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Home My WebLink AboutLavender Country/Folk Dancers 4/22/2018Commonwealth 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 - NEFFA 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:. CHRISTOPHER RICCIOTTI Whose place of business is: LAVENDER COUNTRY & FOLK DANCERS - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: CHRIS RICCIOTTI Permit Expires: April 22, 2018 Food Fee: $75.00 License Number: NEFFA-9 BOARD OF HEALTH MichaeCAcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit#lssued NEFFA-9 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name LAVENDER COUNTRY & FOLK DANCERS - NEFFA 2) Establishment Address MANSFIELD SCHOOL COMPLEX - EAST STREET 3) Establishment Mailing Address (if different) 393 UNION STREET ROCKLAND, MA 02370-1729 4) Establishment Telephone No (339) 204-7644 ---- --- - --- ------ 5) Applicant Name & Title: CHRISTOPHER RICCIOTTI, FOOD BOOTH MANAGER 6) Applicant Address 393 UNION STREET, ROCKLAND, MA 02370-1729 7) Applicant Telephone No.: (339) 204-7644 24 Hour Emergency No.: (339) 204-7644 8) Owners Name & Title CHRISTOPHER RICCIOTTI 9) Owner Address (If different from applicant) 393 UNION STREET, ROCKLAND, MA 02370-1729 Owner's telephone number 3392047644 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. i A Corporation V] An Individual Name Title Address ---------- -- A Partnership FJ Other legal 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CHRIS RICCIOTTI Address: 393 UNION STREET, ROCKLAND, MA 02370-1729 Telephone No: (339) 204-7644 24 Hour Emergency No: (339)204-7644 FAX: (781) 982-1836 E-mail: RICCIOTTI(a)AOL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) F_ N a I me& Title Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No (If appllcab > L16) No. of Food Employees: 40 VOLUNTEE 17) DAYSIHOURS: p,� --_ _ ---� GPI I�PK<, ��s�"9�- 18) Name of Person In Charge Certified in Food Protection Managerrent: CHRIS RICCIOTTI 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 SAMUEL ARFER certificate HARRY KELLOWAY 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more) L] --- l 20) Location: P Permanent LocatioqD1 22) Establishment Type �[� Caterer $25 00 I! Mobile Mobile Stan Date: Location Retail ( Sq. Ft) !I �_j Milk & Cream $10,00 Mobile End Dale: 1 Mobile Comments: 21) Length of Permit: 1 , Annual I j Seasonal Seasonal Dates: 4WI Temporary Temporary Start Date Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (,(Check all that apply): Food Service up to 100 or up to 10' PHF display $125.00 .1 Food Service up to 101 -200 or up to 25' PHF display $160,00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 Food Service - Institution 412012018 ( Meals/pay) 4/22/2018 ❑ Mobile Food & Consession $75.00 1-) Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: Residential Kitchen $100.00 ❑ Retail Food $100.00 Retail Snack Food $25.00 n Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (tlme/lemperature controls required) Non-PHFs - non-potontfally hazardous food(no timeRemperature controls required) RTE- ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs [] Delivery of Packaged PHFs I -! Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only JI Preparation of Non-PHFs Other Food Operations I, the undersigned, attest to the accuracy of the Infor establishment operation will comp) i 105 CMR 5 board of health on how to obtain, op slof 105 CMR 24) Signature of Applicant.�_�w Pursuant to MGL Ch.62C, sec. 4 A, I certify under the and paid stale taxes required under law. 26) Social Security Number or Federal ID: 038-40.22 26) Signature of Individual or Corporate Name: — ❑ PHFCooked To Order 'reparation of PHFs For Hot And 'Old Holding For Single Meal Service 'ale of Raw Animal Foods Intended to be Prepared by Consumer Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility L] vacuum Packaging / Cook Chill ---- --I ❑ Use of Process Requiring A Variance [ j Customer Self -Service and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale _ control) - - -- r] Juice Manufactured and Packaged for I� Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers ATE PHF in Bulk Quantities �] 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 that I, to my r _ , Total Permit Fee: $76.00 Payment is due with application l] waived and affirm that the food '. I have been instructed by the filed all state tax returns a 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. By: Corporate Officer (Mandatory, if Applicable) **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:Vffmlth\J nC's D0Q=enls\PERMIT APPLICATIONSWAX CERTIFICATION FORM.doo The Commonwealth of Massachusetts Department oflndustrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insarance Affidavit: General Businesses. TO BE FILED WITH THE PERIYIITTING AUTHORITY. Business/Organization Are you an employer? Check the appropriate box: 1, ❑ I am a employer with employees (full and/ or part-time).* 2, ❑ lam 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 4. Do employees• [No Workers' comp, insurance required]' We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] ME ,t Business Type (required): 5. ❑Retail 6. ❑Restaurant/BarBating Establishment 7. Q Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment 10. ❑ Manufacturing 11.,❑, Ikalth Cares 12,Vother lib k rr—e j9.G j *Any applicant that checks box#1 must also fill out the section below ahuwing their workers' compensation policy lofmmatiou. `•--t **If fhc corporate officers have excmpled thenaclVcs, but the corporation hu other employers, a workers' compensation policy is required and such so organization should checkbox#I., f ain an employer that is providing workers' compensation insurance for my Insurance Company insurer's City/State/Zip: the policy information. Policy# or Self -ins, Lie. #- Expiration Date: Attach a copy of the workers' compslaglakil policy declaration page (showing the policy number and expiration date). Failure to Secure coverage as r ed under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a fine up to $1,500,00 and/or r -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cover�g�8on, fdo hereby ce r the Sim phone#: 1 Official use only. Do not r City or Town: that the this area, to be completed by city or town officiaL Permit/License is $ue and correct Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other ContactPersan: wvnt'.mass.gov/din z 0 U U w LL ry W Z) rQ MJ Q a4 z 0 a V LL. E— Cie W V V z *NffiI z F-� W z vi .o rl N O O *., N N U N � � goo 0 U O y 0 z Q Q N Wj