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Home My WebLink AboutMansfield Council on Aging 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: MOBILE FOOD In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 11 f, Section 5 of the General Laws, a Permit is hereby granted to:. TOWN OF MANSFIELD Whose place of business is: MANSFIELD COUNCIL ON AGING 255 HOPE STREET PERSON(S) IN CHARGE: DEBRA R. SURPRENANT, DIRECTOR Permit Expires: December 31, 2018 Food Fee: License Number: MF-2 BOARD OF HEALTH -%4ichaeC.T1cCtean, 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: TOWN OF MANSFIELD having a place of business at: MANSFIELD COUNCIL ON AGING 255 HOPE 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.: MF-2 Board of Health NichaeC-%1cCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued MF-2 I I' FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD COUNCIL ON AGING 2) Establishment Address 255 HOPE STREET 3) Establishment Mailing Address (if different) P.O. BOX 232 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 261-7368 1 5) Applicant Name & Title: (oYQ is r fIY-4e ✓Ia Yet r e wee 6) Applicant Address le N& {6we) 12- (p D,fNi l 7) Applicant Telephone No.: (508) 261-7368 24 Hour Emergency No.: 12-so 8) Owners Name & Title TOWN OF MANSFIELD 9) Owner Address (If different from applicant) SIX PARK ROW, MANSFIELD, MA 02048 Owner's telephone number (508) 261-7368 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual — - — A Partnership IV! Other_lec�al-Entity --- --, — 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: '255 HOPE STREET, MANSFIELD MA Telephone No: 'i(508) 261-7368 X 61115 24 Hour Emergency No: 440 FAX: '(508) 339-4886 - O 2( 2 — 6U 2-2 E-mail: Alt E-Mail: - — - 13) District Or Regional Supervisor (if applicable) Name & Title Food Establishment Information 14) WATER SOURCE: MOBILE UNIT 15) SEWAGE DISPOSAL MOBILE UNIT DEP Public Water Supply No: (If applicable) - 16) NO of Food Employees: 4 17) DAYS/HOURS: M-F B AM-3:30 PM 18) Name of Person In Charge Certified in Food Protection Management: DEBRA R. SURPRENANT 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 KATE ALLEN PHYLLIS BUTLER 111912 certificate MAUREEN KILGALLON 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ICI 1 20) Location: [' Permanent Location 22) Establishment Type [ ] Caterer $25.00I Moblie Moblie Start Date: I" Retail ( Sq Ft) [] Milk &Cream $10 00 Moblie End Date: Moblie Comments: 21) Length of Permit: V Annual Seasonal [. i Food Service up to 100 or up to 10' PHF display $125.00 [_ J 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 Seasonal Dates: Temporary -_.-rY --- -- I [l, Food Service - Institution I Temporary Start Date: dj2 Meals/Day) Temporary End Date: Temporary Time: Rain Date: --- -----------------. [] Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream I--] $25.00/freezer l.. Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 1 Retail Food $100.00 I Retail Snack Food $25.00 j_ Tobacco Products $25.00 23) Food Operations Definitions: Potentially( P required) NonFPHF hazardous lood(no time/femperatureucontrols 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 I PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs I [1, Preparation of PHFs For Hot And for More Than a Single Meal Service - -- - — - d', Delivery of Packaged PHFs Cold Holding For Single Meal Service, PHF and RTE Foods Prepared For Highly I. .... _. Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- Customer Self -Service 1,1 and/or HACCP Plan (including bare hand Perishable Foods Only , I __- - and ----_-_-_-� Ice Manufactured and Packaged for contact alternative, time as a public health I Preparation of on-PHFsRetail Sale control) Other Food Operations --- {I Juicnufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal _ - --- — Prepares Food/Sin le Meals for 1 t Offers RTE PHF in Bulk Quantities L] p 9 Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date -r -__-- or Reconditioned Food To be completed by the Board of Health i _--- --- -- Total Permit Fee: Payment is due with application [I 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 o tain copies of 105 CM 590.000 and the federal Food Code. 24) Signature of Applicant � 2 -1 2 G Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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: 046-001-209,y/� /� 26) Signature of Individual or Corporate Name: f,t�i U1St7L� 1d l.,bt9_V1Cv1 6--it A5cl'&q, 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: MANSFIELD COUNCIL ON AGING ADDRESS: 255 HOPE STREET TELEPHONE AT LOCATION: (508) 261-7368 FAX NUMBER: (508) 339-4886 OWNER OF BUSINESS: TOWN OF MANSFIELD TELEPHONE OF OWNER: (508) 261-7368 FEDERAL IDISS NUMBER: 046-001-209 FEE'. $10.00 PERMIT NUMBER: MF-2 SIGNATURE: DATE: 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. ��. `� .� LQ.-�..�- �J �ia�tz � • �u r pry vrCa. vc� Signature of Individual A Corporate Name By: Corporate Officer (Man atory, if Applicable) 4(.0-r.)1 m20 *`Social Security No. (Voluntary) or Federal Identification Number *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:\Hm1thVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc � q4-4 / U O � � � f � 9 \ \ \ j ((\ \)()\± • ] ) ® c ! � \ ) « g / �-n a] \ / � .\ cd 0 0 O � \ � \ � m / � \ \ � 2 \ \ ; g / � � �-n / 3 / / 5' itYJYi� � � y. L wO• "' y C > y c e . W v Q Cd � o � Y p Cd � V d ocdU O taq>1 taw z O .4-4 N CG Y by r J� cd U 00 Cd U � -- � n Ct c � � o � A Q� z � z I � r� W4 z P4 I .. m . C14z� cli� \ cr)\\ ce),� / /( » 0. »z / \~\ / / ° 0 ° $ \ � / Q (! \ ) � lot ƒ 50 / [[\» \ \\-'Zt\ \ r #