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Home My WebLink AboutMansfield Robinson School Lunch 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 ESTABLISLHMENT 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 @ ROBINSON SCHOOL 245 EAST STREET PERSON(S) IN CHARGE: BARBARA PALIE, FOOD SERVICE MANAGER Permit Expires: December 31, 2018 Food Fee: License Number: FS-49 BOARD OF HEALTH %1ich6aeCJA4cC(ean, Chairman LTITE1 A - Milk & Cream C1 FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-49 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD SCHOOL LUNCH @ ROBINSON SCHOOL 2) Establishment Address 245 EAST STREET IV 3) Establishment Mailing Address (if different) 245 EAST STREET F MANSFIELD, MA 02048 r 4) Establishment Telephone No 508-261-7513 x51319 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 261-7400 z33124 24 Hour Emergency No.: (508) 339-6533 ---------- 8) Owners Name & Title TOWN OF MANSFIELD - SCHOOL DEPARTMENT 9) Owner Address (If different from applicant) 2 PARK ROW, MANSFIELD, MA 02048 Owner's telephone number 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 LLI Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title 1BARBARA PALIE, FOOD SERVICE MANAGER Address: 245 EAST STREET, MANSFIELD, MA 02048 Telephone No l(508) 261-7513 x51319 24 Hour Emergency No: (sor) 339-6533 FAX: I(508) 261-7413 — E-mail. I Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: (DAWN LANGTRY, FOOD SERVICE DIRECTOR Address: �250 EAST STREET, MANSFIELD, MA 02048 Telephone No (508) 261 7400 X33124 24 Hour Emergency No: (508) 866-4512 FAX: (508) 261-7413 E-mail: dawn.langtry@mansfieldschools.com 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: M-F 7:00 AM - 3 PM Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 4 18) Name of Person In Charge Certified in Food Protection Management: BARBARA PALIE 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 LANGTRY certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) ❑r' 20) Location: E] Permanent Location 22) Establishment Type ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: [,] Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: [] Annual '-- ] Seasonal r: Seasonal Dates: I Temporary Temporary Start Date Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑d Food Service up to 201 + or 25'+ PHF display $275.00 ❑d Food Service - Institution 950 Meals/Day) ❑ Caterer $25.00 ❑./ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Dessertslice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 i❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) ,Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) F/J Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑� Hot PHF Cooked and Cooled or Hot Held - - ---------- --- ----- ❑ Sale of Commercially Pre -Packaged PHFs -- ------------------ ❑r' Preparation of PHFs For Hot And for More Than a Single Meal Service --------------------- -- - ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑d PHF and RTE Foods Prepared For Highly --- ----- — ❑_ 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 ----- �] Customer Self -Service of Non PHF and Non- - ❑�/ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑Ice Manufactured and Packaged for contact alternative, time as a public health Jj Preparation of Non-PHFs Retail Sale control) Other Food Operations i_] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _RTE_ Offers RTE PHF in Bulk Quantities FVJPrepares 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 Total Permit Fee: Payment is due with application W 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: V V} , tr 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: 04-600120 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 @ ROBINSON SCHOOL ADDRESS: 245 EAST STREET TELEPHONE AT LOCATION: 508-261-7513 x51319 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: FEDERAL ID/SS NUMBER: 04-6001209 FEE$10.00 PERMIT NUMBER: FS-49 SIGNATURE: DATE: � � � _ LLM � A � � K$ \ § 13 %e4 o