HomeMy WebLinkAboutMansfield Cultural Council 7/10/2018Commonwealth 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: STREET FAIR - FAMILY FUN NIGHT
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:
MANSFIELD LOCAL CULTURAL COUNCIL - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
LISA PISCATELLI, CHAIR
Permit Expires: July 10, 2018
Food Fee.
License Number: FFN-14
WAIVED
BOARD OF HEALTH
MichaeCMcCCean, Chairman
A
FOR BOARD OF HEALTH USE ONLY
Date Received Permit Fee
Approved By
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Permit # Issued
Temporary Food Establishment Permit ppJjFvat,&n
(Application must be submitted at least 7 business days before f `e panneop d eningdgte)
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1) Establishment Name: 6 JUL0 f' rat
2) Establishment Address:
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
5) Applicant/Owner Name & Title: n 2t-f'C S�Qt� 17I Prn der Nl ans�-''IN�d�QCp.I (.t�f/'+LOu�iG�
6) Applicant/Owner Address:
7)Applicant/OwnerTelephone No: S6 S_ azlf��.
6) Applicant/Owner Email address: C�// $ap I s
9) Person Directly Responsible For Onsite Operations: ( S
Name &Title:
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Address:
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Telephone No:
Fax:
Emergency Telephone No:
10) Event Attending
Date(s):
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Event Name:
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Event Location:
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Event time:
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11) Check one
❑ Food Truck
❑ caterer/
V Other: ✓eGak 4�C.{-lq(
12) Solid waste disposal plan:
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13) Water Source:
14) Sewage disposal plan:
15 ) Please give a brief description of the food to be served:
Tnd;v;d"a/fl A)raz lied `�eo-rty Bandy �� Ssorfed lavors
16 ) Food will be prepared:
Onsite for immediate consumption
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
❑ 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 Cr 590.000 and the fede�Code.
19) Signature of Applicant: !in(�t.�t Y/�Lp/W - 701
aK s-p-; e jd /,Ocal (24
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: IVA
21) Signature of Individual or Corporate Name:�K�f-cam
Food Protection Questionnaire for Catered Events
Date of Event:
Location of Event:
Event Time:
List all foods that you will be chilling, holding, cooking, and/or re heating at tl event location:
On ice/Refrigerated Cooking eheating
Food Manager Certification Person Trained On Site?
Allergen Awareness Menu Label Present?
List all Potentially Hazardous Food (PHF) and
❑ Yes ❑ No
❑ Yes ❑ No
intended temperature required:
List the required temperatureZeac as it leaves your preparation site:
How will the PHF be
How will the PHF be
Time of PHF? Setup
List all equipment
thermometers, cle;
At or below 41 °F?
at or above 140°F?
Served
Removed
will be supplied for an event, including but not limited to food
Wipes, utensils, non latex gloves, heating utensils, ice etc.
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
"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 IndustriabAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information
Please Print Lelfibly
]lusiness/Organization Name:
11� o r, - ". e . � J� 0 c 0:
y
f' v ( 0 r1,
I (l /� v n c t.
Address: P',
City/State/Zip: r S€ h
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2. ❑ I 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
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.]
Phone #:.•
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.❑ Other
*Any applicant that checks box #1 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.
lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie.
Expiration
Attach 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 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, under thepains andpenalties ofperjuty that the information provided above is true and correct
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 5. Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/dia
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date ? 1"n [ I i 1
Y
We, Y' a/i-s f; C,i j l- 0(4 C u11 ' / I (restaurant/ 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: M4flsC'('f d 10 Ii I U/ 11 !v' I C'�91�.�t:
❑ 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:
Thank you,1.
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date: