HomeMy WebLinkAboutPack 13 Cub Scouts 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:.
JUDY KASPRZYH
Whose place of business is:
PACK 13 CUB SCOUTS - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
JUDY KASPRZYH
Permit Expires: July 12, 2016
License Number: T-140
Food Fee: WAIVED
BOARD OF HEALTH
AichaeCAcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
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FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 7 days prior to planned event)
1) Establishment Name: ?b C K (5 c [,c b 0-6ik,t S
2) Establishment Address 11 w es� S f - � n$
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: 5 z
5) Applicant Name & Title: J Lk Cb� D cl'1
6) Applicant Address /o 0a h Si 7 e (fj--
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title
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
❑ An Association or partner.
IJ A Corporation Name Title Address
❑ An Individual—
❑ A Partnership
❑ Other legal Entity
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Name & Title:
Address:
Telephone No:
24 Hour Emergency No: —
FAX:
__-
----'-
—E-mail•
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
24 Hour Emergency No:
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.
Roquired as of 90/1/2001 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): Q _— -
20) Location: 1-1 Permanent Location
Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments: r -a m l J V
21) Length of Permit:
[] Annual
❑ Seasonal
Seasonal Dates:
fVj Temporary —
Temporary Start Date: f U 2-1 24li�a
Temporary End Date: j Lk J y j Z Z ONO
Temporary Time: Uj pm - (.ply)
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
Milk & Cream $2
❑ Mobile Food & Consession $50
❑ Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
❑ Pushcart $25
❑ Residential Kitchen $25
❑ Retail Food $5 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-potentiolly hazardous food(no timeRomperolure centrals required)
Check all that apply): RTE - roady-to-oat foods (Ex, sandwiches, salads, muffins which need no further processing)
iJ 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
( Delivery of Packaged PHFs - ------ 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 Onlycontact alternative, time as a public health
ElIce Manufactured and Packaged for control
Preparation of Non-PHFs ^ Retail Sale --_T_ )------ ------ - —
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
!r Retail Sale Animal Origin
t�51 CIA{ �tOy -L-T--
Offers RTE PHF in bulk Quantities rPrepares 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 Q 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: LU1/`��✓__L
Pursuant to MGL Ch,62C, sea 49A, I certify der the penalties
and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name: J -I - —F4
that I, to my best knowledge and belief, have filed all state tax returns