HomeMy WebLinkAboutThe Downtown 10/02/2018Commonwealth 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: TEMPORARY FOOD PERMIT
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:.
RALPH LAVOIE
Whose place of business is:
THE DOWNTOWN 11TH ANNUAL TRI-TOWN CHAMBER FOOD TASTING @ THE
XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
BETH STENTIFORD, KITCHEN MANAGER
Permit Expires: October 02, 2018
Food Fee:
License Number: T-3
BOARD OF HEALTH
'MichaeCAcCCean, Chairman
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F--Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name:. �
2) Establishment Address:
3j Establishment Mailing Address (if different):
4) Establishment Telephone No: :3
51 Applicant/Owner Name & Title:
6) Applicant/Owner Address:
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7) Applicant/Owner Telephone No:
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8) ApplicantlOwner Email address: r1 Gi 6,10 i, ,
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9) Person Directly Responsible For Onsite Operations:'
Name & Title:
Address:
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Telephone No:
_
�.1 '-'zC-4F I 3 Z Cs Fax:
Emergency Telephone No:.
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10) Event Attending
Date(s):
Event Name:
Event Location:
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Event time:
11) Check one
posal plan:
Food Truck
Caterer
Other:
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13) Water Source: plan:
15 ) Please give a brief description of the food to be served:
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Date of Event: I / �� Event Time: J
Location of Event: A 1 1 V1 /Z %2�j 7c�-Y7'�ff�/
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated
Cooking
Food Manager Certification Person Trained On Site?
9,'Ves
Allergen Awareness Menu Label Present? Wres
Reheating
Ie
Q No
Q No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
165
List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below
41°F?
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How will the PHF be kept at or above
140°F?
Time of PHF? Setup erved
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List all equipment that will be supplied for an event, including but not limited to food thermometers,
cleaning wipes, utensils, non latex gloves, heating utensils, ice etc.
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Food will be prepared: .
--
Onsite for immediate consumption
Onsite and held at proper hot/ cold holding
temperatures Offsite and held at proper hot/ cold
holding temperatures Offsite, cooled and reheated
on site Other:
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17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
Food Safety Manager: /,J/'NY'vi,� {7�y1 U� /N/�/�71t._
Allergen Awareness: _ �/nnh
10) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the permits:
I, the undersigned, attest to the accuracy of the information provided in this application and I 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 CIA590.000,and the fe0eral Food Code.
19) 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 gaid state taxes required under law. 20)
C
Social Security Number or Federal ID: / j j j j
21) Signature of Individual or Corporate Name:
copies* Please include of
ServeSafe and Allergen
certificatestraining
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.
4'1 _q/
iofd' (dual or Corporate Name
1/7-13`//L35-
"*Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*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.
C:\Users\sleile\Desktop\Stows Documents\Food Est,•Iblishnsnts-TempCTAX CERTIFICATION FORM.doc
Department of I/ldlrstr'ial Accidents
Office of Investigations 600 Wasilillgto/1
UV Sheet Boston, MA 02111 tvtvtP.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
_Applicant Information Please
Print Leeib►y
Business/Organization Name:
Address:
Sk
Are you an employer? Check the appropriate box:
1. 1 am a employer with % employees (full and/
or part-time).*
2. 1 am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]** 4.
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
Phone
Business Type (required):
S. Retail
6. Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. Entertainment
10. Manufacturing
11. Health Care
Any applicmll that checks box 91 must also fill out the section below showing their workers compensation policy mrormation.
rtg*If ate corporate officers have exempted themselves, but the coryordion has other employees, a workers' compensation policy is required and such an
mtizalion should check box NI.
alit all employer that Is provi(liitg workers' contpenstaion insurance for tity employees. Below is the policy iitforntation.
nsurance Company
usurer's
'ity/State/Zip:
'olicy # or Self -ins. Lic. # S,)6 3 i j (j 7 �� — f _ e/
�x-Expiration Date: --/0
kttach a copy of the workers' compensation policy declaration page (showing file policy number and expiration (late).
?allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
)f tip to $250.00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
do hereby certify, under Ibe pains rind penaltiess of peijiny that the information provided above is titre and correct.
-,:�- � , - Late: � -� y—✓�.
(3(l
[0f_f,ek,,.1,use only. Do not write in Ibis arert, to be completed by city or town offtciot.
ity oown: _ Permit/License #
Issuing Authority (circle ate):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5, Selectmen's Office
6. Other
Persmi
www.nmss.gov/dia
Phone
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The Commonwealth of Massachusetts
DEPARTMENT F INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017
617-727-4900 — http:llwww.state.ma.usldia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES.
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
UB-3J073288-18-42-G
POLICY NUMBER
ESTABROOK & CHAMBERLAIN
PO BOX 277
BRIDGEWATER, MA 02324-0277
07-10-18 TO 07-10-19....
EFFECTIVE DATES
NAME OF INSURANCE AGENT ADDRESS PHONE# 0
THE DOWNTOWN 292 W MAIN ST
292 LME INC'DBA NORTON
MA 02766
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL
ADDRESS
002666 W20P1G15 TO BE POSTED BY EMPLOYER
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Mansfield Board of Health Request for
Fee Waiver for Food Permit
Date c / 1
We, 77tle / Jaya
organization )
request a waiver of the Food Service Permit Fee for the following reason:
This is a request from a town department.
Please list the department: Qhctmrr'- up cwwt�f7e�
We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
We are donating ALL proceeds earned directly to a 501(c)(3) organization.
Please list the organization:
for food/drink being served.
We are a religious organization.
Other: The Taste of the Tri-Town
Thank you,
Signature
b(
Title
*Please provide proof of valid 501(c)(3) status
We are not charging a fee
F
Only
oved
ed Reason: Date: