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Home My WebLink AboutNevas NE Vintage Arts 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:. CATHERINE BISHOP Whose place of business is: NEVAS NEW ENGLAND VINTAGE ARTS SOCIETY - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: JOHN BURROWS Permit Expires: April 22, 2018 Food Fee: $75.00 License Number: NEFFA-12 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Temporary Food Establishment Permit Application 1) Establishment Name: NCLIA,5 A,dy G lv 444LA9 VlArz--4- "�.5-�C>GC,!5 r 2) Establishment Address: r6 ,a, +r% c! 5 _323 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: J.As�..�c�-'�� t .._ m� 5) ApplicanUOwner Name &Title: -"� 6) Applicant/Owner Address: SZ3 amcou r-5- 2c) 69�,3 Z6 7) Applicant/Owner Telephone No: 8) ApplicanUOwner Email address:` o �t n C� �u.F•!'cJvvS� 9) Person Directly Responsible For Onsite Operations: Name & Title: � � A) , (� 4aa4"fS Address: / q Telephone No: 7W J'$-z-Fax: 51e`y2 16a6- Emergency Telephone No: 7yl - 2�� 10) Event Attending Date(s): 20 2-1' Z Event Name: ,N ��gl �'6,4,vo Fa"L.k- 7-1 v,-Fe_ Event Location: ��7y ,( ,00, '_ CA4P rL, Event time: � 00 %'i-r't1 `ru /o, of GoN) S'�Gritt6Li%"i �-'CV,evN-,5'00 Psi! S'u 11) Check one ❑ Food Truck 4Wi Caterer pp jc Other: )%G"g: v4yv '6'YZ. 12) Solid waste disposal plan: 13) Water Source: Sal 14) Sewage disposal plan: Pan 5-ce( 15 ) Please give a brief description of the food to be served: $ %GdM�4' O-s"er�a/�, cYiy e_-4ct-' C3d,'Y�'—� GUGb f !3lv7' �i�� .:1'e.dlL�'G'iW t3d'r'7"C�3� %A Food Protection Questionnaire for Catered Events Date of Event: d l/ , 2-11 Z Event Time: Location of Event: G Y� Y7 sInJD_� List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating 7"utee rvl�rr� ��s 7ovcr9'1a tr✓ c wr6r�u4c <f2UPUPW. i,�i ,�unai�ry Food Manager Certification Person Trained On Site? Nyes ❑ No Allergen Awareness Menu Label Present? ,�SeYes ❑ 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: How will the PHF be kept at or below 41 °F? How will the PHF be kept at or above 140°F? Time of PHF? Setup Served Removed 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. rclov sLfzyy , y-s ?64- P T'a-C.5 Nl�uersd4 .sc-YZWAI; 72aYS sit s cscrri�r, E R94 - -a��r �ca�aS Cr�.a3.2a� S 16 ) Food will be prepared: ❑ Onsite for immediate consumption X 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: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: ❑ Food Safety Manager: u Allergen Awareness: 18) 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 CIVP 590.000 and the 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:�`/ �� 21) Signature of Individual or Corporate Name: !"G 4-5 �� J// Cj 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. ature of Individual or Corporate Name "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\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U1V www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Or�gaanizationName: Address: - City/State/Zip: kOCK L-^44-% 1('V 0Z'YAi Phone #: 75'1- `M? - /9/Z Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. . ✓ [No workers' comp. insurance required] 8. IRNon-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing 4. �no employees. [No workers' comp. insurance requh•ed]* We are a non-profit organization, staffed by volunteers, 11.❑ alth Care with no employees. [No workers' comp. insurance req.] 12. Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. #_ Attach a copy of the workers' Expiration Date: information. policy declaration page (showing the policy number and expiration date). Failure to secure coverage as regtt red 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 one-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 coverage verification. I do hereby certify, und;Pdae pg#A and pent jties ofperjury that the information provided above is true and correct. 12 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6.Other Contact Phone www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents I Congress St'ee4 Suite 100 Boston, MA 02114-2017 wwwmass,gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Business/Organization Are you an employer? Check the appropriate box: 1, ❑ I am a employer with employees (full and/ or part-time),* 21® I am a sole proprietor or partnership and have no employees working formo in any capacity, [No workers' comp. insurance required] 3, ❑ We are a corporation end its officers havo exercised their right of exemption per e. 152, § 1(4), and we have ,�, y�o employees. [No workers' comp, insurance required]' 4. EV We are a con-proft organizadon, staffed by volunteers, with no employees. (No workers' comp, insurance roq,] cL Business Type (required): 5. ❑ Retail 6. []Rmtaumnt/Bar/Befing Establishment 7. Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9, [] Eatertainment lo. ❑ Manufacturing' p th 12.0ther Car�O YIC� ql r•'"""' aorporeie officers hive czemplrA Ihcroselvcs, but the wrporatioo hss othu employees, a workcn' wmpcnsation poUcy R required and such an lion should check box'M. f on an employer that is providing workers' compensation Insurance for my Insurance Company Insurer's the policy information.. Policy # or Self -ins. Lin, #• Expiration Date; Attach a copy of the workers' compgal6ion policy declaration page (showing the policy number and expiration date). Failure to secure covemgo as r red 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 o year imprisonment, as well as civil penalties in the form of a STOP WORK ORDBR and a fmo 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 oov'excrifioation. _.. t do �iav Official use only, Do not writel in this area, to be completed by city or town official, City or Town: Permit/Licease is r�eeaml correct ,2& 18 Issuing Aathority(circle one); I. Board of Health 2. Buliding Department 3. City/Town Clerk 4. Licensing Board 5, Selectmen's Office 6. Other Contact Person; Phone 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.\Hm1th\Jm&s Dm==ts\PERMrr APPLICATIONSUAx CPPOWICATION FORM.doc x w W `s r z 0CL Cn U no W U w H W U V z ►--.4 z kgo rV JJ V J W z w 3 z rW V W O U Qi N U O N � N O ti � .0 0 •a Q� P� � U ,hx4i y o 0 � z A Q ��x o v 4 Q w Zi H ry ti y �' C, Z 0 LLM to oOO W V