HomeMy WebLinkAboutMansfield Youth Baseball 12/31/2018Commonwealth. 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: FOOD SERVICE 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:.
MANSFIELD YOUTH BASEBALL
Whose place of business is:
MANSFIELD YOUTH BASEBALL
273 OTIS STREET
PERSON(S) IN CHARGE:
ADAM SCHLOSSER, SAFETY OFFICER
Permit Expires: December 31, 2018
Food Fee:
License Number: FS-52
n. 1
BOARD OF HEALTH
.MlchaeC%1CCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Fateceived: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application Must be Sul ted at leastdays before Tfie planned opening date)---
1) Establishment Name Mansfield Youth Baseball
2) Establishment Address PO Box 702, Mansfield, MA 02048
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title: Adam Schlosser (Safety Officer, Mansfield Youth Baseball)
6) Applicant Address 27 Farm Pond Path, Mansfield MA 02048
7) Applicant Telephone No.: 508-337-6359 24 Hour Emergency No,: 857-636-0640
8) owners Name & Title Mansfield Youth Baseball
9) Owner Address (If different from applicant)
Owner's telephone number
10 Establishment Owned By:
An Association
li._I A Corporation
I An Individual
r 1 A Partnership
L" Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
_
121 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Adam Schlosser, Secretary Mansfield Youth Baseball
Address:
27 Farm Pond Path, Mansfield, MA 02048
Telephone No:
508-337-6359 24 Hour Emergency No: 857-636-0640
FAX:
E-mail:
casch@mlt.edu
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Mike Menard
Address:
397 Elm St. #3, North Attleboro, MA 02760
Telephone No:
508-740-7239 24 Hour Emergency No: 508-740-7239
— FAX:--
Food Establishment Information
14) WATER SOURCE: Town 15) SEWAGE DISPOSAL Town
DEP Public Water Supply No: (If applicable) 16) No, of Food Employees 4
17) DAYS/HOURS: APR-JUL: Weekdays 5-8 pm, Weekends 9a-5p SEPT-OCT: Weekends
18) Name of Person In Charge Certified In Food Protection Management:
If more than 3 Individuals are certified, complete list is on file. Mike Menard
as of 101112001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate
19) Person Trained in Anli-Choking Procedures (If 25 Seats or more):_ �_
20) Location: M Permanent Location
(') Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
Length of Permit:
Annual
P I Seasonal
Seasonal Dales:
,1 Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
t❑i Retail ( Sq. Ft)
0 Food Service up to 100 or
up to 10' PHF display $125.00
r7 Food Service up to 101 -200
or up to 25' PHF display $160.00
F] Food Service up to 201 +
or 25'+ PHF display $275,00
F Food Service - Institution
( MealslDay)
F Caterer $25.00
n Milk & Cream $10.00
n Mobile Food & Consession $75.00
Manufacture Frozen Desserts/ice Cream
$25,001rreezer
0] Pushcart $26 # of Pushcarts:
[j Residential Kitchen $100.00
❑' Retail Food $100.00
[] Retail Snack Food $25.00
tip Tobacco Products $25,00
23) Food Operations Dafin#lons:PHF - Potentially hazardous food (fimeRemperalum controls requireo)
Non-PHFs - non -potentially hazardous food(no finuAtemperalum controls required)
(Check all that apply): I RTE- ready-fo-eaf foods (Ex. sandwiches,salads, muffins which needno furtherprocessing)
I Sale of Commercially Pre -Packaged Non-PHFs
I., J Sale of Commercially Pre -Packaged PHFs
I_ Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
j� Customer Self -Service of Non PHF and Now
Perishable Foods Only
(. ] Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Retail Sale
FI Juice Manufactured and Packaged for
Retail Sale
Offers RTE PHF In Bulk Quantities
Retail Sale of Salvage, Out -Of -Dale
ar Reconditioned Food
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging I Cook Chill
Use of Process Requiring A Variance
andlor HACCP Plan (Including bare hand
contact alternative, time as a public health
Offers Raw Or Undercooked Food Of
Animal Origin_ _
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Total Permit Fee:
Payment Is due with application F-1 waived
I, the undersigned, attest to the accuracy of the Information provided in this application and affirm that the food
establishment operation will comply with 106 CMR 590.000 and all other appllcnbN )Ay$.,stA%y' dRRgA!?a9,lrgl;tqg„by the
board of health on how to obtaincopley.fiLgVMI�.69D.AA0 Se NJ Ve gl&odn e[k4�r-ma::a.n,,,en:,o=ma,:arn�:al: m,ww. ofT«h�olosy.
ll..11JJ lU.1'' `L CCiy FF11lU-I QQ II'"' Jl.' I V CI ou Clie lCA VL m=C.unn yAd.. Sohlone,, eMm4=<az111AMITEDU
24) Signature of Applicant: Date 201804o5 11:47:10-0400
Pursuant to MOIL Ch.62C, sec, 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 037-52-8677
26) Signature of Individual or Corporate Name:
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
Olgnally sgned In, Cwnney Adam Scld.111,
Courtney Adam ON1=CS.st=Mazmahmen"
o=Massat CA,l, e1.ul.ey Andt.logy.
Schlosser chle"tK `=e h@MIT yAdam
Ze 1.,emzll=<zlm@Mlr Eou
nam::oleoaos u:m:av-ae.
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
037-52-8677
"*Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless this 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 Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Scott's Documms\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department offndustrial Accidents
up,
1 Congress Street, Suite 100
Boston, ATA 02114-2017
www. mass.gov/dia
Workers' Compensation Insurance Affidavit; General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbiy
Business/Organization Name: Mansfield Youth Baseball
City/State/Zip: Mansfield, MA 02048 Phone #: 857-636-0640
Are you an employer? Check the appropriate box:
Business Type (required):
I. ❑ I am a employer with employees (full and/
5, ❑ Retail
6. 'gRestaurant/Bar/Eating Establishment
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
?. Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity,
8. ❑ Non-profit
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § I (4), and we have
10, ❑ Manufacturing
OF no employees, [No workers' comp, insurance required]*
11,❑ Health Care
4.Y We are a non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. [No workers' comp, insurance req.]
'Any applicant that checks box #1 must also filI out the section below showing their workers' compensation policy information,
r"If the corporate officers have exempted themselves, but the corporation haft other employees, a workers' compensation policy is required sod such an
organization should check box M.
I ant an employer that is providing workers' compensation Insurance for my employees. Below is the policy information.
insurance company Name: Robert W. Eames Insurance
Insurer's Address: 126 North Main St.
City/State/zip: Mansfield MA 02048
Policy # or Self -ins, Lic, # 6S62UB-M97841-7-17 Expiration Date: 3/22/2019
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 e. 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 DfA for insurance coverage verification.
t do hereby certify, under the pains and penalties of perjury that the it formation provided above is true and correct
Courtney Adam Schlosser "fxti;:;^ b ;;.'° s° „bra 4/05/18
Date:
Pr7-Fqa-nnAn
Official use only. Do not write !it (his 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
Phone
G