HomeMy WebLinkAboutFirst Baptist Church 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: 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:.
FIRST BAPTIST CHURCH
Whose place of business is:
FIRST BAPTIST CHURCH
52 NORTH MAIN STREET
PERSON(S) IN CHARGE:
DOROTHY FOWLER
Permit Expires: December 31, 2018
Food Fee:
License Number: FS-27
BOARD OF HEALTH
MichaecmcCCean, Chairman
WAIVED
Milk & Cream V]
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Sell Milk and Cream
This is to certify that:
FIRST BAPTIST CHURCH
having a place of business at:
FIRST BAPTIST CHURCH
52 NORTH MAIN STREET
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-27
Board of Health
MichaeCMcCCean, Chairman
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
�r _
i 1
V4 FOR BOARD OF HEALTH USE ONLY
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name
2) Establishment Address
FIRST BAPTIST CHURCH
52 NORTH MAIN STREET
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
Permit#Issued FSFS27
52 NORTH MAIN STREET '
MANSFIELD, MA 02048
(508)339-7047
5) Applicant Name & Title: DOROTHY FOWLER, COORDINATOR FOOD N' FRIENDS SOUP KITCHEN
6) Applicant Address 18 GLEN STREET, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508( 339-7097 24 Hour Emergency No.: (508) 339-7097
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number (508) 339-7047
10 Establishment Owned By: T
Y � 11) If a corporation or partnership, give name, title, and home address of officers
Ili An Association or partner.
i I A Corporation Name Title Address
I ] An Individual
I l A Partnership
FIRST BAPTIST CHURCH
52 NORTH MAIN STREET, MANSFIELD 02048
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: IDOROTHY FOWLER
Address 18 GLEN STREET, MANSFIELD, MA 02048
Telephone No: �(508) 339-7097 24 Hour Emergency No: (508) 339-7097
- - — - -
FAX: I(508)222-2008
E-mail: DOTE7679(a@YAHOO.COM
Alt E Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title
Address
;Telephone No: 24 Hour Emergency No:
FA" J E-mail:
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: VARIES
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: VARIES
18) Name of Person In Charge Certified in Food Protection Management: PAMELA L. TARALLO
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 25Seats or more)
20) Location: [Jl Permanent Location
_. I Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
'V1 Annual
j..] Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Check all that apply):
22) Establishment Type
❑ Retail ( Sq. Ft)
[] 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)
I Caterer $25.00
] Milk & Cream $10.00
Mobile Food & Consession $75.00
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 gunarlemperature controls required)
Non-PHFs - non -potentially hazardous food(no lime/temperature controls required)
RTE - ready-to-eal 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
[/I 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
FOOD N' FRIENDS SOUP KITCHEN
❑d 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
Ice Manufactured and Packaged for
Retail Sale
[] Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging / Cook Chill
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
[? Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities 1 ❑ Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
..__.. __-----------_l
Total Permit Fee:
Payment is due with application n 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 19,5 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: e_J CPILe cS
Pursuant to MGL Ch.62C, sec. 49A, I certify under the
and paid state taxes required under law.
25) Social Security Number or Federal ID: 04-£
26) Signature of Individual or Corporate Name:
of perjury 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: FIRST BAPTIST CHURCH
ADDRESS: 52 NORTH MAIN STREET
TELEPHONE AT LOCATION
FAX NUMBER:
OWNER OF BUSINESS
(508)339-7047
FIRST BAPTIST CHURCH
TELEPHONE OF OWNER: (508) 339-7047
FEDERAL ID/SS NUMBER: 04-3028252
FEE: $10.00
PERMIT NUMBER: FS-27
SIGNATURE: /L 0,� / lZ
% �7
DATE: 1 ._7_11 /
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 Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
fl`J
**Social Security No. (Voluntary) or Federal
Identi 'ca.' ber
*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:\Hn1th\Jane's Docwnents\PERMTT APPLICATIONS\TAX CERTIFICATION FORM.doc
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
r, www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERIvIrTTING AUTHORITY.
Applicant Information Please Print Le> ibly
Business/Organization Name:
Address: `J /� %%% <'�
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2.0 1 am 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. ❑Retail
6. Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. jn Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.0 Health Care
12,❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information.
**If the corporate ofdcers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #I.
I am an employer that is providing workers' cyryipensation insurance for my employees. Below is the policy information.
Insurance
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer`tifyopunder
,the�pains andpenalties ofperjury that the information provided above is true and correct
Signature: �[/ a"'�' t-1 �•�'1 Date: 2/.t- `
INUMM
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 S. Selectmen's Office
6. Other
Contact Person: Phone
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Mansfield Board of Health
We,v g % ��'� ✓l
Food Service Permit Fee for the following reason
Thank you,
Signature
Title
Date` r ///7
request a waiver of the