HomeMy WebLinkAboutGerry's Catering 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: MOBILE FOOD
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:.
GERALD DOHERTY
Whose place of business is:
GERRY'S CATERING
157 CHESTNUT STREET
PERSON(S) IN CHARGE:
GERALD DOHERTY
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-54
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MichaeCMcCCean, Chairman
Milk & Cream V
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that
GERALD DOHERTY
having a place of business at:
GERRY'S CATERING
157 CHESTNUT STREET
Town of Mansfield
6 Park Row
Mansfield, MA 02048
in the Town of Mansfield has been granted a license to sell MILK and CREAM and is
subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to
the terms and conditions, and to the rules and regulations established by the Board of
Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain
in force until 1213112018 , unless previous to that time is suspended or revoked.
Expires 1213112018
License No.: FS-54
Board of Health
NichaeCMcCCean, Chairman
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
FOR BOARD OF HEALTH USE'O,NLY Permit#Issued FSFS54
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name
2) Establishment Address
GERRY'S CATERING
157 CHESTNUT STREET
3) Establishment Mailing Address (if different) 157 CHESTNUT STF
FOXBOROUGH,MA
4) Establishment Telephone No (774) 254-0200
5) Applicant Name & Title: GERALD DOHERTY, OWNER/OPERATOR
Nov 9 () 2_0171
6) Applicant Address 157 CHESTNUT STREET, FOXBOROUGH, MA 02035
7) Applicant Telephone No.: (774) 254-0200
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
L1 An Association or partner.
7 A Corporation Name Title Address
An Individual
❑ A Partnership
24 Hour Emergency No.: (500) 930-7755
GERALD DOHERTY
(774) 254-0200
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: GERALD DOHERTY
Address: i157 CHESTNUT STREET, FOXBOROUGH, MA 02035
Telephone No: (774) 254-0200
FAX:
E-mail:
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
24 Hour Emergency No: (508) 930-7766
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: MOBILE 15) SEWAGE DISPOSAL NIA
T16)
DEP Public Water Supply No (If applicable) No of Food Employees: 1
17) DAYS/HOURS: M-F 5 AM - 5 PM
18) Name of Person In Charge Certified in Food Protection Management: GERARD F. DOHERTY
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):
20) Location: [J Permanent Location
22) Establishment Type
❑ Caterer $25.00
❑� Mobile Moblie Start Date:
i�_J Retail ( Sq. Ft)
�] Milk & Cream $10.00
Mobile End Date:
[ Food Service up to 100 or
❑ Mobile Food & Consession $75.00
Mobile Comments: MOBILE CANTEEN
up to 10' PHF display $125.00
- Manufacture Frozen Desserts/Ice Cream
21) Length of Permit:
❑ Food Service up to 101 -200
$25.00/freezer
[j Annual
or up to 25' PHF display $150.00
❑ Pushcart $25.00 # of Pushcarts: 0
[_I Seasonal
❑ Food Service up to 201 +
❑ Residential Kitchen $100.00
I Seasonal Dates:
or 25'+ PHF display $275.00
" Retail Food $100.00
�-�
' [ _ Temporary
❑ Food Service - Institution
❑ Retail Snack Food $25.00
Temporary Start Date:
I
( Meals/Day)
❑ Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date:
--_-- ---__—_-- -
hazardous food (time/temperature controls required)
23) Food Operations Dalmilions PHF -Potentially
Non-PHFs
non -potentially hazardous food(no time/lemperatum controls required)
(Check all that apply): RTE- ready
-to -eat foods (Ex sandwiches, salads, muffins which need no furtherprocessing)
[Vi Sale of Commercially Pre Packaged Non-PHFs
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
- ---
[-/I Sale of Commercially Pre Packaged PHFs
---- --- --- -
❑ Preparation of PHFs For Hot And
for More Than a Single Meal Service
.
❑ PHF and RTE Foods Prepared For Highly
- -- --- —-------
jd] Delivery of Packaged PHFs
Cold Holding For Single Meal Service
--- --- - --- -
_..__._
❑ Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially
to be Prepared by Consumer
[] Vacuum Packaging / Cook Chill
rp/I
Processed Foods for Service Within 4 Hours
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
-- --- -
❑j Customer Self-service of Non PHF and Non-
-
❑ Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
_
Ice Manufactured and Packaged for
I ] Preparation of Non-PHFs _ _
Retail Sale
control)
_
[ ] Offers Raw Or Undercooked Food Of
Other Food Operations
[] Juice Manufactured and Packaged for
Retail Sale
Animal Origin
❑_ Prepares Food/Single Meals for
--rIa RTE PHF _-_--- in -"- --" Quantities]
Otte rs
❑ Bulk
ICatered
Events or Institutional Food Service
I Retail Sale of Salvage, Out -Of -Date I -
or Reconditioned Food - To be completed by the Board of Health
------- -----_--- Total Permit Fee: $125.00
Payment is due with application ❑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 obtain copieslf 105 CMR 590_000 and the federal Food Code.
24) Signature of Applicant: , d/ f Xf
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of
and paid state taxes required under law.
25) Social Security Number or Federal ID: 021-38-9627
26) Signature of Individual or Corporate Name:
that I, to my best knowledge and belief, have filed all state tax returns
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Milk and Cream Permit
I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year.
NAME OF BUSINESS: GERRY'S CATERING
ADDRESS: 157 CHESTNUT STREET
TELEPHONE AT LOCATION: (774) 254-0200
FAX NUMBER:
OWNER OF BUSINESS: GERALD DOHERTY
TELEPHONE OF OWNER: (774) 254-0200
FEDERAL ID/SS NUMBER: 021-38-9627
FEE: $10.00
PERMIT NUMBER: FS-54
SIGNATURE: - 1 7/t
DATE: ✓/C�
TAX CERTIFICATION FORM
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.
3 �
/f �,dL
Signature of Individual or Corporate Name
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*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.
R:\HwIth\lane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
1-9 N The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
k1ri www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PER114ITMG AUTHORITY.
Applicant Information Please Print Legib]V
Business/Organization Name:
Address:
Citv/State/Zip:
X—_. KI) kx'�4, :
rfl, K)
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2:04am 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. 0.Rftail
6. Restaurant/Bar/EatingEstablishment
T ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9, ❑ Entertainment
10,❑ Manufacturing
11. F1 Health Care
12.❑ Other
*Any applicant that checks box ql must also fill out the section below showing their workers' compensation policy information.
**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 91.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informadori.
Insurance Company
Insurer's
Policy # or Self -ins, Lic. #- Expiration Data:
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 certify, under the pains, andpenalties ofperjury that the information provided above is true and correct.
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
w .nnnagov/ma
Phone
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