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HomeMy WebLinkAboutSamburis 04/22/2018Commonwealth. 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:. ROTA MICKUNAS Whose place of business is: SAMBURIS, LITHUANIAN FOLK DANCE GROUP OF GREATER BOSTON - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE: RUTA MICKUNAS, PRESIDENT Permit Expires: April 22, 2018 Food Fee: $75.00 License Number: NEFFA-6 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued NEFFA-6 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name SAMBURIS, LITHUANIAN FOLK DANCE GROUP OF GREATER BOSTON - NEFFA 2) Establishment Address MANSFIELD SCHOOL COMPLEX - EAST STREET 3) Establishment Mailing Address (if different) 12 VISTA CIRCLE CENTERVILLE, MA 02632 ( �� 4) Establishment Telephone No (508) 736-6244 ------------ 5) Applicant Name & Title: RUTA MICKUNAS, PRESIDENT 6) Applicant Address 12 VISTA CIRCLE, CENTERVILLE, MA 02632 7) Applicant Telephone No.: 808-736.6244 24 Hour Emergency No.: 508-736-6244 '8) Owners Name & Title RUTA MICKUNAS 9) Owner Address (If different from applicant) 12 VISTA CIRCLE, CENTERVILLE, MA 02632 Owner's telephone number 5087366244 10) Establishment Owned By: ❑ An Association ❑ A Corporation ❑ An Individual ❑ A Partnership R Other leoal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: RUTA MICKUNAS, PRESIDENT Address: 12 VISTA CIRCLE, CENTERVILLE, MA 02632 Telephone No: (508) 735-6244 24 Hour Emergency No: 508.735.6244 FAX: E-mail: RUTAMICK@_YAHOO.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 16) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (if applicable) 16) No. of Food Employees: 17) DAYS/HOURS: Y Ii a aol? — d1Q 2 Q ( g 18) Name of Person In Charge Certified in Food Protection Management: AUDRA VEITAS AVIZONIS If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 /n accordance with 105 CMR 590.003(A) Please attach copy of TADAS DILBA certificate 19) Person Trained In Anti -Choking Procedures (11`25 Seats or more): ❑ 20) Location: ❑ Permanent Location Y2) Establishment Type ❑ Caterer $25.00 ❑ Mobile Mobile Start Dale: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Date: ❑ Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 ❑ Food service up to 101 -200 ❑ Manufacture Frozen Dessertshce Cream $25.00/freezer _ 21) Length of Permit: ❑ Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ pushcart $25.00 # of Pushcarts: ❑ Residential Kitchen $100.00 E] Retail Food $700.00 ❑ Seasonal Seasonal Dates: E] Food Service - Institution ❑ Retail Snack Food $25.00 © Temporary Temporary Start Date: 4/20/2018 ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: 4/22/2018 Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions:PHF -Potentially hazardous food(IlmaAamperature controls required) Non-PHFs - non -potentially hazardous food(no limedemperature controls required) RTE - ready-to-eal foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PHFs © PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service_ ❑ Sale of Commercially Pre -Packaged PHFs E] Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs ❑ ry 9 Sale of Raw Animal Foods Intended F1E] to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours C]Vacuum Packaging / Cook Chill ❑ Use of Process Requiring di Variance and/or HACCP Plan (Including bare hand contact alternative, time as a public health control) ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ----------- -- E] lee Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin SPECIALTY LITHUANIAN FOODS & CAKES ❑ Prepares ventsFood/SingleIns Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $75.00 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the Information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.00D and all other applicable law. I have been Instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. 24) 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. 26) Social Security Number or Federal ID: 04-2743412 r 26) Signature of Individual or Corporate Name: 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. Signature of Individual or Corporate Name 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.-\HIthVme's Doo=onts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth ofAfassachuselts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERM TTING AUTHORITY. AlppHeant Information Please Print Legibly Business/Organization Name: SaMV--ul-iS Li4huctrhicin ro�k� Zcmcf?..GfOV�O-q ka city/statD/Zip: Are you an employer? Check the appropriate box: L ❑ I am a employer with employees (full and/ or part-time).* 2,0 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 f no employees, [No workers' comp, insurance required]4 4, I]( PJc are anon -profit organization, staffbd by volunteers, `with no employees. [No workers' comp, insaranceroq,] MA OQG 6"08 - 735- (aA/Aj Business Type (required): 5. Q Retail 6. QRestauranliBufflatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11. ❑ Health Cara 12,❑ Other tAny appliomt that checks box #1 must also fill out the section bolow showing thcirwaTktm' compensation policy Information• ttEtbe corporate offieera have exempted fhcroselyes, but the corporation has other cmploytes, a workers' compoasation poBcy Is rcquhed and such an urgsnization should check box''#l. [on an employer rhat is provlding workers' compensadon tnsurance for my employees• Betow U the policy informafior . Insurance Company Name: Insurer's City/State/zip: Policy # or Self -ins, Lic. #• Expiration Date: Aftaeb a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required 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 imprisonmea% 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 this copy of this statement may be forwarded to the Office of investigations of the DL4 for insurance coverage verification, [do hereby certify, und/eerr�the pains andpenaliies ofperjury thatthe inforntation provided above is fru/e/ and correct. Sinnature: �`��t�-S,f/7L.Oa�s Date: ell 7<a 50�3 - -735 6az/ 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 Clerk 4, Licensing Board S. Selectmen's Office 6. Other Contact Person: Phone#: Gcen4ev QosAvo Mi M z O W W X w MOO WK, w H W U 0 z *04z H Un W z !4 r Z W O"..u. O CL)N Z Q U q