HomeMy WebLinkAboutTastefully Simple 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:.
LISA GALLAGHER
Whose place of business is:
TASTEFULLY SIMPLE - MANSFIELD FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
LISA GALLAGHER
Permit Expires: July 12, 2016
License Number: T-114
Food Fee: WAIVED
BOARD OF HEALTH
"A4ichaeC-q4cCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
T-1 14
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submritea4116as-f30 mays before the planned opening -date)
j 1) Establishment Name TASTEFULLY SIMPLE - MANSFIELD FAMILY FUN NIGHT
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2) Establishment Address NORTH MAIN STREET
3) Establishment Mailing Address (if different) 104 PURCHASE STREET
EASTON, MA
4) Establishment Telephone No (508) 2384938
5) Applicant Name & Title: LISA GALLAGHER
6) Applicant Address
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title LISA GALLAGHER
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 j
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: ,LISA GALLAGHER
+ _
Address: rt t X
-- --
V�
Telephone No: 24 Hour Emergency No:
FAX:
E-mail
Alt E -Mail:
13) District Or Regional Supervisor (if applicable) '
Name & Title:
Address:
Telephone No: 24 Hour Emergency No: T V r
FAX:
E-mail:
Food Establishment Information
14) WATER SOURCE: 1 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) I 16) No. of Food
,
Employees:
17) DAYS/HOURS: 7/14/2015 6 PM -10 PM
( 18) Name of Person In Charge Certified in Food Protection Management:
I If more than 3 individuals are certified, complete list is on file.
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
! Caterer $12.50
Mobile Mobile Start Date: Retail ( Sq. Ft)
Milk & Cream $5.00
Mobile End Date: i Food Service up to 100 or
Mobile Food & Consession $37.50
Mobile Comments: I up to 10' PHF display $62.50
i
Manufacture Frozen Desserts/Ice Cream
21) Length of Permit: I Food Service up to 101 -200
$12.50/freezer
i Annual or up to 25' PHF display $75.00
; Pushcart $12.50 # of Pushcarts: 0
Seasonal Food Service up to 201 +
( Residential Kitchen $50.00
i or 25'+ PHF display $137.50
Retail Food $50.00
Seasonal Dates:
Food Service - Institution
Retail Snack Food $12.50
emporary
Temporary Start Date: ( Meals/Day)
Tobacco Products $12.50
Temporary End Date: 1
I
Temporary Time:
Rain Date: � . . --- ---------
Definitions: PHF - Potentially hazardous food (timMemperature controls required) i
23) Food Operations I Non-PHFs - non-potenfielly 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 T
PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Heid
-.------- --- - -- -- - - • - - --
Sale of Commercially Pre -Packaged PHFs
--
Preparation of PHFs For Hot And
for More Than a Single Meal Service
_ __-..- _-__ _ _.._-. _._. __ _ .. _ . _ ... -11
- --- --- - --- ---- - - - -
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
t_
Reheating of Commercially
i to be Prepared by Consumer
Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
i ---- -.- -- - _ -
_-
L.._ ._ __...._.____.-____—______._ ... _ ......I
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 ~-- - ---- - - --contact
Ice Manufactured and Packaged for
alternative, time as a public health
_ --- -___ . - . .-. - ._--_- ____..i
Preparation of Non-PHFs
Retail Sale
1 control)
,. __ __.._ _ . _ ,
Other Food Operations
Juice Manufactured and Packaged for;
Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
PRE-PACKAGED FOOD
_.._._..___.___ _.___ ._.__.
-in -Bulk -
Offers RTE PHF in Bulk Quantities
' Prepares Food/Single Meals for
in -e -- for
I
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
! _ - -- -- - - --_..___ __ .... ._-- -- - ;
; To be completed by the Board of Health
I-- -- _.. --- --
-- !Total Permit Fee:
Payment is due with application waived
1, 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,)05 CMR 590.0 0 and the federal Foo Code,
�24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of periury hat 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:
K26) Signature of Individual or Corporate Nam