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HomeMy WebLinkAboutAcacia Cafe Food Truck 4/17/2016Commonwealth 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 ESTABLISHMENT 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:. DAWN BROOKS - RAPP Whose place of business is: ACACIA CAFE FOOD TRUCK - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE 17-11TA i! 1 2601 "I&M 9 -AW r Permit Expires: April 17, 2016 License Number: T-67 Food Fee: $75.00 BOARD OF HEALTH michaecmcCtean, Chairman M 11 6,N\r, V 0, '4! kn . IN Good ood on Hie G.o! C."pt." R! rr To: A Phone - Re: P � Da ges: I t; Date, z C cc: IJ Urgent 11 For Review 0 Blease Cornment 0 Ploase Reply Please Recycle Comments: Acacia Caf6 Food Trucl� tg Simmons Road, Little C n, fel 02837 Phone 401 323 3002 Fax 401 636 3662 acaciacafel @gmail.com FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: Address: 2) Establishment Address: Telephone No: Fax: Emergency Telephone No: 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 2,- 5) Applicant Name & Title: W 6) Applicant Address: kV 7) Applicant Telephone No.: 24 Hour Emergency No.: Z' `/ 8) Owner Name & Title (if different from applicant): 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 or partner. ❑ An Association RA rporation An Individual ❑ A Partnership R Other legal entity 121 Person Directly Responsible For Dailv Operations (Owner, person in charge, Supervisor, Manaqer, etc.) Name & Title: Address: Telephone No: Fax: Emergency Telephone No: 13) District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: BLANK FOOD MWIT APPLICATION Food Establishment Information 14.) Water Sour15) Sources �,� 11 I / Sewage Disposal DEP Public Water Supply No: (if applicable): 161 Days and Hours of Operation: j,/j 17) No. of Food Employees ZdH 18) Name of Person In Charge Certified in Food Protection Management: A/, -f 4 ,%'2;% f. Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach co of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): k4c'-l!" 20) Location: 22) Establishment Type: El caterer El Retail ( Sq. Ft) El Food Delivery El Food Service — ( ) Seats F1 Residential Kitchen for Retail Sale ❑ Permanent Mobile (Dates) El Food Service - Institution Meals/Day) F1 Residential Kitchen for Bed & Breakfast Home EJ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert manufacturer Other (Describe) 21) Length Of Permit: (check one) F] Annual Elseasonal/Dates F1 Temporary/Dates/Times 7f T-7It, 71__ 23) Food Operations: Definitions: PHF— Potentially hazardous food (time/temperature controls required) (check all that apply): Non-PHFs— non -potentially hazardous food (no tima4emperature controls required) 1,(?TE — ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no lurtherprocessing) Sale of commercially Pre- El PHFCooked To Order El Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service Sale of Commercially Pre- EY Preparation Of PHFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Holding For Single Meal Service Susceptible Population Facility F] Delivery of Packaged PHFs El sale of Raw Animal Foods Intended to EJ Vacuum Packaging/Cook Chill be Prepared by Consumer Reheating of commercially F] Customer Self -Service ❑ Use of Process Requiring A Variance and/or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours, alternative, time as a public health control) ❑ Customer self-service of Non ❑ ice Manufactured and Packaged for 0 Offers Raw or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Only, ❑ Preparation of Non-PHFs El juice manufactured and packaged for ❑ Prepares Food/Single Meals for Catered ail Sale or institutional Food Service ❑ Offers RTE PHF in Bulk Quantities 0 be completed by the Board of Health ❑ Retail Sale of Salvage, Out -Of -Date or Re (Fr �ra'ymevnt "Islure with application 1, the undersigned, attest to the accuracy of the information provided in this application and I 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: Pursuant to MGL Ch.62C, see. 49A, I certify under the penalties s of peq'ury that 1, to my best knowledge and belief, have filed all state returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: BLANK FOOD PERWT APPLICATION {{ p Menu for NEFFA 2016 On the foodtruck: 1) Organic Turkey Burger, havarti cheese, fruit chutney, greens on a toasted roll 2) Black Bean Burger: Made in house, chipotle sour cream, purchased salsa on a toasted roll 3) Mushroom roll up- roasted mushrooms, greens, sweet onions, balsamic dressing, goat cheese spread on a wheat rollup 4) Bahn Mai: marinated shrimp, salad of radish, carrot, cucumbers, cilantro, lettuce, lime mayonnaise & and a thai marinade. 5) India goes to Vermont: marinated chicken grilled, Raita(yogurt cucumber dressing) carrots, and lettuce on a grilled Naan (purchased Indian flat bread) Indoor Vegetarian Meal: to be served in one of the home economic rooms Food brought cold and heated and served in chafing dishes. 1) Dahl: red lentils cooked in coconut milk, vegetarian broth with onions 2) Cauliflower curry: turmeric and veggie broth 3) Indian style eggplant, cumin, coconut oil 4) Basmati rice: cooked with a vegetarian broth 5) Raita: yogurt based dressing, made with cucumbers and scallions 6) Naan: purchased Indian style flat bread. All food will be prepared at Hope & Main, 691 in Warren RI in accordance with the RI health department. I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law. Signature of Indivd}�al or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the certification clause is signed by the applicant. ** Your Social Security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street , UW Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: _ City/State/Zip: =f` ;. . f _ ,� 'Pone t ; f f #: ._ Are you an employer? Check the appropriate box: r 1 I am a employer with employees (full and/ or part-time).* 2.R I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.0 Health Care 12. Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Phone #: ° 0' Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: www.mass.gov/dia Phone #• Is Your Insurance Identification Card Correct? It is important that the information appearing on your Insurance Identification Card(s) is correct. Please take a few moments to verify the information. Of particular importance are your name and address, vehicle description and vehicle identification number. If any of this information is incorrect please contact the agent listed on your policy. RHODE ISLAND INSURANCE IDENTIFICATION CARD (STATE) 088-41840 ALLMERICA FINANCIAL BENEFIT COMPANY NUMBER COMPANY 18 AWF—A877515 03-18-16 03-18-17 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE 98 CHEV P30 1GBKP32R9W311150 YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER AGENCY/COMPANY ISSUING CARD 5701624 BROWN J& BROWN I -NS SERVICES 3697 MT. ; DIABL_ O:::BLVD, #100 LAFAYETTE,o CA 94549 INSURED r `ACACIA CAFE CATERING, LLC. DBA ACACIA CAFE FOOD TRUCK 9 SIMMONS'RD. LITTLE-COMPTON, RI 02837 THIS POLICY PROVIDES COVERAGE AS PRESCRIBED BY LAW SEE IMPORTANT INFORMATION ON REVERSE SIDE 271-6051 (12/14) 9 343 0 o � 3 FUO. A � O+q1•`� W U g1 F N a. i Coao z Al Cc 0 614 a G0 H 0 Q > 4 � 0 4) '*+ .w i•r 0 o � 3 FUO. A � 5 c�mxm' N a. i n0 ^ Al 0 Q CO . ai co / \ W w � U.may O ,.; Ci Lz yt�a"-0 E,CiS 0 o � 3 FUO. A � 5 c�mxm' N a. i o' Q 0 o � 3 5 c�mxm' N m 00 U N O oa zQz 0 w UOU F34 tz nr;sgkiil�- cql I al 03 4-1 0 co CIO m Itl Cot ,art o rn q6� 4" LK O 7i CA CZ rA SOD Q tz • 12 Marshfield Board of Health 870 Moraine Street Marshfield, Ma. 02050 781-834-5558 Fax 781-837-6047 Permit # Fee Early Registration Fee: $15.00 per day (if received 14 days prior to event) $25.00 per day (if received less than 14 days prior to event) PLEASE NOTE: Applications will not be accepted less than 72 hours prior to an event. APPLICATION FOR TEMPORARY FOOD ESTABLISHMENT PERMIT *Applications will not be accepted unless a copy of your up-to-date food certification s) and Allergen Awareness Training is enclosed. PLEASE PRINT CLEARLY Name of Establishment:.`r Name of Certified Food Handler: Name of Owner: Email Address: �' -1�� Business Address: Complete Mailin_a Address; (if different than above) Town • Zip: Fed. ID # Phone: Event Location: , Cell Phone .G Date(s) of Event:. , Hours of Operation: Menu: List all food items proposed to be prepared and served Will all foods be prepared at the temporary food establishment booth? Y N If no, attach a copy of the agreement with the licensed food establishment where the food will be prepared, including dates & times of food preparation. Describe how food will be safely transported to the event. List sources if serving meat/poultry/seafood/shellfish (Shellfish tags must be maintained for 90 days) List water source and storage method How will wastewater be stored and disposed? How will garbage be stored and disposed? STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the above, without prior approval from the Board of Health, may nullify final approval. Signature(s) Date: Early Registration Fee: $15.00 per day (if received 14 days prior to event) $25.00 per day (if received less than 14 days prior to event) PLEASE NOTE: Applications will not be accepted less than 72 hours prior to an event. APPLICATION WILL NOT BE ACCEPTED UNLESS IT IS COMPLETE I Approval of these plans does not indicate compliance with any other code, law or regulation that may be required. It further does not constitute approval for operation. A pre -opening inspection of the establishment, with equipment in place and operational, will be required to determine compliance.