The URL can be used to link to this page

Home My WebLink AboutEdible Arrangements 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:. Whose place of business is: EDIBLE ARRANGEMENTS - 11TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: JOHN BARRY, OPERATOR Permit Expires: October 02, 2018 Food Fee: License Number: T-20 ilii/e1Ul2191 BOARD OF HEALTH Michae(McCCean, Chairman �1 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; 0"J 60c c:)d os,�� 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 3 5) Applicant/Owner Narne& Title: 1 6) Applicant/O 17�Acld,ess: 7) Applicant/Owner Telephone No: ? �6') , 2 3 8) Applicant/Owner Email address:/YIh S8 C"� 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: Telephone No: Fax: Emergency Telephone NO: 10) Event Attending Date(s): ZIT Event Name: Event Location:V' cc--� - Event time: 12) Solid waste disposal plan: 11) Check one ooAjruck �-Latergr--- Other: 13) Water Source: 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: 0"OLO �', , � C 0 V-Ij- 1� �4Q,v. , Food Protection Questionnaire for Catered Events Date of Event: /6/L9 / ! Location of Event: List all foods that you will be On ice/Refrigerated C1�oe a�;p�x�l Event Time: _ 2,202 holding, cooking, and/or re heating at the event location: Cooking Reheating Food Manager Certification Person Trained On Site? 'YT'Xes 0 No Allergen Awareness Menu Label Present? "es 0 No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: 1 ' �r 1 -!�j� L How will the PHF be kept at or below 41°F? How will the PHF be kept at or above 140°F? Time of PHP? Setup Served Removed TIC(- 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. 43'A 'yfit 6}4'tx-XC 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hot/ cold holding temperatures ) 9ffsite and held at proper hot/ 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: Food Safety Manager: Allergen Awareness:—A)14 18) For caterers: Cityrrown 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 obtsio 4—op`ios of 105 CMR 590.000 and the federal Food Code. 19) Signature of Applica 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: L47- /4 t4 ,, 7/ ? 21) Signature of Individual or Corporate Name: trainingPlease include copies of ServeSafe and Allergen certificates 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. of In ividual or Corporate Name By: Corporate Office (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number "y =17MIS-77TtIT isslie ess Ir by 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:\Usccalsleile\Deskbp\Scull's Documcros\pool Gslublislnnenls-'Temp\TAX CER "I'IPICA] ION FOltbl.Joe Deparinteul of Iitdush•ia1 Accidents Office of Investigations 600 Washington Street Boston, MA 02111 tvtvtv.nrnss.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please PPint Lceibly / Business/Organization Name: �E M %1 , s 5 a �ttc_ p f 5,,V We A f, -,,w,,,6.4 w -, Address. /C�l n x%2ur L� j ,, , L ,F& /114, L) O L 5i- City/State/Zip: i-City/State/Zip: Phone #: Are you an employer? Check the appropriate box: I. I 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 it corporation and its officers have exercised their right of exemption per c. 152, § )(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.] Business Type (required): 5. Retail -6. Restaurant/Bar/Eating Establishment 7. Office and/or Sales (incl. real estate, ,into, etc.) 8. Non-profit 9. Entertainment 10. Manufacturing 11. Health Care Any applicant that checks box # 1 mist also fill out the section below showing their wofkcrs' compensation policy infomm�ion. *If Ilse corporole officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. ata an eneployer flat is pro'itling workers' compensation iw.sarotce for tety eatployees. Below is the policy infortu(tliot. nsurance Company Name: —YA usurer's Address: 3.��_j?tt-7,c)-�rl J ((-o 'ily/Slate/Zip:i 'olicy # or Self -ins. Lic. # 76 y 6 2G y 3 Expiration Date: jgW*- Witch a copy of the workers' compensation policy declaration page (showing the policy ntunber and expiration (late). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a lite 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 if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of uvestigations of the DIA for insurance coverage verification, do hereby c�erWfyan72 r lite pains ani penalties of perjury that the information provider/ above is true and correct. hone #: y a5 �969 t/43 Official use only. Do not write in this area, to be contpteled by city or toren official. 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 6. Other Phone urrw.nmss.gov/din (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: The Twin City Fire Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 14974 Company Code: 7 Suffix LARS RENEWAL POLICY NUMBER: 76 WEG NG9633 Previous Policy Number: 76 WEG NG9633 1. Named Insured and Mailing Address: MJM ENTERPRISES INC (No., Street, Town, State, Zip Code) 375 CENTRAL ST FOXBORO MA 02035 FEIN Number: 20-5658561 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Florists Other workplaces not shown above: 2. Policy Period: From 10/02/18 To 10/02/19" ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY 71 HANOVER ROAD FLORHAM PARK NJ 07932 Producer's Code: 76250717 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 !8771287-1316 Total Estimated Annual Premium: $1,767 Deposit Premium: Policy Minimum Premium: $288 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: The policy is not binding unless countersigned by our authorized representative. Countersigned by C"� �' 08/23/18 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 08/23/18 Policy Expiration Dater 10/02/19 Z 0 LAWa low ce W U rl .'Q N c w M <4 xi w o j w,.p a ` 7 \\ CEO /\ § � \ k , P 4 ; ) LL §\ )} 0 k= Mansfield Board of Health Request for Fee Waiver for Food Permit Date `� .dy //8 We, urant/ 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: 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, gnature Title%—° *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: