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Home My WebLink AboutLavender Country Food 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 - NEFFA 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:. CHRISTOPHER RICCIOTTI Whose place of business is: THE LAVENDER COUNTRY & FOLK DANCERS ITALIAN KID FRIENDLY FOOD BOOTH - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE CHRIS RICCIOTTI & SAM ARFER Permit Expires: April 17, 2016 License Number: T-68 Food Fee: $75.00 BOARD OF HEALTH NichaeC CCCean, 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) 17\ Deronn r)ir— lv Pnennneihla Fnr nnily Onarntinnc tnwnar nArRnn in nhnrdP_. Supervisor. Manager. etc.) Name & Title: Lavender Country & Folk Dancers 1) Establishment Name: 393 Union Street Rockland, MA 02370-1729 2) Establishment Address: 393 Union Street Rockland, MA 02370-1729 3) Establishment Mailing Address (if different) SAME 4) Establishment Telephone No: 617-852-4042, 339-204-7644, 781-982-8042 5) Applicant Name & Title: Christopher Ricciotti - Food Booth Manager 6) Applicant Address: 393 Union Street Rockland, MA 02370-1729 7) Applicant Telephone No.: 617-8524042 24 Hour Emergency No.: 617-852-4042, 339-204-7644 8) Owner Name & Title (if different from applicant): Same 9) Owner Address (if different from applicant): Same 11) If a corporation or partnership, give name, title, and home address of 10) Establishment Owned By: officers or partner. x An Association: The Lavender Country & Folk Dancers ❑ A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal entity 17\ Deronn r)ir— lv Pnennneihla Fnr nnily Onarntinnc tnwnar nArRnn in nhnrdP_. Supervisor. Manager. etc.) Name & Title: Chris Ricciotti & Sam Arfer Address: 393 Union Street Rockland, MA 02370-1729 Telephone No: 617-852-4042, 508-545-1594 Fax: 781-982-1836 Emergency Telephone No: 617-852-4042, 339-204-7644, 508-545-1594, 781-982-8042 1'41 r)ie4rirt r)r Raninnni Giinaniicnr (ifnnniirnhia) Name & Title: Same as above Address: Same as above Telephone No: Same as above Fax: Same as above BLANK FOOD PERMIT APPLICATION (2).doc Food Establishment Information Other (Describe): LJ 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.... have been instructed by the board of health on how to obtain copies of 105 CMR 590.d the federal Fode- 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the 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 (2).doc of perjury that I, to my best knowledge and belief, have filed all state 15) Sewage Disposal Mansfield, MA 14.) Water Source Mansfield, MA DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: Friday April 15th, 6:00pm-10:30pm 17) No. of Food Employees 40 volunteers Saturday, April 16th, 9:00am-10:30pm Sunday, April 17th, 9:00am - 5:30pm 18) Name of Person In Charge Certified in Food Protection Management: Chris Ricciotti & Sam Arfer 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): Chris Ricciotti & Sam Arfer 20) Location: Mansfield Middle School 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 X Mobile (Dates) 4/15/2016, 4/16/2016, ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast 4/17/2016 Other (Describe): Establishment Volunteer Food Booth Fundraiser ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) ❑ Annual ❑Seasonal/Dates X Temporary/Dates/Times 04/15/2016 - 04/17/2016 23) Food Operations: Definitions: PHF— Potentially hazardous food (time/temperature controls required) (ch k 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 -PRFs More Than a Single Meal Service ❑ Sale of Commercially Pre- ❑ Preparation Of PRFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packa ed 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 LV 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 institutional Retail Sale Food Service Events or Other (Describe): LJ 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.... have been instructed by the board of health on how to obtain copies of 105 CMR 590.d the federal Fode- 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the 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 (2).doc of perjury that I, to my best knowledge and belief, have filed all state 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. I * Signature of Indiv ual or Corporate Name andatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number a' * 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 PF Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address 1.913 or� 023, City/State/Zip: 1\ ® hone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 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.X We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] d Jmfflvm 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. ❑ Health Carle 12. LY Other 1 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. \,-J * *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 Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. Expiration Date: Attach a copy of the workers' compensation policy_,Aeclaration page (showing the policy number and expiration date). Failure to secure coverage as required under Sec n 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 imprison ent, 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 cer, ' ,under the as and penal e� o perjury that the information provided ap9ove i true and —correct. �f 1G� 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 #: