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Home My WebLink AboutMansfield Qualters 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 @ QUALTERS MIDDLE SCHOOL 240 EAST STREET PERSON(S) IN CHARGE: 3 7 kG7-meelaih114La; oxowl4CIT/[y:4iy lrnr!/e-oi4 Permit Expires: December 31, 2018 Food Fee: License Number: FS-51 BOARD OF HEALTH Michael 9McCCean, Chairman T 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 @ QUALTERS MIDDLE SCHOOL 240 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-51 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-51 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD SCHOOL LUNCH @ QUALTERS MIDDLE SCHOOL 2) Establishment Address 240 EAST STREET .. -------------- a 1 t Ed t' 3) Establishment Mailing Address (if different) 240 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No 508-261-7530 X23108 5) Applicant Name & Title: DAWN LANGTRY, FOOD SERVICE DIRECTOR j 6) Applicant Address 250 EAST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (608) 261-7400 x33124 24 Hour Emergency No.: (608) 339-7618 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 — - ---- 11) If a corporation or partnership, give name, title, and home address of officers 10) Establishment Owned By: ❑ An Association or partner. I 1 A Corporation j Name Title Address I ] An Individual _ 7 A Partnership l Other legal Entity -_----- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title IBRENDA CORMIER, FOOD SERVICE MANAGER Address. 240 EAST STREET, MANSFIELD, MA 02048 Telephone No: (508) 261-7530 X23108 24 Hour Emergency No. (508) 339.7618 FAX (508) 261-7413 E-mail: BRENDA.CORMIER(cDMANSFIELDSCHOOLS.COM -- 1 -- Alt E Mail: 13) District Or Regional Supervisor (if applicable) --- -- Name & Title:--- itle DAWN M. LANGTRY, FOOD SERVICE DIRECTOR Address: Telephone No: FAX EAST STREET, MANSFIELD, MA 02048 508) 261-7400 X33124 24 Hour Emergency No: (508) 866.4512 (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: 17) DAYS/HOURS: M F 6.30 AM - 2 PM 18) Name of Person In Charge Certified in Food Protection Management: BRENDA CORMIER 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) 111 20) Location: [] Permanent Location Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: n Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 ii Food Service up to 201 + or 25'+ PHF display $275.00 [J] Food Service - Institution '450,,, 2M Meals/Day) ❑ Caterer $25.00 � jf Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 �-] Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 I I Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food dime/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ill Sale of Commercially Pre Packaged Non-PHFs F/ PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held —_- ----o _. -- aged_ --------- r i select Commercially Pre Packaged PHFs -------- ❑�/ Preparation of PHFs For Hot And for More Than a Single Meal Service --- -- -- --- ❑ Delivery of Packaged PHFs 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 --- - --- -1 --- C] 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 n 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 j or Reconditioned Food To be completed by the Board of Health L- — - — --- Total Permit Fee: Payment is due with application LI 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 obt copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: `.li") Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalti`eSeof°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: 04-60012Q8___- 26) Signature of Individual or Corporate Name: ) 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 @ QUALTERS MIDDLE SCHOOL ADDRESS: 240 EAST STREET TELEPHONE AT LOCATION FAX NUMBER OWNER OF BUSINESS: TELEPHONE OF OWNER: 508-261-7530 X23108 (508)261-7413 TOWN OF MANSFIELD - SCHOOL DEPARTMENT FEDERAL ID/SS NUMBER: 04-6001209 FEE: $10.00 PERMIT NUMBER: FS-51 r-- SIGNATURE: DATE: TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Ap ale) C) 4 _ tr,C)vl:n "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. R:\Health\Ian6s Doenments\PERMIP APPLICATIONS\TAX CERTIFICATION FORM.doe M3 ❑ ❑ /\ ME3 Lw :ZE x\ �! » /$ \\r 2 co u > n � � G V ti o i C U Q N V1 N c (0 L 4� O v — t„ 4 � aJ 4 Y (3) c � U O v x 4m >, C 4- 4' O N o Q L O to c a O v •� � � � Y L � O (y N a� U Q 0) a; Q c N _0 ru v E m —C Q O c w v V O E Q° °�° v z � (� m V) w N � � O az x i c V O� L Ltl LL w T 4 a U1 N 0 7 Q .-a > z N O D p Of CL r.. H O � H s JON=: 3 � A "�W Mansfield Food Service List of Staff ServSafe Certified School Year2017-2018 Dawn M. Langtry — Food Service Director Mansfield High School Carol D'Ambra — Food Service Manager Thea Pesce —Senior Cook Deb Harney Carol Otto Krissy Schleicher Deb Cosgrove Qualters Middle School Brenda Cormier— Food Service Manager Anne Murphy — Senior Cook Charlotte Bliss Geraldine Curtin Jordan Jackson Diane Pennellatore—Food Service Manager Robin Nunes —Senior Cook Lisa Allen Robinson Barbara Palie — Food Service Manager Sheila DePalma —Senior Cook Marcie Jones Patricia McLoughlin Mansfield Board of Health Date Food Service Permit Fee for the following reason Thank you, ►tl'�ll-) request a waiver of the Signature Title