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Home My WebLink AboutMansfield Council on Aging 12/31/2018 (2)Commonwealth 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:. 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: FS-42 BOARD OF HEALTH MichaeCMcCCean, Chairman DJ/e11y/2197 Milk & Cream Ll 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.: FS-42 Board of Health MichaeCblcCCean, 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 FSFS42 -'I FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening da 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 y 5) Applicant Name & Title:( 6) Applicant Address L- T,` ��3� f� NCL CiVtf4' 1zCfVte �� C��OByOJ —j �y-��, 7) Applicant Telephone No.: (soal zs�asss 24 Hour Emergency No.: 5p\ Raa•v¢ao lcos}aacaaos V - z6 S�`21Z-�OZB �i3, 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 e Other legal E ny -- 12) + — — - Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: I J��Ovc� K Y2VV� ((2GaY Address: 255 HOPE STREET, MANSFIELD MA Telephone No: (508) 261-7368 X6111q 24 Hour Emergency No. (503) 543-7339 (508) 345.3303 FAX: I(508) 3394886 E-mail: mail: : SLL V pa VtQ W ✓ t tnS tC 2rL� K/W_ • 60--`1 Alt F 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: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If applicable) 16) No of Food Employees 3 ff 17) DAYS/HOURS: MON FRI 8:00 AM - 3:30 PM 18) Name of Person In Charge Certified in Food Protection Management: DEBRA SUPRENANT 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 MAUREEN KILGALLON I. certificate KATE ALLEN PHYLLIS BUTLER 1/19/2 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): I1 20) Location: i_J_1 Permanent Location ! 22) Establishment Type III j Caterer $25.00 -; Mobile Mobile Start Date: Retail ( Sq. Ft) V Milk & Cream $10.00 Mobile End Date: /J Food Service up to 100 or Lj Mobile Food & Consession $75.00 � Mobile Comments: up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream 21 Length of Permit: $z5.00/freezer g i _ 1 Food Service up to 101 -200 � I Annual or up to 25' PHF display $150.00 !I-_-':. Pushcart $25.00 # of Pushcarts: p Seasonal �... Food Service up to 201 + ! ) Residential Kitchen $100.00 or 25'+ PHF display $275.00 Seasonal Dates: Retail Food $100.00 li Temporary - !,', Food Service - Institution _!, Retail Snack Food $25.00 Temporary Start Date: `2 Meals/Day) I I Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: ---- _-- ' _---- Definitions: PHF Potential) hazardous food (tlmeltem erature controls required 23) Food Operations Non PHFs non potentially hazardous food(no hmelemperature controls required) !(Check all that apply) RTE- ready to eat foods (Ex sandwiches, salads, muffins which need no furtherprocessmg) Sale of Commercially Pre -Packaged To Sale of Commercially Pre -Packaged PHFs HFs J P Preparation at ondOrder of PHFsFor Hof And for More Than a Single Meal Service Held �I Delivery of Packaged PHFs Cold Holding For Single Meal Service I PHF and RTE Foods Prepared For Highly ry g -- - --- - - i - Susceptible Population Facility Reh a eating F ods meforSery ce Within 4 Hours Sale of rcially o be Prepared ' ended sed by Consummal Foods er Vacuum Packaging / Cook Chill ProUse of Process uiring A Customer Self -Service of Customer Self -Service and/or Pla PreparPerishaation ole of Noo PHFs Non PHF and Non- i 1 Retail Sale Manufactured and Packaged for J onteIHACCP ive, me(includingapbare hand y contact alternative, time as a public health Other Food Operations 11 I Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin j Offers RTE PHF in Bulk Quantities 1 Prepares Food/Single Meals for I Catered Events or Institutional Food Service I I Retail Sale of Salvage, Out -Of -Date - -- --- or Reconditioned Food To be completed by the Board of Health ----- --- -- - Total Permit Fee: Payment is due with application l:/1 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 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. 25) Social Security Number or Federal ID: 046-00 -209 (f'�� /1• fy 26) Signature of Individual or Corporate Name: i,vt'& id COLI_yAc f ) CYV1 Pa f�,c 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 OWNER OF BUSINESS: (508)339-4886 TOWN OF MANSFIELD TELEPHONE OF OWNER: (508) 261-7368 FEDERAL ID/SS NUMBER: 046-001-209 FEE: $10.00 PERMIT NUMBER: FS-42 SIGNATURE: t -4a 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. +, `lawn 04'l1'aMSs eld 06f_Lr1C1% on ape LA Signature of Indivi al or Corporate Name By: Corporate Officer (Mandatory, IF Applicable) C)q .& 00120 0/ Social Security Number (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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 UIV www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �j Please Print LeObly Business/Organization Name: fflo 6&Ld e0L-0V1Ce t 1 o V1 Hit Phone #:Z7- Zoo/ ` % Ar�e y an employer? Check the appropriate box: Business Type (required): I am a employer with 00 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/BatingEstablishment 2. ❑ 1 am a sole proprietor or partnership and have no y, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 I.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, _ eg / M with no employees. INo workers' comp, insurance req.] 12. +' Other (i�id$1' (/l Cad - u4t C,t *Any applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information. **If the corporate officers have exempted thcrosclvcs, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box M. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address; d YI ti yt.00 Q td t Ciry�� H /state/Zip; /QM 61 "d a O Policy #or Self -ins. Lie. #_ .�t�� /t%."'r 90l `7 Expiration Date: 7 / / 1 (2CJ(2� 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 hereby, certify, under the pains and penalties ofperjuty that the information provided above is true and correct r2 Date: %_)t3% l— Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Permit/License 3. City/Town Clerk 4. Licensing Board 5. 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