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HomeMy WebLinkAboutTown of Mansfield Rec. Dept 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:. TOWN OF MANSFIELD Whose place of business is: TOWN OF MANSFIELD PARK RECREATION DEPARTMENT C29-11:7:i3��►i►I PERSON(S) IN CHARGE: SHERRI GURNON, RECREATION DIRECTOR Permit Expires: December 31, 2018 Food Fee: License Number: FS-93 WAIVED BOARD OF HEALTH Aichae(AcCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS93 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name TOWN OF MANSFIELD PARK RECREATION DEPARTMENT 2) Establishment Address 6 PARK ROW 3) Establishment Mailing Address (if different) 6 PARK ROW MANSFIELD, MA 02048 4) Establishment Telephone No (508) 851-6458 5) Applicant Name & Title: SHERRI GURNON 6) Applicant Address 6 PARK ROW, MANSFIELD, MA 02048 7) Applicant Telephone No.. (508) 851-6458 24 Hour Emergency No. 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number -_I (508) 802-3 TOWN OF MANSFIELD 6 PARK ROW, MANSFIELD, MA 02048 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation j Name Title Address An Individual -_ A Partnership V Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ',SHERRI GURNON, RECREATION DIRECTOR Address: HOPE STREET, MANSFIELD, MA 02048 Telephone No I(508) 851-6458 24 Hour Emergency No: (508) 802-3951 FAX: 1 ---- - - E-mail: RECREATION(cDMANS FIE LDMA.COM Alt E-Mail: - 13) District Or Regional Supervisor (if applicable) Name & Title: oo CAMP DIRECTOR iA I are 4yav _ -- Address: ,6 PARK ROW, MANSFIELD, MA 02048 Telephone No: ',(508) 261-7383 24 Hour Emergency No: FAX: (508) 261-7426 1 E-mail:- - — -- - Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 1 16) No. of Food Employees. 5 17) DAYS/HOURS: MON-FRI 8 AM-4 PM JUNE 26- AUGUST 2201N 18) Name of Person In Charge Certified in Food Protection Management: COURTNEY GURNON 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 or certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ICI Permanent Location 1, 22) Establishment Type Moblie Moblie Start Date: ! [ 'Retail ( S Ft Moblie End Date: Moblie Comments: 21) Length of Permit: V.. Annual Seasonal Seasonal Dates: -', Temporary Temporary Start Date: Temporary End Date: Temporary Time: q ) ICI Food Service up to 100 or up to 10' PHF display INCLUDING FOOD TRUCKS $125.00 _.i Food Service up to 101 -200 or up to 25' PHF display $150.00 [ ] Food Service up to 201 + or 254 PHF display $275.00 [.] Food Service - Institution ( Meals/Day) [ ] Caterer $25.00 Milk & Cream $10.00 ❑ Mobile Food Consession NO PHF PREPARED ON SITE $75,00 -ii Manufacture Frozen Desserts/Ice Cream -- $25.00/freezer [. ] Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 [_-J Retail Food $100.00 ❑ Retail Snack Food $25.00 I 1 Tobacco Products $25.00 ream Mare: 23) Food Operations Definitions: PHF- Potentially hazardous rood dime/temperature controls required) Non-PHFs - non -potentially hazardous rood(no timeRemperature controls required) (Check all that apply): 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 Delivery of Packaged PHFs J Reheating of Commercially Processed Foods for Service Within 4 Hours _.I Customer Self-service of Non PHF and Non - Perishable Foods Only 'V. Preparation of Non-PHFs Other Food Operations NO PHFS 14) WATER SOURCE: TOWN dj 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 Pnr and N i t roods Prepared ror nignry Susceptible Population Facility Vacuum Packaging / Cook Chill - --- - ---- - -- --- [ I Customer Self Service I f Use of Process Requiring A Variance and/or HACCP Plan (including bare hand I I Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale _ control) - Juice Manufactured and Packaged for I. ] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin. Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date --- ----- -- ---- ---, or Reconditioned Food 1 To be completed by the Board of Health __-- -__-- -- --- Total Permit Fee: j Payment is due with application 11 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 copies of W5 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I cer6lly 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: 04-6001209 26) Signature of Individual or Corporate Name: 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. cu Signa 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:\HmIthUa e's Doo=eats\PERMTT APPLICATIONS\TAX CERTIFICATION FORM.doo ST•2 MASSACHUSETTS DEPARTMENT OF REVENUE CERTIFICATE OF EXEMPTION Ieiy Oertificatton is hereby made that the organization herein named Is an exempt purchaser under General Laws, Chapter 04H, Sections 0(d) and (4 All purchases of tangible personal property by this organization are exempt from taxation under said chapter to the extent that such property Is used In the conduct of the buSlnaas of the purchaser. Any abuse or misuse of this certificate by any tax-exempt • W IBu mtfon or isuse of his Grtlficate of Exemuse of ption Is subjecrtificate ttoany senctIndividual �laa oltUP t serious year lviolation aprlson•and $10,000 (060,000 for corporations) in arms, (See reveres side). EXEMPTION NUMBER E TOWN OF MANSFIELD 046-001-209 SIX PARK ROW lssuE DATE MANSFIELD, MA 02048 0 1 /04 / 8 9 CERTIFICATE EXPIRES ON NONE NOT'ASSIONABLE OR TRANSFERABLE COMMISSIONER OF REVENUE STA)FREN,W. KIDDE.R. .a The Commonwealth ofMassachusefts Department of Industrial Accidents 1 Congress Sheet, 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 Lt blY Business/Organization Are you an employer? Check the appropriate box: 1, © I am a employer with 26 employees (full and/ or part-time).* 2: �] 1 an 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 e. 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.] Phone Business Type (required): 5. ❑ Retail 6. Restaurant/Bar/BatingEstablishment 7. ❑Office and/or Sales (inch. real estate, auto, etc.) 8. W Non-profit 9. ❑ Entertainment 10. ❑ Manufacturing 1 I.❑ Health Care 12.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have cxempled themselves, but the corporation has other employees, a workers compcosation policy is required and such an organization should check box M. lam an employer that is providing workers' conrpensagon insurance for my employees. Below is the policy informadOA. Insurance Company Name: 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 e, 152 can lead to the imposition of criminal penalties of a fine up to $1r500.00 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. f do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Official use only. Do nob 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: ry w ry Z) O CU Cl) N 0 N O Cl) n y fd c 0 0 v v w O w cc a V H w O w U w H w U z O z W m N y� cd Q V. o 0 F a y�y M � M I„ 0 d � •v � s max` 1- 1.0 p t3 a C r le��',� y G•i 4 �o�� a Mansfield Board of Health Request for Fee Waiver for Food Permit Date 06,2.5.1n We, 6 rant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: VI This is a request from a town department. 11 Please list the department: Mc&l & I-/ 1�C2llb� ❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. * Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, &� Signature 6 L Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: