HomeMy WebLinkAboutOur Daily Bread 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:.
CONGREGATIONAL CHURCH
Whose place of business is:
OUR DAILY BREAD - MANSFIELD'S COMMUNITY FOOD PANTRY
15 WEST STREET
PERSON(S) IN CHARGE:
RICHARD KELSAY, DISTRIBUTION COORDINATOR
Permit Expires: December 31, 2018
Food Fee:
License Number: FS-74
WAIVED
BOARD OF HEALTH
-%1ichaeC-%4CCCean1 Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS74
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name OUR DAILY BREAD - MANSFIELD'S COMMUNITY FOOD PANTRY
2) Establishment Address 15 WEST STREET
3) Establishment Mailing Address (if different) 15 WEST STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-1343
5) Applicant Name & Title: DEBBIE CHAMBERS
6) Applicant Address 3 NOREEN ROAD, MANSFIELD, MA 02048
7) Applicant Telephone No.: (774) 719-2276
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
24 Hour Emergency No.: (847) 372-0027 (508) 339-2504
CONGREGATIONAL CHURCH
5083394793
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
I:1 An Association or partner.
C A Corporation Name Title Address
C7 An Individual
El A Partnership
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: jRICHARD KELSAY, DISTRIBUTION COORDINATOR
Address: 52 STEARNS AVENUE, MANSFIELD, MA 02048
Telephone No: I(508) 339-2504
FAX:
E-mail: 1DEBBIE@CHAMBERS - FAMILY.NET
24 Hour Emergency No: (947) 372-0027 (508) 339-2504
Alt E Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title. RICHARD KELSAY, DISTRIBUTION COORDINATOR
Address: 52 STEARNS AVENUE, MANSFIELD, MA 02046
Telephone No: I(508) 339 2504 24 Hour Emergency No: (847) 372-0027
FAX
E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: SATURDAYS 8:30-11:30
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: ALL VOLUNTE
18) Name of Person In Charge Certified in Food Protection Management: DICK KELSAY
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
L19> Person Trained in Anti -Choking Procedures (If 25 Seals or more) Fi 6 R
20) Location: [J] Permanent Location 22) Establishment Type
IF l'. Mobile Mobile Start Date: I I R t it S Ft
Moblie End Date:
Mobile Comments:
21) Length of Permit:
❑/ Annual
❑ Seasonal
Seasonal Dates:
El Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Check all that apply): A
._.I as ( q. )
[] 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
L ] Food Service up to 201 +
or 25'+ PHF display $275.00
[' Food Service - Institution
( Meals/Day)
Ll Caterer $25.00
[v Milk & Cream $10.00
❑ Mobile Food & Consession $75.00
Ei 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
Definitions. PHF- Potentially hazardous food (tlmekemperalure controls required)
Nan-PHFs -non-potentially hazardous food(no timeRemperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ Sale of Commercially Pre -Packaged PHFs
ri Delivery of Packaged PHFs
Processed Foods for Service Within 4 Hours
Customer Self Service of Non PHF and Non
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
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
(__ 1 PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
-- - --- - I I Use of Process Requiring A Variance
Customer Self Service and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for contact alternative, time as a public health
Retail Sale control)
❑ Juice Manufactured and Packaged for ([] Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in k Qtities Buluan[ ] Prepares Food/Single Meals for
Catered Events or Institutional Food Service
I Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food I To be completed by the Board of Health
- Total Permit Fee:
Payment is due with application ,�,aived
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 c pies of 105 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. C�
25) Social Security Number or Federal ID: 34-1927049\.
26) Signature of Individual or Corporate Name: V J
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. ( } C
Signature of Individual or Corporate Name
"*Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory,
*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:\HealthVaue's Doc=mts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of IndustrialAceldents
1 Congress Street, Suite 100
Boston, MA 02114-2017
= www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Nam e: CX C� C
Address:
Phone#:5fi)'(1�1 7�s`B*4 J
Are you an employer? Check the appropriate box: Business Type (required):
I. ❑ I am a employer with employees (full and/ S. ❑ Retail
"'part-time).* 6. Restaurant(Bar/Eating Establishment
2; ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity. `
[No workers' comp, insurance required] 8• demon -profit
3. ❑ We are a corporation and its officers have exercised 9. El Entertainment
their right of exemption per c. 152, § 1(4), and we have lo. ElManufacturing
no employees. [No workers' comp. insurance required]*
4 We are a non-profit organization, staffed by volunteers, 11. ❑Health Care
with no employees. [No workers' comp, insurance req.] 12.❑ Other
"Any applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information,
e^If the corporate officers have exempted thcrosdves, but the corporation has other employees, a workers' compcusation policy is required and such"
organization should check box #].
I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy inforrnadoia
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic. # - Expiration Date:
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 her ertify, k n(er the pains p..d penalties ofRerjury that the information provided above is true and correct
0
Official use only. Do not write in this area, to he completed by`city or town officiaL
City or Town:
Permit/License
�My
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#:
www.mass.gov/dia
Mansfield Board of Health
W
Food Service Permit Fee for the following reason
Thank you,
Signature
Title
Date_
request a waiver of the