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Home My WebLink AboutMansfield High School Lunch 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 - SCHOOL DEPARTMENT Whose place of business is: MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL 250 EAST STREET PERSON(S) IN CHARGE: CAROL D'AMBRA, FOOD SERVICE MANAGER Permit Expires: December 31, 2018 Food Fee: License Number: FS-48 BOARD OF HEALTH MlchaeCMCCCean, Chairman WAIVED Milk & Cream ❑O Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that., TOWN OF MANSFIELD - SCHOOL DEPARTMENT having a place of business at.- Town of Mansfield 6 Park Row Mansfield, MA 02048 MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL 250 EAST 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-48 Board of Health MichaeCMcCCean, 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 FS-48 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL 2) Establishment Address 250 EAST STREET 3) Establishment Mailing Address (if different) 250 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No 508-261-7400 x33124 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (608) 261-7400 x33124 24 Hour Emergency No.: (508) 339-3241 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number TOWN OF MANSFIELD - SCHOOL DEPARTMENT 2 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 Name Title Address An Individual 1 .I A Partnership Other legal Entity_ -- — -- — ___-- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CAROL D'AMBRA, FOOD SERVICE MANAGER Address: 1250 EAST STREET, MANSFIELD MA 02048 Telephone No: (508) 261-7400 x33142 24 Hour Emergency No: (508) 339-3241 FAX: (508) 261 7413 E-mail: ICAROL.D'AMBRA@MANSFIELDSCHOOLS.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: (DAWN M. LANGTRY, FOOD SERVICE DIRECTOR Address: 250 EAST STREET, MANSFIELD, MA 02048 Telephone No: l(508) 261-7400 X33124 24 Hour Emergency No: (508) 866-4512 FAX: (508) 261-7413 E-mail: dawn.langtry@mansfieldschools.com Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 10 17) DAYS/HOURS: M-F 6:30 AM 2 PM 18) Name of Person In Charge Certified in Food Protection Management: CAROL D'AMBRA 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 DAWN M. LANGTRY certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑� 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $25.00 (] Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Milk & Cream $10.00 Moblie End Date: [� Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Dessertslice Cream $25.00/freezer 21) Length of Permit: Annual or up to 25' PHF display $150.00 Pushcart $25.00 # of Pushcarts: 0 �J Seasonal [I Food Service up to 201 + ❑ Residential Kitchen $100.00 Seasonal Dates: or 25'+ PHF display $275.00 ❑ Retail Food $100.00 Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Temporary Start Date: '&o Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (tlme/temperature controls required) Non-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) - - -_. _.--- - ___-__-. n Sale of Commercially Pre -Packaged Non-PHFs [J] PHFCooked To Order r/ Hot PHF Cooked and Cooled or Hot Held -- - - --------- ----- for More Than a Single Meal Service ] Sale of Commercially Pre Packaged PHFs (] Preparation of PHFs For Hot And Delivery of very of Packaged PHFs --- - - Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility - - --- - ----- - ❑Sale of Raw Animal Foods Intended _ [] Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ------- -- - ----- - Customer Self -Service of Non PHF and Non- Perishable Foods Only Preparation of Non-PHFs --- Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑Ice Manufactured and Packaged for Retail Sale Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin 0 Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities .__-.-. Retail Sale of Salvage Out -Of -Date J or Reconditioned Food To be completed by the Board of Health Total PermitFee: 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 ob-taiacogies of 105 CMR 59Q.000 andtthe federal Food Code. 24) Signature of Applicant: <" pr" I V P. Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-6001209 26) Signature of Individual or Corporate Name: 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: MANSFIELD SCHOOL LUNCH @ MANSFIELD HIGH SCHOOL ADDRESS: 250 EAST STREET TELEPHONE AT LOCATION: 508-261-7400 x33124 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: FEDERAL IDISS NUMBER: 04-6001209 FEE: $10.00 PERMIT NUMBER: FS-48 SIGNATURE:�/},� DATE: ¢ ! l p 13 m R� Z w O c Z � _ E 1 x.2 w N o (0 w Q N r x � w o .