2,0 k (p
Reheating of Commercially
Caterer $12.50
Milk & Cream $5.00
Mobile Food & Consession $37.50
Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
Pushcart $12.50 # of Pushcarts: 0
Residential Kitchen $50.00
Retail Food $50.00
Retail Snack Food $12.50
Tobacco Products $12.50
Rain Date:
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF's - 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 PRFs
PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
- -- -- for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PRFs
Preparation of PRFs For Hot And
Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly
Delivery of Packaged PRFs
ry g
Susceptible Population Facility
Sale of Raw Animal Foods Intended
Reheating of Commercially
to be Prepared by Consumer Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
- Use of Process Requiring A Variance
Customer Self -Service of Non PHF and Non-
Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only
- - - -
Ice Manufactured and Packaged for contact alternative, time as a public health
Preparation of Non-PHFs
Retail Sale control)
Other Food Operations
Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin ,
COTTON CANDY
Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
qb(2 CO P-4JCatered
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
0.000 and t eral Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify underige
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:
Y26)
fe
Signature of Individual or Corporate Name: