HomeMy WebLinkAboutCreative Community Studio 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishment
Type: RETAIL SNACK 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:.
LESLIE MCCONAGHY
Whose place of business is:
CREATIVE COMMUNITY STUDIO
66 WEST STREET
PERSON(S) IN CHARGE:
LESLIE MCCONAGHY, OWNER
Permit Expires: December 31, 2018
Food Fee: $25.00
License Number: RS-26
BOARD OF HEALTH
MichaeCMCCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days /before the planned opening date)
1) Establishment Name Ca ve /�+ rn�LUwll 1 S L)
2) Establishment Address
-- -- -
3) Establishment Mailing Address (if different)
4) Establishment Telephone No-
5) Applicant Name & Title: (�f/I e r JG PA
nzcLf
6) Applicant Address cyu ,
7) Applicant Telephone No.: �� 0 24 Hour Emergency No.: SLQ-m
8) Owners Name & Title 6esfic- Lk Co yt&� �r
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 j
An Association or partner.
A Cor oration Name Title Address
An Individu -
A artnership
- Other legal Entity--
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
AddressRod Alcalc 4 Hour Emergency No/ ky
Telephone No g y
-
----- - -- - I � �� y
U a-, 7�'l
FAX h✓L - - -1
E-mail: i slt (frn cx--lw Nnq GliJ'-h <-i '
Alt E-Mail:
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: 15) SEWAGE DISPOSAL
DEP Public Water Supply No: (If applicable) 16) N0. of Food Employees:
17) DAYS/HOURS --�1 A)4—_
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)
20) Location: 'Permanent Location 22) Establishment Type
Moblie Moblie Start Date: �tetail ( S Ft)
Moblie End Date:
Moblie Comments:
21) Length of Permit:
ZOAnnual
_, Seasonal
Seasonal Dates:
_ 1,, Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
q
[J Food Service up to 100 or
up to 10' PHF display $125.00
I,. Food Service up to 101 -200
or up to 25' PHF display $150.00
_J Food Service up to 201 +
or 254 PHF display $275,00
Food Service - Institution
( Meals/Day)
Caterer $25.00
i-_ Milk & Cream $10.00
[j Mobile Food & Consession $75.00
-i Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $25.00 # of Pushcarts:
I l Residential Kitchen $100.00
n Retail Food $100.00
Retail Snack Food $25.00
El Tobacco Products $25.00
Rain Date: i
23) Food Operations Definitions: PHF- Potentially hazardous food (time4emperature controls required)
Nan-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 further processing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
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
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
i ] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
i ] Vacuum Packaging / Cook Chill
FT -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 i _ control) _.
i- Juice Manufactured and Packaged for El 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
i Retail Sale of Salvage Out -Of -Date -- ----- ----
or Reconditioned Food I To be completed by the Board of Health
i
— -- -- Total Permit Fee:
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 cgpie)gof 105 CMR 590.900 Wd the fedefal Food Code.
24) Signature of Applicant:
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
Customer Self -Service
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:
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.
Signature of IndividuT al or Corporate Ntme
**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.
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