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HomeMy WebLinkAboutTrolley Dogs 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:. JOYCE & GERALD DENTE Whose place of business is: DENTE ENTERPRISES, LLC - TROLLEY DOGS - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE JOYCE DENTE Permit Expires: April 17, 2016 License Number: T-53 Food Fee: $75.00 BOARD OF HEALTH MichaecMcClean, 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 30 days before the planned opening date) 1) Establishment Name: t % 2) Establishment Address: (p Ua LL lft�L TA U4,n 0 L 3) Establishment Mailing Address (if different) Emergency Telephone No: 4) Establishment Telephone No: 1 -7 a (� 2 — C2 (a q 1 5) Applicant Name & Title: 6) Applicant Address: 7) Applicant Telephone No.; G1-7 — f i 2 _C/4 51` 24 Hour Emergency No.: C 7 -- y1 ���• 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. �} CC Cd- �-4XQ"-"ElAn Association ot❑ t('Q A Corporation`--� ❑ An Individual f} 01-70, ❑ A Partnership [Other legal entity L—C, 12 Person DirectIv Res onsible For Dailv O erations Owner person in charge, Supervisor, Manager, etc. Name & Title: Address: t % Telephone No: & q j Fax: Emergency Telephone No: ' C('- S- -a 13) District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: BLANK FOOD PERMIT APPLICATION Food Establishment Information 14.) Water Source 15) Sewage isposal P� DEP Public Water Supply No: (if applicable):" 16) Days and Hours of Operation: 17) No. of Food Employees 18) Name of Person In Charge Certified in Food Protection Management: 9CQ k-t,� Required as of 10/1/2001 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): 20) Location: 22) Establishment Type: ❑ Caterer ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Food Service - ( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Bed & Breakfast Home 'Mobile (Dates) ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one)pt F] Annual ❑Seasonal/Dates emporary/Dates/Times 23) Food Operations: Definitions: PHF — Potentially hazardous food (time/temperature controls required) (check all that apply): Non-PHFs — non -potentially hazardous food (no time/temperature controls required) TE — read -to-eat foods Ex. Sandwiches, salads, muffins which need no further processing) ❑ Sale of commercially Pre- HFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Holding For Single Meal Service Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill be Prepared by Consumer ❑ Reheating of commercially ❑ 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 ❑ Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Only. ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Retail Sale Events or institutional Food Service Other (Describe): H Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application I, 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 'tt' Pursuant to MGL Ch.62C, seY49A, I certify under the penalties of perjury 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 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. �06�1 i ature of Individual or C rporate Name (Mandatory) 9va"dZ/V- 13 orporate Officer (Mandatory, if applicable) G �43 P? q�/� ** 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 Print Form --" lip Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 A Boston, MA 02114-2017--_ -- - V www.mass.gov/dia Workers' Compensation Insurance Affidavit. General Businesses Applicant Information Please Print Letzibiv Business/Organization Name: Dente Enterprises LLC, dba Trolley Dogs/Boston Italian Ice Address:26 Claudette Circle - — - City/State/Zip:Framingham _Phone #:617-412-9641 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 2 employees (full and/ or part-time).* 2. ❑ 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 I i.❑ Health Care 12.Z✓ Other Mobile Food *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **lfthe corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box M1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. insurance Company Name:The Hartford Insurer's Address:26 Claudette Circle CityiState/Zip: Framingham, MA 01701 Policy # or Self -ins. Lic. # 0kl)6Gc 7 No --;i-1 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 c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisomnent, 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. 1 do hereby certify, under the pains andpenalties ofperjury that the information provided above is true and correct. 7-4 Official use only, Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # 3. City/Town Clerk 4. Licensing Hoard 5. Selectmen's Office www.mass.gowaia Phone # 9 # In k= =ux \ x%22 mƒ �Za« ƒ ) 2 ( § \ � } \ R \ w m g» A 90- 0 © k= =ux \ x%22 mƒ �Za« ƒ ) 2 a \{\ � ~ � g» A » k a