HomeMy WebLinkAboutPro's Car Care 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 Establishmentz
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:.
DENNIS MEDINA
Whose place of business is:
THE PRO'S CAR CARE COMPLEX - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
Permit Expires: J u ly 12, 2016
License Number: T--144
Food Fee: WAIVED
BOARD OF HEALTH
MichaeC-'AlcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 7 days prior to plonned event)
1) Establishment Name: C
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No.: --l-ILA -a' j4 — 9-7qJ24 Hour Emergency No,: C
8) Owners Name & Title
9) Owner Address (If different from applicant):
\A <A
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
�0 A Association
A Corporation
0
or partner.
Name Title Address
An Individual
El A Partnership
C -x SL- V ---c . 'S
Ll Other legal Entity
191 Pprsnn Directly Responsible For Ualiv UoeratiOns (owner, person in cnarqe, supervisor, manager utu.]
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Aft 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) \ V 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.
Required as of 10/9/2001 In accordance with 905 CMR 690,003(A) Please attach copy of certlilcate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
20) Location: ❑ Permanent Location
❑ Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
211).ength of Permit:
[ReAnnual
❑ Seasonal
Seasgnal Dates
v i emporary
Temporary Start Dale: I1 t
Temporary End Date: '7
Temporary Time: G., w�
Rain Date:
22) Establishment Type
Retail ( Sq. Ft)
❑ Food Service up to 100 or
up to 10' PHF display $75
❑ Food Service up to fol -2o0
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
F1 Manufacture Frozen Desserts/Ice Cream
$6/freezer
❑ Pushcart $25
Residential Kitchen $25
El Retail Food $6 of Pushcarts:
❑ Retail Snack Food $10
❑ Tobacco Products No Fee
23) Food Operations Definitions: PHF - Potentially hazardous food (tlmellemperalure controls required)
Non-PHFs - non -potentially hazardous food(no limeltemperature controls required)
Check all that apply): RTE - readylo-eal foods (Ex. sandwiches, salads, mums which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ Sale of Commercially Pre -Packaged PHFs
❑ Delivery of Packaged PHFs
❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHF and Non -
Perishable Foods Only
n Preparation of Non-PHFs
❑ PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill T
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
0 Retail, Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
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 accurac�f9� ormation provided in this application and affirm that the food
establishment operation will comply th 105,C R 590.000 and all other applicable law. I have been Instructed by the
board of health on how to obtain cgAes of5 CMR 590.000 and the federal Food Code,
24) Signature of Applicant: r�
Pursuant to MGL Ch.62C, se 49A, I certify under the penalties of psrjury that I, to my beat knowledge and belief, have filed all state tax returns
and paid state taxes required under law,
25) Social Security Number or Federal ID,
26) Signature of Individual or Corporate Name: