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Home My WebLink AboutMansfield Jordan Jackson 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 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 @ JORDAN JACKSON 255 EAST STREET PERSON(S) IN CHARGE: DIANE PENNELLATORE, FOOD SERVICE MANAGER Permit Expires: December 31, 2018 Food Fee: License Number: FS-50 BOARD OF HEALTH MichaeCMcCCean, Chairman. WAIVED Milk & Cream ❑O 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 - SCHOOL DEPARTMENT having a place of business at: MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON 255 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-50 Board of Health Nic(1aeC9bicCCean, 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-50 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD SCHOOL LUNCH @ JORDAN JACKSON 2) Establishment Address 255 EAST STREET 3) Establishment Mailing Address (if different) 255 EAST STREET NOV0 20 MANSFIELD, MA 02048 4) Establishment Telephone No 508-261-7525 x44127 -- --- 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 x33124 24 Hour Emergency No.: (508) 338-3670 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 (508) 261-7525 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 1 7 An Individual I._.I A Partnership ----------- ICI Other legal Entity_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) 13) District Or Regional Supervisor (if applicable) Name & Title: (DAWN M. LANGTRY, FOOD SERVICE DIRECTOR Address: I250 EAST STREET, MANSFIELD, MA 02048 Telephone No: I(508) 261-7400 X33124 FAX: (508) 261-7413 24 Hour Emergency No: (508) 866-4512 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: 8 17) DAYS/HOURS: M F 6.30 AM - 2:30 PM f 18) Name of Person In Charge Certified in Food Protection Management: DIANE M PENNELLATORE If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 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). �] — 20) Location: IV] Permanent Location 22) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ] Milk & Cream $10.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments ..___ __ ....... _._._.__ up to 10' PHF display $125.00 ❑ Manufacture Frozen Desserts/Ice Cream 21) Length Of Permit: ❑Food Service up to 101 -200 $25.00/freezer ] Annual or up to 25' PHF display $150.00 i] Food Service up to 201 + ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Lj Seasonal Seasonal Dates: or 25'+ PHF display $275.00 [ i Retail Food $100.00 ❑ Temporary ❑d Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Start Date: 400 Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperatum controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) i(Check all that apply): RTE -ready-to-eat foods (Ex, sandwiches, salads, muffins which need no further processing) E/] Sale of Commercially Pre -Packaged Non-PHFs [] PHFCooked To Order [VI Hot PHF Cooked and Cooled or Hot Held [_ J Sale of Commercially Pre -Packaged PHFs ❑./ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs ry Cold Holding For Single Meal Service ❑ 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- di Variance ❑Use of Process Plan (including HACCP Plan (including bare hand ] Customer Self -Service Perishable Foods Only ❑ Ice Manufactured and Packaged for contact contact alternative, time as a public health i] Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑r' 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 --- Total Permit Fee: 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 obtain copies of 105 CMR 5P0.000 and the federal Food Code. 24) Signature of Applicant: )� V V i Pursuant to MGL Ch.62C, sec. 49A, I certify under the penaltie and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-6001209- 26) Signature of Individual or Corporate Name: i `D 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 @ JORDAN JACKSON ADDRESS: 255 EAST STREET TELEPHONE AT LOCATION: 508-261-7525 x44127 FAX NUMBER: (508) 261-7413 OWNER OF BUSINESS: TOWN OF MANSFIELD - SCHOOL DEPARTMENT TELEPHONE OF OWNER: (508) 261-7525 FEDERAL ID/SS NUMBER: 04-6001209 FEE: $10.00 PERMIT NUMBER: FS-50 SIGNATURE: ` DATE: a i_ S I 9 w O LLJ Z W n W 0 M- 1 I