HomeMy WebLinkAboutGourmet Bae Catering 10/02/2018Commonwealth 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: 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:.
BAILEY REYNOLDS
Whose place of business is:
GOURMET BAE CATERING, LLC - 11TH ANNUAL TRI -TOWN CHAMBER FOOD
TASTING @ THE XFINITY CENTER
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
BAILEY REYNOLDS
Permit Expires: October 02, 2018
Food Fee:
License Number: T-76
ViG E
BOARD OF HEALTH
MichaeCMCCCean, Chairman
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Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned openip date),
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1) Establishment Name: h �V 11 21M
2) Establishment Address:
3) Establishment Mailing Address (if different): 3-39 2- '
(IK4 03 It
4) Establishment Telephone No: (oZZ' 5, 2 -2S Z
5) Applicant/Owner Name & Title:
6) ApplicantlOwnerAddress:
7) Applicant/Owner Telephone No:4 )Y 2, S 15 3 (
8) Applicant/Owner Email address: ( (efrw IrctA --\
9) Person Directly Responsible For Onsite Operations:
Name & Title:
— c ^<, -
Address:
Telephone No:
A/ Fax:
Emergency Telephone No:
10) Event Attending
Date(s):
Event Name:
""
Event Location:,`
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Event time:
11) Check one
12) Solid waste disposal plan:
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Foq,d Truck
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13) Water Source: MV 7C;WXlei
14) Sewage disposal plan:
15 ) Please give a brief description of the food to be served:
s, 4nrO 4 t,\, Y\vfi t
16 ) Food will be prepared:
Onsite for immediate consumption
-40nsite and held at proper hot/ cold holding
temperatures Offsite and held at proper hoU cold
holding temperatures Offsite, cooled and reheated
on site Other:
17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates: ?I-
Food Safety Manager:
F Av\ zee,4L�
Allergen Awareness: 1"ly ' a I "I
18) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit:
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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 obtainc9pies of 105 CMR 590.000 an4the federal 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 paid state taxes required under law. 20)
Social Security Number or Federal ID: O t ` :�111#!�
21) Signature of Individual or Corporate Name:
Please Include copies of
ServeSafe and Allergen
training certificates
Print Legibly
Department of lndnsb'inl Accidents
Office of htves'tigations 600 Wit.0higton
Sheet Boston, NLA 02111 wit,minoss.gon/dio
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please
Business/Organization Name:
Address:
Are you an employer? Check the appropriate box:
I. 1 am it employer with employees (Pull and/
or part-time)."
2. 1 am it sole proprietor or partnership and have no
employees working forme 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' com]). insurance required]** 4.
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #: 5C?x'_ (s 17. -
Business Type (required):
5. Retail
11 1
6.—) Restaurant/Bar/Eating Establishment
7. Office and/or Sales (incl. real estate, auto, etc.)
8. No-prolit
9. Entertainment
10. Manufacturing
It. Health Care
Any applicant that checks box 111 must also lit out the section belmw showing IIle ir workers' compensation policy information.
-I ['tile corporate officers have exemplet] themselves, but the corporation hors other employees, it workers' conipcnsulion policy is required and such an
rganizalion should check box 01,
aui nn eniplgrer fhnl is provirlifrg uvol-kers' couipeit.satimi in.surrrnrce foi' n0, ereiplgyees. Belou, is Nte police infi)rrrin(ion.
_—
nsurer's
'ity/State/Zip:
'olicy 11 or Self -ins. Lia 11
Expiration Date:
4ttach it copy of the workers' compensation policy declaration page (showing the policy number and expiration (late).
'ailure 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 tine
if up to $250.00 a day against the violator. Be advised that it copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
rto hereby ceriifp, under ane pains and penatNes g1'peijurd, that the iglirrnmtion provided above is five mud correct.
0111cial use onhr. Do not tvrife in Ihir area, to be completed hl' cite' or lorou q%Jicittl.
City or Town:
Permit/License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
G. Other --
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Mansfield Board of Health Request for
Fee Waiver for Food Permit
Date G /--w
►fis
rant/ 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: &xuo 1 46t)"L
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:
We are not charging a fee
for food/drink being served.
We are a religious organization.
Other: The Taste of the Tri -Town
Thank you,
J
Sign#e
Ck, 222
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date: