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HomeMy WebLinkAboutSamburis Dance 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 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:. RUTA MICKUNAS Whose place of business is: SAMBURIS, LITHUANIAN FOLK DANCE GROUP OF BOSTON - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE RUTA MICKUNAS, PRESIDENT Permit Expires: April 17, 2016 License Number: T-70 Food Fee: $75.00 BOARD OF HEALTH AichaeCMcCCean, Chairman Date Received t FOR BOARD OF HEALTH USE ONLY . d7 0 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: Sambvc 5, U*Lzvni an FOtVN bcance (Sqovp C c (;( e -W 8015+0r) 2) Establishment Address: la u1.5i-O, 6rcke, Yl'ie,(Ull le MA 0"3D. 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 50'6- 735- Gd -'4k( 5) Applicant Name & Title: r�(+`(�1`G%VY�CIS 6) Applicant Address: �a f S'ECv 1, irG(+e° Cers}evvi tle) MA 0-9168Z 7) Applicant Telephone No.: 5(�)a „ ? 35_ (,p.14 { 24 Hour Emergency No.: 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 ❑ A Corporation ❑ An Individual ❑ A Partnership 5a Other legal entity 121 PPrsnn nirr?rtiv ResnnnSihle Fnr naiiv nnPrntinns (Owner nPrcnn in nharna gijnP.niiRnr Mnnnnar atr.) Name & Title: �Ro4G,. V`tl� Gkuf-,as PCe5�len+ Address: k VtSim, Ctrcle I CeoierVikIe� M 0-ZG13 �. Telephone No: '735- (a.Z44 Fax: Emergency Telephone No: 13) District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: BLANK FOOD PERMIT APPLICATION.doc Food Establishment Information 14.) Water Source 15) Sewage Disposal DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: 17) No. of Food Employees v 1'FG. ()U 5 -VT Qcj 18) Name of Person In Charge Certified in Food Protection Management: W v' a, 30r)da. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach cd 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 f'Food Service - ( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Bed & Breakfast Home IKMobile (Dates) ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) ❑ Annual ❑Seasonal/Dates Tempor ry/Date [Ties y/is�X �I 1T�i�/G 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) RTE — ready -to -eat foods Ex. Sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of commercially Pre- ❑ PHFCooked 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 Ll 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): Offers RTE PHF in Bulk Quantities To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -Of -Date or Total Permit Fee: Reconditioned Food 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. 4 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, 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 PERMIT APPLICATION.doc 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. baw'&'� / Atzt16_44�. * Signature of Individual 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 of Industrial Accidents Office of Investigations 600 Washington Street Boston, IIIA 02111 )V IV IV. natass.govId t to Workers' Compensation Insurance Affidavit: General Businesses A> plicant Information Please Print Legibly Business/Organization Name: 50t mby r 5, L �ihuanlian FOLK Dance Grove 13C&tOn Address: \a y t sia. di rcke City/State/Zip: �elrwVitle ., MA 0-G3-. Phone #: Are you an employer? Check the appropriate box: I. ❑ I am a employer with employees (fid] 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 worl<ers' comp. insurance required]*: 4.X We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 5a$ - 735- 6Q q.</ Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. Q Non-profit 9. ❑ Entertainment l0. ❑ Manufacturing 11. [j Health Care 12. ❑ Other 'Any applicant that checks box # I must also [ill out the section below shoFving their workers' compensation policy information. **irthe corporate officers have exetnpted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I ain an employer that is providing workers' compensation insurance fir my employees. Below is the policy inforrrzation. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. #. Expiration 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 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 certifyl�, under the pains and penalties of perjm y that the information provided above is true and correct. Sienature: �✓u'� Date: v©g - -73 5- (aAl Official use only. Do not write in this area, to be completed by city or town offr"cial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Nvww.mass.gov/dia Phone #: S zC: O I J U) -.-z �� V ® ° O ® � CL h _77 coc u_ O m V O o F- n_) ti d U { LL cn Ju FE + SF�Ep LO LLI uj t l L� m V v J yO N N CnGi. O 'f' Fa r N C � U c m Z o � U � N N sm.. N CL /" 1 F E\ —` \ Q 3 sa® aUi O N Q d U a vim- wM W \ � LL 0 v .N C) U O ° 3 r U c w w m U) U Q U LIU f 4 Lo a M 01 M (4 Q1 qt CO d C1 Z W it. 0' H T ce �Q W IIJ U o HZ 'ZO CL w U z c c •� •� L) QU,^O C V �-•��,l b O 07 O U- 0 O o in LL Z N 3 _ m � E m O E O m � E c = o in n V l @ z OV O a C N N Z ] ' m aC� z `~ C"D O Q ccV s ` f N Z rn o 1 z a ... M a M a� t Cs � so o O o 0 O N �4 7- N U _C ui E' Q w ~ m Q a �����..... 1 U , X V N d Z 0 o O J a o Z na � a ao ® �Q �1.1:;, P O IA7 m G _ C u p g 7 Z m c O CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Al"' CertifiF. berg eM67 Date of GO Date of 'E" 'o Issued By: The above-named person is hereby issued tbis: certif-te for tmnplefing an'allergen awareness tralning.Prograln -recognized by. the Massachusetts Department of Public H-Itb blassachuxtts Restaumei t Association 800.1,65.2122 in,ac,ordanee with 105 CMR 590,009(G)(3)(4). 333 Turnpike Road, Suite 102 SnuthlornughMA 017772 Ibis eertyFcar, will be valid forfive (5) years from dale of completion. 508-303-9905 jvww.rnuemumntwoc.ol9 M T- o CN h � c1r) O i bqR. C) � � � CY) O z 0 F a z a X W LL 0 F- a 4M 40 z o O F 3 CE: 0 a U X W a U- 0 3 W a U � J 0