HomeMy WebLinkAboutMansfield Youth Football & Cheer 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 FOOTBALL AND CHEER
Whose place of business is:
MANSFIELD YOUTH FOOTBALL AND CHEER
250 EAST STREET
PERSON(S) IN CHARGE:
GLENDA SMITH, CONCESSIONS MANAGER
Permit Expires: December 31, 2018
Food Fee:
License Number: FS-47
WAIVED
BOARD OF HEALTH
NichaeCMcCCean, Chairman
file
FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-47
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
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1) Establishment Name MANSFIELD t90"ARNER-FO0TBAtt @-Mt M ` PARK
2) Establishment Address 250 EAST STREET tea
-
3) Establishment Mailing Address (if different) P.O. BOX 92 _-----
MANSFIELD, MA 02048
4) Establishment Telephone No r§00)-56250739
5) Applicant Name & Title: SCOTT SMITH, PRESIDENT
6) Applicant Address 7 MARTHA'S WAY, MANSFIELD, MA 02048
7) Applicant Telephone No.: pa�l3as-szss 24 Hour Emergency No.: ha1> 389-9259
8) Owners Name & Title MANSFIELD•POP-WARNER ` (',J ivi i ooi Y3A t.
9) Owner Address (If different from applicant) i
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
An Association I or partner.
A Corporation Name Title Address
An Individual
A Partnership
Other legal Entity- - _-_ --— _- --
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title GLENDA SMITH, CONCESSIONS MANAGER
Address: 7 MARTHA'S WAY MANSFIELD, MA 02048
Telephone No: 1(781) 389-9259 24 Hour Emergency No: (781) 389-9259
FAX: - I -
E-mail: GLENDA.SMITH(cDCOMCAST.NET
I
Alt E-Mail: �MANSRELDPOPWARN IER0�0MAiL-:EOM
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX: E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN I 15) SEWAGE DISPOSAL: SEPTIC
DEP Public Water Supply No (If applicable) 116) No of Food Employees: 6 8
17) DAYS/HOURS: SAT & SUN 7 AM-9 PM - -
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 'i14
20) Location: ;V Permanent Location III 22) Establishment Type
Mobile Mobile Start Date: L i Retail ( Sq Ft)
Mobile End Date:
Moblie Comments:
21) Length of Permit:
lei Annual
Seasonal
Seasonal Dates:
',. Temporary ---
Temporary Start Date:
[] Food Service up to 100 or
up to 10' PHF display $125.00
Food Service up to 101 -200
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275.00
[.._ Food Service - Institution
( Meals/Day)
Temporary End Date:
Temporary Time:
I
Rain Date:
GLENDA SMITH
1 1; Caterer $25.00
P Milk & Cream $10.00
(� ] Mobile Food & Consession $75.00
f--� Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
Retail Food $100.00
_] Retail Snack Food $25.00
-,] Tobacco Products $25.00
23) Food Operations Definitions:PHF- Potentially hazardous food (timeltemperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
!(Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
;..
Sale of Commercially Pre -Packaged Non-PHFs
[] PHFCooked To Order
rr ] Hot PHF Cooked and Cooled or Hot Held
--
Sale of Commercially Pre Packaged PHFs
- —
I ] Preparation of PHFs For Hot And
for More Than a Single Meal Service
_-
- Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
Delivery of Packaged PHFs
--- - --
---- - -
[ Sale of Raw Animal Foods Intended
Susceptible Population Facility
____
Reheating of Commercially
-]
to be Prepared by Consumer
_
1 I -1 Vacuum Packaging /Cook Chill
Processed Foods for Seance Within 4 Hours
_.
- --- ---
-- - --- -- -
Use
; of Process Regwring A Variance
Customer Self -Service of Non PHF and Non-
Customer Self -Service
1 and/or HACCP Plan (including bare hand j
Perishable Foods Only
----- - - -----
I Ice Manufactured and Packaged for
I contact alternative time as a public health
_
ice.. Preparation of Non-PHFs
Retail Sale _ _.
._control)
Other Food Operations
i Juice Manufactured and Packaged for
[ Offers Raw Or Undercooked Food Of
Retail Sale
( Animal Origin
Offers RTE PHF in Bulk Quantities
i, ] Prepares Food/Single Meals for
�!
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
Reconditioned Food
--
ITo be completed by the Board of Health
or
-_-- -- -- - --
Total Permit Fee:
Payment is due with application iV, 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 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to oboin copies of 10r5;CMR 590.000 and the federal Food Code.
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 tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 043-227- 70-
26). Signature of Individual or Corporate Name: A ')
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Mansfield Board of Health Date Apri/
We, MQv).SA6)4 IDV-+h f{ o/I ar) 4 0- he,&K request a waiver of the
Food Service Permit Fee for the following reason
UO " Pro Al- —
Thank you,
Title
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress RM64 Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERIAITTIN'G AUTHORITY.
Applicant Information
PIease Print Lel=ibIy
Business/Organization Name: 1 j �y
]
=�'>p,( j-i } # ] (
r,i Atvc-) C hd ,ey
Address: I C-i .
City/State/Zip: i 4 41 A Phone #: J} �1}
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a employer with employees (full and/
S. ❑ Retail
or part-time).*
6. Restaurant/Bar/Eating Establishment
2E 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.
S. Non-profit
[No workers' comp. insurance required]
3, ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per e. 152, § 1(4), and we have
I0. ❑ "Wring
no employees. [No workers' comp, insurance required]*
11. ❑ Health Care
4.0 We are a non-profit organization, staffed by volunteers,
12, [] Other
with no employees. [No workers' comp. insurance req j
*Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information.
**If the corporate oflieta bave cxempicd themselves, but the corporation bas other employees, a worker: compensation policy is required and such as
organization should check box M.
lam an employer that is providing workers' conepensadon insurance far my employees. Below is the policy information'.
Insurance Company Name:
Insurer's
Policy # or Self -ins: Lic. # - ExpirationDate:
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Too hereby certify, under the pains.gnd penalties ofperjuty that the information provided above is true and correct
Official use only. Do not mite 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
Phone