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HomeMy WebLinkAboutCongregational Church 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:. JENNIFER JOHNSON Whose place of business is: THE CONGREGATIONAL CHURCH OF MANSFIELD - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: JENNIFER JOHNSON Permit Expires: July 12, 2016 License Number: T-137 Food Fee: WAIVED BOARD OF HEALTH AichaeCAcCCean, Chairman Jund25121116 2,04-17.) IM Wyss Nurva.b.sanc 7818214-445 113 14 ("llssachusebts ip National N Lr 'rill] wil M urses I'M ) �, Nurs,5kq Assoclatlen, No do ;a United 340'(tiunpikv Sia -eel: - Cimton, M4 02021 y d Tel: (781) 821`4625 o Fac (781) 82144•45 ,Nww. imssmuses.oxg ata:_•_i ) fl'A) J t la _.®._�_.... JF ax Number: —.s Q .b�' �� .. � ��... Frog:•,g.^,__...a2��'��_'i..:�_S}�G�.�°' _ x _'dty°•+""nisi.���d[::d:����-.a�.1"J�C_'Z.����-:�_�.e�_!� S:x:�_ ;���"`��N ... ._....r.n.:n,�-..+_•.w...+-.,__T__g�r�.w.,.�n,.._....__-!�� ���� '�-•-�_....J....�-+r.,..+ � � I�,Y 3� 63 ,_,f' - _�._—._•_._•.__,®.,.••...___��._.._�_�!���_. -•�..�i_G3d✓+3..:�d][}ll�iy,�•+1 �, - I - -.. tiny Jennifer Johnson AWD Jun/2512016 2'04-17 AIM Wias Nurwm flassoc; 7818214445 3/3 FOR BOARD Of' FIEALTI4 USE ONLY Date receivocl, Dift Inspected: Approved By. Permit 4 Issued FOOD ES) TABLI SI -IM ENT PERMIT APPLICATION ,'Applloatlon must bo subf nit(od at least 7 days prior to planned event) Ishmarit Addrei 2) EsIal I 3) Establishment Mailing Addrecss (if different) 91 An el 4) Establishment Telephone. No: 5) Applicant Name &'Tltle: 6) Applicant Addrar>,q 7) Applicant Tc lephorio No.; 24 Hour Emergency No.: L503 - s3 I?,' - 8) Owners Name & Title 9) Owner Addresii (If difl-'e-rent frorn applicant): 10) E:stabIli3hrrierit Owned By: 11) If a rnorponatlon or :iarinership, give name, title, and home address of offiacm CII An A ooia'15 'I11 or partner. Narne Title Address 0- An IndlUa I CIA Pa n e r e� CJ ot r 1611al I ear legal 111tity L 12)personDirectly Responsible For pinyon In chane, manager etc.) Name & Title: Address: Teloplione No: :24 Hour Emergency No: FAX: FAX Alt 13) Dkitriat Or Regional Supervisor (if applicable) Name & Title: Address: Telephone NO: 24 Hour U-nergency No: FAX Jun/2512016 2,04 17 AM M91EIa NLiraes Assoc7818214445 2/3 Food Estal7lis:i`tment Information 14) WPB PER 5001' CE: o n 1r) SEWAGE DISPOSAL; DEEP Public Water Supply No: (11 epplicabiej � ry' 16) N4. of Food Employeer:1 17) DAYSMOLIF::y: 18) Name of Person In Charge Certified 1;1 Fond Proteoton Manapment: If ITt01'O then 3 individuals arc) corlified, completa list it on file, Required as oy 101f/2001 ?n i9voordanc+p with 106 CMR 590.00.11(AJ F'1 ease atrsch ropy of oerfificate 1d) Person Trained 1n Anti.-GN)king Proo)dures (If AS Seats or more); 20) Location; Irj F ermtanent Location t2) Cstribll> hment Type Mobilo hiloblte Steil Dele; �) Caterer ^a<,5 , [] ftmttil ( Sq. Ft) Cj Milk & Creani $2 Nlablla land D�rt�t: � � [] F'eod � �rvio,a up to 00 9po Mobilo Fosxl & Oonsi if(o Mobile Comments, up to 'I,'TPHF'd1sMayPr5 _.__. ti__—_--__ ❑ Meblie Food Tamporgp4b 21) t .engti� of F�,�fiit: ED Foot I 101 -200 Cl Manufacture Froz Vosaelts/loe Orearr, j Annualor up to 2a57NF display $100 $5lfraezer ® Pushcart $2 \ ,. [:] Seasonal C:l i='ood J`anralce up to 201 + t,� y`(( ot�i*'4 PHF display. ► I75 Reside 1'Kitchen $2ti Ssaeonal Dates: W T 1"`t / it of Puohtrartst + — —_ _.� • _----- I'Vood ser ice ®Inn uti� Rota occl $50 npore y ' Temporary Start gate; .r+P ) I P. � � �+ ( „�h fit sloay) �I R ail Snardc rood $to `9 Temporary End Date:r � (� Tobacco Prt�ducle No Feta T -I / I;� ill f t Tompol'a y 1111 10; Rain Datii: 23) food Cp6iYatlol:e LtelnlUons; FMF• Fotendlallyha�rurriotrsfe,s•9(flit,„tdtrlearoluraeanPrutsrequtred) �•-4�•�����_—_.. r Norr PHR-nco-porentlally hom(dava 100(no flmelfemperaturs controls, rugtdntd) ;Chock all that iapp4 ); _ IRTE- readyre aiv feces (err.4andwMim, +salads, mufllns which needrla lurflwrpmoussin9) Sulo of Commercially Pro -Packaged Non-PHFs stder of Commercially Pro-Pookaged PHFs. Delivery ofPackaged PHFs ��-----i� ❑ Reheating of Commercially Processed Foods Foods for Sr rvVo WNW 4 Hours MCuetiuner hof So-ivicti 51 Ni,,ii P'HI' and Non - Poarlehable Foods'Only F'reparotlon of Non,PHFs�- Ihiar Faod Operations CI PI-IFclooked To Order ?reptiration of iyHFs.^or Not And old Iloldlru For Vnt11e 10001 Service Salo of Raw Animal F'oode Intended to bet Prelived by Consumer -CJ "usto:�mar8alf-3mrvioe -��-- 17171710ufaetWed ane' Packaged I'or 0 Juice Manufactured and Packaged (al I@tr O $ate © -13Fterii fiTEePHI: In Bulk t uantitles Retail Salo of Salvago, Dut-OPDate or Reconditioned Food 1 ❑ Hot PHF Cooked and tooled or Hot Hald for More pian is single MoW Softy PHF and RTE Foods Prepared For Highly SusceplWo Population Facility El Vacuum P+aoitaging / o/ 1-5 ak Chill ”— Use of Pro Gass I�EquIrilT®A Velfanco �— andlor HA000P Plan (including bate hand contact aftornalive, time ea a public health (� offers Raw or Undercooked Food Of _ Animal Orii�in Prepares FoodlEiingle Meals for - Catered Events or Inatltutional Food Sarvloo To be completedby tha r feard of h1eeith— (--_---.. Total Permit'. oo: Payment is due with application 0 tvalved I, the undrarsIgned, attest to IN accuracy of the Inroimatlon provided ir, this applli.ation and affirm that the food�— establishment operation will comply with 1 CMR 590.000 and all other applicable law. I have been Instructed by the hoard of health on how to obtain coples 11 1 'piR 690.00 ani:I the f dotal Food Cade, 24) Signature of Applicant: � Pursuant to MGt. Ch.82C, sec. 49A, cert nder the peneltieu of penury that 1, to my best knowledge and belief, have flied all slate tax returns, and paid state taxes required undo IoW, � 26) 5ioctal Security Number or Fe rate; r ' 20) $Ignature of Individual or Corp (e Namel � �� _w _.__ � p.0 1� eS�A `ti., tC•�'�