HomeMy WebLinkAboutR.F. Sibilia DMD 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:.
ROBERT F. SIBILIA
Whose place of business is:
ROBERT F. SIBILIA DMD - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
ROBERT F. SIBILIA
Permit Expires: July 12, 2016
License Number: T-139
Food Fee: WAIVED
BOARD OF HEALTH
NichaeCNcCCean, Chairman
07-12-16;02:24PM;
FOR BOARD OFHE"ALTH USE ONLY
Date received: Date Inspected', Approved by: Permit # Issued
13 1
FOOD ESTABLISHMENT PERMIT APPLICATION
# '1/ 2
(Application must be Submitted at least 7 days prior to planned event)
1) Establishment Name:
2) Establishment Address '
3) Establishment Mailing Address (if different) _� 44-7
mans-, K4,1 0,9-0 4 F
4) Establishment Telephone No:
5) Applicant Name & Title: Ko
'fLn Mee
rCe �4 0',
6) Applicant Address 5;= aWn KAA QcVlaa)
7) Applicant Telephone No.: 24 Hour Ewergency 0.:
8) Owners Name & Title
9) Owner Address (if different from applicant), q
±
10) Establishment Owned By:
11) if a corporation or partnership, give name, title, and home address of officers
El An Association
or partner.
El A Corporation
Name Title Address
D Individual
LJ A Partnership
0 Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person In charge, supervisor, manager eto.)
Name & Title:
Address:
esaa-y_�' Ou� CL60 Ve-,,-
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Tolophone No: 24 Hour Emergency No:
FAX
07-12-16;02;24PM; # 2/ 2
14) WATER SOURCE:
Food Establishrijnt't'rformation
15) SEWAGE DISPOSAL:
DEP Public Water Supply No; (If applicable) 163 No. of Food F -m to ees•
17) DAYS/HOURS:
183 Name of Person In Cha Certified in Food Protection Management:
If more than 3 individual re certified, complete list is on file.
as of 10/712009 /n accordance with 105 CMR 590,003(A) Ploaso attach copy of certificate
19) Person Trained In Anti -Choking Procedures (If 25 Seats or more): El
20) Location; Q Permanent Location
n Mobile Mobile Start Date:
Mobile End Date;
Mobile Comments:
21) Length of Permit:
Q Annual
0 Seasonal - —
Seasonal Dates;
Q Temporary
Temporary art bete:
Temp ry End Date:
Temporary Time:
Rain Dato;
22) Establishment Type
0 Retail ( Sq. Ft)
n Food Service up to 10
up to i0' PHF displ $7
Q Food Service to 101 -200
or up to 25' HF display $100
Q Food rvice up to 201 +
or 2 + PHF display $125
Q F od Service. Institution
( Meals/Day)
Q Caterer $25
�]
Milk & Cream $2
0 Moble Food & Consesslon
Q Mobile Food Tempora 5
0 Manufacture Froze assertsllco Croom
$5/freoxer
[3 Pushcart $25
Q Resident Kitchen $25
Q Relal cad $5i of Pushcarts;
0 R all Snack Food $10
Q Tobacco Products No Fee
23) Food Operations I Definitions: PHP-Patentlauy hamfdous rood (limallamporeture controls requlmd)
Non-PHi+'s - non•pofonllally hazaedous lood(d) tlmetlompomlom contras raqurmd)
(Chock all that apply): RTE - ready-to-eaf foods (Ex. sandwiches, salads, muffins whiah nood no farther processing)
n Sale of Commercially Pre -Packaged Non -PRFs
❑ Sale of Commercially Pre -Packaged PRFs
Q Dolivory of Packaged PHFs
❑ Reheating of Cammercfally
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
O Preparation of Nan-PHFs
E] PHFCooked To Order
Q Preparation of PHF& For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer self•9ervtce
E3 ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meat Service
PHF and RTi= Foods prepared For Highly
Su5captlblo Population Facility
i] Vacuum Packaging / Cook Chill
Use of Process Requiring A Vadance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Other Food Operations Q Juice Manufactured and Packaged for I] Offers Raw Or Underceoliod Food Of
Retail Sala Animal Origin
rr M Q Offers RTE PHF In Bulk Quantities i Prepares Food/Single Meals for
Ratan Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food To be complatod by the Board of Health
Total Permit Fee:
Payment is due with application [j waived
1, the undersigned, attest to the accuracy of the Information provldod in this application and affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have bean instructed by the
board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code.
24) Signature of Appllcant:
Pursuant to MGL Chs2C, sec, 49A, I certify un or the penalties of periury that 1, to my brut knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number arFederalN / � r
20) Slgnaturo of individual at Corporate Name: j�