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HomeMy WebLinkAboutStrawberry Fields 7/27/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: XFINITY 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:, IAe1 WA 3111101 IN.1 Whose place of business is: STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 855 SOUTH MAIN STREET PERSON(S) IN CHARGE: LARY BUDNICK, PRESIDENT Permit Expires: July 27, 2018 Food Fee: $25.00 License Number: XT -11 BOARD OF HEALTH .Michael .McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit#Issued XT -11 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 2) Establishment Address 855 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 1316 MADISON STREET HOLLYWOOD, FL, 33019 4) Establishment Telephone No (9 54) 347-6747 5) Applicant Name & Title: LARY BUDNICK 6) Applicant Address 1316 MADISON STREET, HOLLYWOOD, FL. 33019 7) Applicant Telephone No.: (964) 347-6747 24 Hour Emergency No.: (954) 341-6747 8) Owners Name & Title LARY BUDNICK 9) Owner Address (If different from applicant) 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Owner's telephone number 9543476747 10) Establishment Owned By: r 11) If a corporation or partnership give name, title, and home address of officers J An Association or partner. ri A Corporation Name Title Address 'An Individual A Partnership Other legal Entity. —_. _ -- --- - -_-_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (LARY BUDNICK, PRESIDENT - Address: Telephone No: FAX: E-mail: - 16 MADISON STREET, HOLLYWOOD, FL. 33019 347-6747 923-9873 24 Hour Emergency No: (,954)347-6747 Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: (LARY BUDNICK Address: 11316 MADISON STREET, HOLLYWOOD, FL. 33019 Telephone No (954) 347-6747 24 Hour Emergency No: (954) 347.6747 E -mall• LARY@STRAWBERRYFIELOSINC.COM FAX: I (954) 923-9873 Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: I DEP Public Water Supply No (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 1 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. 'Required as of 1011/2001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seals or more): i 20) Location: I I Permanent Location 22) Establishment Type Mobile Mobile Start Date: !-I Retail ( Sq Ft) Mobile End Dale: Mobile Comments: 21) Length of Permit: 1-- 1 Annual Seasonal Seasonal Dales: _ I Temporary Temporary Start Date: Temporary End Date: Temporary Time: L_. [_J Food Service up to 100 or up to 10' PHF display $125.00 [] Food Service up to 101 -200 or up to 25' PHF display $150.00 [l Food Service up to 201 + or 25'+ PHF display $275.00 [] Food Service - Institution ( Meals/Day) I-] Caterer $25.00 1- Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Dessertslice Cream $25.00/freezer ushcart $25.00 If of Pushcarts: ❑ Residential Kitchen $100.00 U Retail Food $100.00 F Retail Snack Food $25.00 [r] Tobacco Products $25.00 Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food ffime/lemperature controls required) Non-PHFs - non -potentially hazardous food(no timelhunperature controls required) (Check all that apply): RTE- ready -lo -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 1 f Sale of Commercially Pre -Packaged Non-PHFs �I__ j Sale of Commercially Pre -Packaged PHFs j Delivery of Packaged PHFs j Reheating of Commercially i Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only i 9 Preparation of Non-PHFs Other Food Operations PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ,old Holding For Single Meal Service I U PHF and RTE Foods Prepared For Highly -- -- SuscaphbIs Population Facility Tale of Raw Animal Foods Intended to be Prepared by Consumer I El Vacuum Packaging I Cook Chill or Reconditioned Tobe completed by the Board of Health Total Permit Fee: 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 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 1,05 C1 4g 590.000 andJhFQederal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I certifyr the penallies of perjury that I, to my best knowledge and belief, have filed all state lax returns and paid slate taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporal e Name: D Use of Process Requiring A Variance Customer Self -Service andlor HACCP Plan (including bare hand Fj Ice Manufactured and Packaged for contact alternative, time as a public health Retell Sala control) I] Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin IL I Offers RTE PHF in Bulk Quantities t1 Prepares Food/Single Meals for Catered Events or Institutional Food Service —_-_ _ or Reconditioned Tobe completed by the Board of Health Total Permit Fee: 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 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 1,05 C1 4g 590.000 andJhFQederal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I certifyr the penallies of perjury that I, to my best knowledge and belief, have filed all state lax returns and paid slate taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporal e Name: Commonwealth 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: XFINITY 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:. LARY BUDNICK Whose place of business is: STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: LARY BUDNICK, PRESIDENT Permit Expires: ,July 27, 2018 Food Fee: $25.00 License Number: XT -10 BOARD OF HEALTH Michae[McCtean, Chairman FOR BOARD OF HEALTH USE ONLY Permlt # Issued XT -10 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 1316 MADISON STREET HOLLYWOOD, FL.33019 4) Establishment Telephone No (954) 347.6747 5) Applicant Name & Title: LARY BUDNICK, OWNER 6) Applicant Address 1316 MADISON STREET, HOLLYWOOD, FL. 33019 7) Applicant Telephone No.: (954) 347-6747 24 Hour Emergency No (954) 3476747 8) Owners Name & Title LARY BUDNICK 9) Owner Address (If different from applicant) 1316 MADISON STREET, HOLLYWOOD, FL 33019 Owner's telephone number 9543476747 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ,, An Association or partner. ii A Corporation Name Title Address An Individual— A Partnership ;_Okhe[ leg-al-Entity- 12) lEntity_12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ILARY BUDNICK, PRESIDENT Address: 11316 MADISON STREET, HOLLYWOOD, FL 33019 Telephone No: {954) 347-6747 24 Hour Emergency No: (954) 347.5747 FAX: (954)923 9873 E-mail: LARY(aSTRAWBERRYFIELDSINC.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: ILARY BUDNICK Address: 1316 MADISON STREET, HOLLYWOOD, FL 33019 Telephone No: i(954) 347-6747 24 Hour Emergency No: (954) 347.5747 FAX: (954) 923-9873 E-mail: LARY@STRAWBERRYFIELOSINC.COM 14) WATER SOURCE: Food Establishment Information 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) L16) No. of Food Employees: 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: 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 certificate 19) Person Trained in Anti Choking Procedures (If 25 Seats or more) L) 20) Location: Permanent Location l 22) Establishment Type Mobile Mobile Start Date: EJ Retail ( Sq. Ft) Mobile End Dale: L] Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 j 21) Length of Permit: ❑ Food Service up to 101 -200 _ Annual or up to 25' PHF display $150.00 Seasonal L. J FoodServiceup to 201 + or 25'+ PHF display $275.00 Seasonal Dates: �. Temporary --� i_ ] Food Service - Institution Temporary Start Date: ( Meals/Day) Temporary End Dale: Temporary Time: LARY BUDNICK SCOTT KOLINSKY ❑ Caterer $25.00 ❑ Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 n Manufacture Frozen Desserts/Ice Cream $25.00/freezer [wq'Pushcart $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 F -I Retail Food $100.00 [_] Retail Snack Food $25,00 [� Tobacco Products $25.00 Rain Dale: - --- 23) Food Operations Defrnilions: PHF- Potentially hazardous food (IlmeRempermure controls required) Non-PHF's -non-pofenhally hazardous food(no flme/femperature controls required) I(Check all that apply): RTE - ready to -eat foods (Ex. sandwiches, salads, muffins which needno furtherprocessing) [� Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer j ! Customer Self -Service IIce Manufactured and Packaged -to Retail Sale Juice Manufactured and Packaged Retail Sale Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service LJ PHF and RTE Foods Prepared For Highly Susceptible Population Facility r-1 Vacuum Packaeino i Cook Chill andior HACCP Plan (including bare hand contact alternative, time as a public health Offers Raw Or Undercooked Food Of Animal Origin -------- ❑ Offers RTE PHF in Bulk quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage Out -Of -Data - — ---- ---- - --,II or Reconditioned Food Tobe completed by the Board of Health "-_ — "-" -- -_-- Total Permit Fee: $26.00 Payment is due with application L.] 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 590.000 and all other applicable law. I have been Instructed by the board of health on how to obtain cgp*s ofp105 GMR 590,000 end 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. 25) Social Security Number or Federal ID: 144.52.0046 `,-r-Z,ibeit�� J'�f'6'.f� - 26) Signature of Individual or Corporate Name: � ^`- f�1f � 'j( (�ckJ Commonwealth 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: XFINITY 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:. LARY BUDNICK Whose place of business is: STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: LARY BUDNICK, PRESIDENT Permit Expires: July 27, 2018 Food Fee: $25.00 License Number: XT -9 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XT -9 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER i 2 Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 1316 MADISON STREET HOLLYWOOD, FL. 33019 (954)347-6747 5) Applicant Name & Title: LARY BUDNICK, OWNER 6) Applicant Address 1316 MADISON STREET, HOLLYWOOD, FL 33019 7) Applicant Telephone No.: (964) 347-6747 24 Hour Emergency No.: (964) 347-6747 8) Owners Name & Title LARY BUDNICK 9) Owner Address (If different from applicant) "1316 MADISON STREET, HOLLYWOOD, FL 33019 Owners telephone number 9543476747 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers !An Association I or partner. V1 A Corporation Name Title Address f l An Individual A Partnership i Other.iegaLEnttty -_ - -- -- - _._ -_j 12 Person Directly Responsible For Dally Operations (owner, person in charge, supervisor, manager etc.) Name &Title: LARY BUDNICK, PRESIDENT Address: 11316 MADISON STREET, HOLLYWOOD, FL 33019 Telephone No: 1(954) 347-6747 24 Hour Emergency No: (954) 347.6747 FAX: ;(954) 923-9873 E-mail: ILARYPSTRAW BERRYFIELDSINC.COM Alt E -Mail. 13) District Or Regional Supervisor (if applicable) Name & Title LARY BUDNICK Address: 11316 MADISON STREET, HOLLYWOOD, FL 33019 Telephone No: !(954) 347-6747 24 Hour Emergency No: (954) 347.6747 FAX: (954)923-9873 E-mail: LARY@STRAWBERRYFIELDSINC.COM 14) WATER SOURCE: ON SITE Food Establishment Information 15) SEWAGE DISPOSAL: ONSITE DEP Public Water Supply No: (If applicable) 16) NO of Food Employees: 17) DAYSIHOURS: 18) Name of Person In Charge Certified In Food Protection Management: LARY BUDNICK If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SCOTT KOLINSKY certificate JESSE BUDNICK 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ' j Permanent Location i. 22) Establishment Type 'J. Mobile Mobile Start Dale: i LJ Retail ( Sq. Ft) Mobile End Date: Mobile Comments: 21) Length of Permit: I j Annual Nl Seasonal Seasonal Dates: L Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Dale: ❑ Food Service up to 100 or up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 Food Service up to 201 + or 254 PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) Caterer $25.00 Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/ice-Cream $25.00/freezer $25.00 # of Pushcarts: 0 Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 ;23) Food Operations Definitions:PHF - Potentially hazardous food flime.4empermuna controls required) Non-PHFs - non -potentially hazardous lood(no timeAemperalurs controls required) I(Check all that apply): L RTE - ready -lo -eat loods (Ex. sandwiches, salads, muffins which need no lurthorprocessing) Sale of Commercially Pre Packaged Non-PHFs Sale of Commercially Pre Packaged PHFs I L I Delivery of Packaged PHFs 1. 1 Reheating of Commercially Processed Foods for Service Within 4 Hours 'I Customer Self -Service of Non PHF and Non - Perishable Foods Only j Preparation of Non-PHFs Other Food Operations FRUIT AND JUICE BAR L] PHFCooked To Order U Preparation of PHFs For Hot And Cold Holding For Single Meal Service L] Sale of Raw Animal Foods Intended to be Prepared by Consumer Retail Sale [] Juice Manufactured and Packaged I Retail Sale Li Offers RTE PHF in Bulk Quantities L] Hot PHF Cooked and Cooled or Hot Held j for More Than a Single Meal Service 11 ❑ PHF and RTE Foods Prepared For Highly Susceptible Populatlon Facility and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service f J Retail Sale of Salvage, Out -Of -Dale - --------- --- ____. or Reconditioned Food - To be completed by the Board of Health -" """—"---"--- Total Permit Fee: $25.00 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 590.000 and all other applicable law. I have been Instructed by the board of health on how to obtain copies (K1Q&AqVR190_0bD1aiW the federal Food Code, 24) Signature of Applicant: 12:1 1 Pursuant to MGL Ch.62C, sec. 49A, I ce unc and paid state taxes required under law. 25) Social Security Number or Federal ID: 144 26) Signature of Individual or Corporate Name: the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: XFINITY 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:, LARY BUDNICK Whose place of business is: STRAWBERRY FIELDS @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: LARY BUDNICK, PRESIDENT Permit Expires: ,July 27, 2018 Food Fee: $25.00 License Number: XT -8 BOARD OF HEALTH Michae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XT -8 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) ! I 1) Establishment Name STRAWBERRY FIELDS @ THE XFINITY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 1316 MADISON STREET HOLLYWOOD, FL. 33019 4) Establishment Telephone No (954) 347-6747 5) Applicant Name & Title: LARY BUDNICK, OWNER 6) Applicant Address 1316 MADISON STREET, HOLLYWOOD, FL. 33019 7) Applicant Telephone No.: (954) 347-6747 24 Hour Emergency No.: (954) 347-6747 8) Owners Name & Title LARY BUDNICK 9) Owner Address (If different from applicant) 1316 MADISON STREET, HOLLYWOOD, FL 33019 --------- _ — — ---- - Owner's telephone number 9543476747 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual A Partnership Other J gal.Entity- 12) Person Directly Responsible For Dally Operations (owner, person in charge, supervisor, manager etc.) Name & Title: !LARY BUDNICK, PRESIDENT Address; 1316 MADISON STREET, HOLLYWOOD, FL 33019 Telephone No: (954) 347-6747 24 Hour Emergency No: (954) 347.6747 - -- _- -- - -- -- FAX: (954)923-9873 E-mail: (LARY@STRAWBERRYFIELDSINC.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: LARY BUDNICK Address: ;1316 MADISON STREET, HOLLYWOOD, FL 33019 Telephone No (954) 347-6747 24 Hour Emergency No: (954) 347.6747 FAX: JE mall: LARY@STRAWBERRYFIELDSINC.COM Food Establishment Information 14) WATER SOURCE: ON SITE 15) SEWAGE DISPOSAL ONSITE DEP Public Water Supply No: (If applicable) - L 16) No. of Food Employees 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: LARY BUDNICK If more than 3 individuals are certified, complete list Is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SCOTT KOLINSKY certificate _ JESSE BUDNICK 19) Person Trained in Anti Choking Procedures (If 25 Seats or more): 20) Location: ( J Permanent Location 22) Establishment Type ❑ Caterer $25.00 V) Mobile Mobile Start Date. 7J Retail ( Sq. Ft) ❑ Milk & Cream $10.00 j Mobile End Date: F1 Food Service up l0 100 or Mobile Comments: I up to 10' PHF display $125.00 21) Length of Permit ❑Food Service up to 101 -200 or up to 25' PHF display $150.00 JAnnual ', Seasonal i__J Food Service up to 201 + or 25'+ PHF display $275.00 ' Seasonal Dates: 'J. Temporary i 1_i Food Service -Institution Temporary Start Date: I ( Meals/Day) Temporary End Date: - Temporary Time: Rain Date: ❑ Mobile Food & Consession $75,00 ❑ Manufacture Frozen Dessertslice Cream $25.00/freezer ushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 E] Retail Snack Food $25.00 -J Tobacco Products $25.00 23) Food Open Ilona Definitions PHF- Potentially hazardous food(lime4emperalure controls required) Non PHFs - non-pofenlially hazardous lood(no time/fempendure controls required) (Check all that apply). RTE - readylo-eat foods (Ex. sandwiches, salads, muffins which needno furlherprocessing) _ Sale of Commercially Pre -Packaged Non-PHFs -Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- i Perishable Foods Only _ f j Preparation of Non-PHFs Other Food Operations SMOOTHIES/AREPAS PHFCooked To Order 'JI Preparation of PHFs For Hot And Cold Holding For Single Meal Service i Sale of Raw Animal Foods Intended to be Prepared by Consumer Dustomer Self Service ce Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service F_ PHF and RTE Foods Prepared For Highly Susceptible Population Facility IJ Vacuum Packaging f Cook Chill - - ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Saivage, Out -Of -Dale or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $25,00 Payment Is due with application �t.) 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 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 1 Q6tCMB_%"00artd4hle federal Food Code. 24) Signature of Applicant: p, K`) Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all slate lax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 144-52-0046 26) Signature of Individual or Corporate Name: Commonwealth 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: XFINITY 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:. LARY BUDNICK Whose place of business is: STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE. LARY BUDNICK, PRESIDENT Permit Expires: ,July 27, 2018 Food Fee: $25.00 License Number: XP -9 BOARD OF HEALTH alichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# issued XP -9 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 1316 MADISON STREET HOLLYWOOD, FL. 33019 4) Establishment Telephone No (954)347-6747 5) Applicant Name & Title: LARY BUDNICK 6) Applicant Address 7) Applicant Telephone No.: 1316 MADISON STREET, HOLLYWOOD, FL. 33019 24 Hour Emergency No.: (954) 347.6747 8) Owners Name & Title LARY BUDNICK 9) Owner Address (if different from applicant) 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Owner's telephone number 9543476747 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. :V. A Corporation Name Title Address Lar�3_u6 ._ n_Ir,_k. ____FreS� .1 An Individual A Partnership ) 5 1 iv'_ "!5--G-n--3f­!Ac144nd� 1. 31 Other. Jeal, E try 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: LARY BUDNICK 11316 MADISON STREET, HOLLYWOOD, FL. 33019 -Telephone No: 1(954) 347-6747 24 Hour Emergency No: (954) 347-6747 FAX: 1(954) 923-9873 E-mail: LARYPSTRAWBEIRRYFIELDSINC.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: BUDNICK Address: 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Telephone No: (964) 347-6747 24 Hour Emergency No: (954) 347-6747 T LARY@STRAWBERRYFIELOSING COM d� 0 FAX: 1(954) 347-6747 1 E-mail; �+ Oda ----- - - - ----- - 0\_ 0 Food Establishment Information 14) WATER SOURCE: ON SITE 15) SEWAGE DISPOSAL ON SITE - - --- - — DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees. .17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: LARY BUDNICK If more than 3 individuals are certified, complete list is on file. .� Required as of 10/1/2001 In accordance with 105 CMR 590.003(A) Please attach copy of SCOTT KOLINCKY cenircafe JESSE BUDNICK 19) Person Trained in Anti Choking Procedures (If 25 Seats or more): 17 20) Location: 1 Permanent Location 22) Establishment Type Caterer $25.00 IV Mobile Mobile Start Date: Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Mobile End Dale: F] Food Service up to 100 or L] Mobile Food & Consession $75.00 Mobile Comments: up to 10' PHF display $125.00 0 ! 1 f t r Frozen Desserts/lce Cream 21) Length of Permit: Annual ;yl Seasonal I Seasonal Dates: 11 Temporary---- emporary- -- j Temporary Start Date: (_ I Food Service up to 101 -200 or up to 25' PHF display $150.00 I Food Service up to 201 + or 25'+ PHF display $275.00 [] Food Service - Institution ( Meals/Day) anu ae c u $25.00/freezer []'Wushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 Tobacco Products $25.00 I Temporary End Date: Temporary Time: Rain Dale: Definitions., PHF - Potentially hazardous food (lime/tempemture controls required) 23) Food Operations ! Non-PHFs- non -potentially hazardous food(no llmegemperature controls required) ',(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no /unherprocessing) I i Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order T Hot PHF Cooked and Cooled or Hot Held .... --... ... _ _ I for More Than a Single Meal Service Sale of Commercially Pre Packaged PHFs U Preparation of PHFs For Hot And ___... -__-.. --- --- Cold Holding For Single Meal Service ❑ PHF and SITE Foods Prepared For Highly ! Delivery, of Packaged PHFs _ _ _ _ -- Susceptible Population Facility Sale of Raw Animal Foods Intended I!-1 Reheating of Commercially to be Prepared by Consumer U Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ---.- - -- __-.- _..e of N__ - - - -- Use of Process Requiring A Variance F —_I Customer—elf-S Servicon PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (Including bare hand Perishable Foods Only [] Ice Manufactured and Packaged for contact alternative, time as a public health ____.. ------ --- Preparation of Non-PHFs Retail Sale ._ control) .. Other Food Operations ❑ Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of Retail Sale Animal Origin SMOOTHIES/AREPASr- �_1 Offers RTE PHF in Bulk Quantities Prepares Food/vents r Insngle Meals for Catered Events or Institutional Food Service ! Retail Sale of Salvage, Out -Of -Date -- ut Of -Dale----- - - -- ---- -I -- -- ._.._-._ --1 or Reconditioned Food �o be completed b the Board of Health i -------------- _-- To al Permit Fee: $26.00 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 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of_15 fVR 599.000 and the federal Food Code. 24) Signature of Applicant: l- 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 stale lax returns and paid slate taxes required under law. 25) Social Security Number or Federal ID: 144 52 0046 26) Signature of Individual or Corporate Name: Commonwealth 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: XFINITY 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:. LARY BUDNICK Whose place of business is: STRAWBERRY FIELDS, INC. @ THE XFINTIY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE. LARY BUDNICK, PRESIDENT Permit Expires: July 27, 2018 Food Fee: $25.00 License Number: XT -12 BOARD OF HEALTH .%Iichaet`McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # issued XT -12 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name STRAWBERRY FIELDS, INC. @ THE XFINTIY CENTER 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 1316 MADISON STREET HOLLYWOOD, FL. 33019 4) Establishment Telephone No 5) Applicant Name & Title: LARY BUDNICK (954)347.6747 6) Applicant Address 1316 MADISON STREET, HOLLYWOOD, FL. 33019 7) Applicant Telephone No.: (954) 347-6747 24 Hour Emergency No.: (964) 347-6747 8) Owners Name & Title LARY BUDNICK 9) Owner Address (If different from applicant) 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Owner's telephone number 9543476747 10) Establishment Owned By: 11) if a corporation or partnership, give name, title, and home address of officers .J An Association or partner. IV] A Corporation Name Title Address 7 An Individual . I A Partnership Other legal_Entlty..--- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ;LARY BUDNICK, PRESIDENT Address: 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Telephone No: x(954)347-6747 24 Hour Emergency No: (954)347.5747 FAX: 1(954) 923-9873 E-mail: LARY(aDSTRAWBERRYFIELDSINC.COM �Alt E -Mail.' -- 13) -Mail -13) District Or Regional Supervisor (if applicable) Name & Title. 'LARY BUDNICK Address: 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Telephone No: 1(954) 347-6747 24 Hour Emergency No: (954) 347.5747 FAX: (954) 923-9873 Email: LARY@STRAWBERRYFIELDSINC.COM 14) WATER SOURCE: ON SITE DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: Food Establishment Information 15) SEWAGE DISPOSAL: ON SITE 16) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Required as of 1011/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained In Anti -Choking Procedures (If 25 Seats or more) ! 20) Location: [_I Permanent Locallon 22) Establishment Type Mobile Mobile Start Dale: ❑Retail ( Sq. Fl) Mobile End Date: Mobile Comments: 21) Length of Permit: :Annual 1-A Seasonal Seasonal Dates: J! Temporary Temporary Start Date: ❑ Food Service up to 100 or up to 10' PHF display $125.00 [] Food Service up to 101 -200 or up to 25' PHF display $150.00 71 Food Service up to 201 + or 25'+ PHF display $275.00 .� Food Service - Institution ( Meals/Day) Temporary End Date: Temporary Time: Rain Date: I— - - LARY BUDNICK SCOTT KOLINSKY ❑ Caterer $25.00 ❑ Milk & cream $10.00 ❑ Mobile Food & Consession $75.00 L1 Manufacture Frozen Desserts/Ice Cream $25.0D/freezer Pushcart $25.00 # of Pushcarts: 0 [I Residential Kitchen $100.00 ❑ Retail Food $100.00 IJ Retail Snack Food $25.00 1 -! Tobacco Products $25.00 ' 23) Food Operations Definitions:PHF- Potentially hazardous rood flimelTempwaWre controls required) Non-PHFs - non -potentially hazardous food(no time4emperalure controls required) '(Check all that apply): RTE- ready -to -eat foods fEx. sandwiches, salads, muffins whloh need no further processing) I..; Sale of Commercially Pre -Packaged Non-PHFs 'Sale of Commercially Pre Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs - - - Other Food Operations P ITAS/BURRITOS/AREPAS/SMOOTH IES ❑ PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer f ] Customer Self -Service ] Ice Manufactured and Packaged for Retail Sale J Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantities 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 Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand contact alternative, time as a public health ❑ Offers Raw Or Undercooked Food Of _Animal Origin 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 -----"- Notal Permit Fee: $26.00 Payment Is due with application I-� 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 590.000 and all other applicable law. I have been Instructed by the board of health on how to obtain copies of'W. CMR 5_9D.0l the federal Food Code, 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I art fy unc and paid state taxes required under law. 25) Social Security Number or Federal to: 144 26) Signature of Individual or Corporate Name: of perjury that I, to my best knowledge and belief, have filed all stale tax returns Commonwealth 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: XFINITY 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:. LARY BUDNICK Whose place of business is: STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: LARY BUDNICK, PRESIDENT Permit Expires: July 27, 2018 Food Fee: $25.00 License Number: XT -15 BOARD OF HEALTH 3blichae(McC(ean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XT -15 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address STRAWBERRY FIELDS, INC. @ THE XFINITY CENTER 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 1316 MADISON STREET HOLLYWOOD, FL. 33019 ----------- .---.____ - 4) Establishment Telephone No (954) 347-6747 - - ----- -- - - --- - .._..--- 5) Applicant Name & Title: LARY BUDNICK, OWNER 6) Applicant Address 1316 MADISON STREET, HOLLYWOOD, FL. 33019 7) Applicant Telephone No.: (964) 347-6747 24 Hour Emergency No.: (954) 3476747 8) Owners Name & Title LARY BUDNICK 1 9) Owner Address (If different from applicant) 1316 MADISON ST., HOLLYWOOD, FL. 33019 Owner's telephone number 9543476747 - _ .. ---- --- - --- - — 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 Name Title Address An Individual A Partnership Other legalEntit 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: LARY BUDNICK Address: 1316 MADISON STREET, HOLLYWOOD, FL. 33019 Telephone No: (954) 347-6747 24 Hour Emergency No: (954) 347.6747 FAX: (954) 923-9873 E-mail: ILARY(a)STRAW BERRYFI ELDSINC.COM Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: 'LARY BUDNICK Address: 11316 MADISON ST., HOLLYWOOD, FL. 33019 Telephone No LARY BUDNICK 24 Hour Emergency No: (954) 347-6747 FAX: E-mail: LARY@STRAWBERRYFIELDSINC.COM Food Establishment Information 14) WATER SOURCE: ON SITE 15) SEWAGE DISPOSAL: ON SITE DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: LARY BUDNICK If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of SCOTT KOLINSKY caIlificale JESSE BUDNICK 1 19) Person Trained in Anti -Choking Procedures (If 25 Seals or more): ❑ 20) Location: L_� Permanent Location 22) Establishment Type _ _ — --- .— -11 Sale of Commercially Pre -Packaged PRFs [ ] Caterer $25.00 V: Mobile Mobile Start Dat ..__ ❑ PHF and RTE Foods Prepared For Highly Retail ( Sq. Ft) Cold Holding For Single Meal Service L] Milk & Cream $10.00 Mobile End Date: Susceptible Population Facility ; L I Food Service up to too or I Sale of Raw Animal Foods Intended ❑ Mobile Food & Consession $75.00 Mobile Comments: _I to be Prepared by Consumer up to 10' PHF display $125.00 Processed Foods for Service Within 4 Hours I --I Manufacture Frozen Desserts/Ice Cream . 21) Length of Permit: Customer Self -Service of Non PHF and Non- L -j Food Service up to 101 -200 - and/or HACCP Plan (Including bare hand - $25.001freezer -' Annual _ Ice Manufactured and Packaged for or up to 25' PHF display $150.00 Retail Sale 1_, -pushcart $25.00 # of Pushcarts: 0 j -/I Seasonal -I Juice Manufactured and Packaged for I LI Food Service up to 201 + L] Residential Kitchen $100.00 Origin PITAS/BURRITOS/AREPAS/SMOOTHIESL� or 25'+ PHF display $275.00 _Animal prepares Food/Single Meals for L] Retail Food $100.00 Seasonal Dates: Catered Events or Institutional Food Service - JI Temporary LJ Food Service - Institution ❑ Retail Snack Food $25.00 Temporary Start Date: ( Meals/Day) [] Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Dehmhons:PHF - Potentially hazardous food illma/temperature controls required) Non-PHI's - non -potentially hazardous food(no lime/temperature controls required) (Check all that apply): RTE- ready -lo -eat foods (Ex. sandwiches, salads, muffins which read no fudherprocessing Sale of Commercially Pre Packaged Non PHFs i i PHFCooked To Order [I Hol PHF Cooked and Cooled or Hot Held _ _ — --- .— -11 Sale of Commercially Pre -Packaged PRFs for More Than a Single Meal Service -- — -- ---- 11 Preparation of PRFs For Hot And ..__ ❑ PHF and RTE Foods Prepared For Highly -- - ---- ---- Cold Holding For Single Meal Service Delivery of Packaged PHFs _.— —_— _.--- —-.— Susceptible Population Facility ----- - ----- -- I Sale of Raw Animal Foods Intended ;Reheating of Commercially _I to be Prepared by Consumer [] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours - ------ -- fJ Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- I -J Customer Self -Service — - and/or HACCP Plan (Including bare hand Perishable Foods Only contact alternative, time as a public health _ Ice Manufactured and Packaged for Preparation of Non -i Retail Sale control) Other Food Operations -I Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Origin PITAS/BURRITOS/AREPAS/SMOOTHIESL� [; Offers RTE PHF In Bulk Quantities _Animal prepares Food/Single Meals for Catered Events or Institutional Food Service Ketaa bale or bawage, or Reconditioned Food I, the undersigned, attest to the accuracy of the Information provided in this establishment operation will comply with 105 CMR 590.0 nd-alkother_aG board of health on how to obtain cpP_W of 10h,C 0.000 and the feder I I To be completed by the Hoare or Heartn I Total Permit Fee: $26.00 Payment Is due with application ❑ waived lion and affirm that the food law. I have been Instructed by the Code. 24) Signature of Applicant: Pursuant to MGL Ch.620, sec. 49A, cerfivurl4er the penalties of perjury that I, to my best knowledge and belief, have filed all slate tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 144.52.0046_(/� 26) Signature of Individual or Corporate Name: __ X�' `4J The Commonwealth of Massachusetts 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 87TH THE PERAff'rTINGAUTHORITY, Applicant Information I n 1 IPleasePrintLegibIv Business/Organization Name: 5 l Y A UJ b&((q 'P� P � (71 7 1V(X i Aad tilo to ' nC 1'IcA1Stii'1 qc� ,c Are ytyu an employer? Check the appropriate box: 1. M 1 am a employer with employees (full and/ or part-dmc).� 2:❑ I am a sole proprietor or partnership and have no employees working for me in any capacity, [No workers' comp. insurance required] 3, ❑ Weare a corporation and its officers have exercised their right of exemption per c. 152, §I (4), and we have no employees, [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees, rNo workers' comp• insurance req.] Business Type (required): 5. E] Retail 6. Restaurant/Bar/BatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11.❑ Health Care 12.[S�r Other 1O©D CC'�CC1fIC.+/3 *Any applicant that checks box #I must also fill out the section below showing Meir workers' mmpensation policy information. t'lf Me corporate ofHccrs bave cxcroptad fl crosclVcs, but the corporation Les other employees, a workers' compensation policy is required and such au organisation should cbmk box V. Lam an employer that is provrl�dingworkers' conrpensadatr insurance for my employees. Below is the policy information. Insurance Company Name: t-YVI�Uy p/S 0)6,1ce— Ns S,JCs INL fnsurer'sAddress: 2-10 -t Cafyi7,0t) A City/State/Zip: O cf-a n S J e-, CA q 2 Policy # or seif-ins, Lie. #• _I l 3 o � 9 2-'' � g Expiration Date: L+ 121 1 261 Ci Attach a copy of the workers' compensation policy declaration page (showing the policy number and expfration date). Murata, secure coverage as required under Section 25A of MGL e. 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 fare 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, and Ins and penalties of perjury that the information provide above true and correct _6 %i Official use only. Do not write in this area, to be completed by city or tarps offidaL City or Town: Permft/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 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 diva wl or Corporate Name 620040 *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. R\HmfthVane's Doo=..fs\PERM1T APPLICATIONS\TAX CERTIFICATION FORM.doo N Candidate Name; Your srquiedtsA scaled score of75 ieropsthe exam. Your Passing score is not official until validated by the National Registry. National Registry does not take responsibility for exams that are retaken before National Registry has confirmed the score. Congratulations on successfully completing the Food Safety Manager Examination. You have now demonstrated that your knowledge and skills meet measurable and specific food safety standards adopted by the Conference for Food Safety Protection to protect the public from foodborne illnesses. Shortly you will receive your official score and a certificate that you can frame and a wallet card. The wallet card is a handy way of showing your current employer or new employer that you are certified. Your certification is valid for a period of five years or less, depending on your local jurisdiction requirements. We recommend contacting your local health department to verify your local statutes. You also have an obligation to provide food safety training for those who work for you. More information about food safety worker training and your own certification can be found at the NRFSP website at www.nrfsp.com or by calling their toll-free number at 1-800-446-0257. Candidate Name: Food Safety Manager Certification Examination Notification of Test Results Exam Date: May 27, 2016 Your scaled exam score is 94 A scaled score of 75 is required to pass the exam. Your Passing score is not official until validated by the National Registry. National Registry does not take responsibility for exams that are retaken before National Registry has confirmed the score. Congratulations on successfully completing the Food Safety Manager Examination. You have now demonstrated that your knowledge and skills meet measurable and specific food safety standards adopted by the Conference for Food Safety Protection to protect the public from foodborne illnesses. Shortly you will receive your official score and a certificate that you can frame and a wallet card. The wallet card is a handy way of showing your current employer or new employer that you are certified. Your certification is valid for a period of five years or less, depending on your local jurisdiction requirements. We recommend contacting your local health department to verify your local statutes. You also have an obligation to provide food safety training for those who work for you. More information about food safety worker training and your own certification can be found at the NRFSP website at www.nrfsp.com or by calling their toll-free number at 1-800-446-0257. National Registry of Food Safety Professionals, Inc. Food Safety Manager Certification Examination Notification of Test Results Candidate Name: Scott r,h Exam Date: May 27, 2016 Your scaled exam score is 88 A scaled score of 75 is required to pass the exam. Your Passing score is not official until validated by the National Registry. National Registry does not take responsibility for exams that are retaken before National Registry has confirmed the score. Congratulations on successfully completing the Food Safety Manager Examination. You have now demonstrated that your knowledge and skills meet measurable and specific food safety standards adopted by the Conference for Food Safety Protection to protect the public from foodborne illnesses. Shortly you will receive your official score and a certificate that you can frame and a wallet card. The wallet card is a handy way of showing your current employer or new employer that you are certified. Your certification is valid for a period of five years or less, depending on your local jurisdiction requirements. We recommend contacting your local health department to verify your local statutes. You also have an obligation to provide food safety training for those who work for you. More information about food safety worker training and your own certification can be found at the NRFSP website at www.nrfsp.com or by calling their toll-free niimho«.,+ I onn Anti n)c7 Caitxclidate Name: i f r �_: d� t3 Isxa�n Ia�ite: July 21� �(ilfd CI ItT)1 ❑Ip�. - A scaledscore Your scat reed wired re is 96 Pass the exam. 1'tntr i'ti situ sectre is not Official until validated by the National Registry. National tion.titry does before Natioaartrot tale responsibiiity for- exams that are retaken '�egis rY h2s confirmed the score. Congrtttulttt7on4 01" ,ix , tir, r;taliy conlOcting the Food Safety )Manager Examination. YotI have now d�a:ou,;,� stic'.dtl2rlt "rout' lcnovrieclge and skills meet measurable and specific food sr, tory suand'�rds adopted by the Conference for Food Safety Protection tc protect the fsul>Iic flMoin iooc boMe illnesses. Short13 you,will receivo your o fig; 11 score Wid a eertificate' rh at ybu can frame and a;' `, `t •'wallet card.: The wallet cerci is, a handy way of showing your current e nplgyer, or ilewr emp!6yet' the Cyiott arcs rctttfi��l. Otlr CEIt1ltCiiltOii 1S vatid 76r riod lnl five yews or less, depEndill y lltl Ottt lt�Ca1 =� l b y U"15CIICL10ri l'BgtlitE312Fv27iG. : c t ;t 9C';i? dltl tiC7iit�t4t;ng your local heGiltll Cit vXt 'your'Iocat sh i 71I £ijSO hfj.V�' �1Y1 (3, f1 Y; ;"f Lf , •" 3 i_� nod �af'ot�� trainin dol' gloseVW'3C3.V�fovl' i.lfoz-e itifur ineenir'� ,M'e y Walter traixlirig wid your be found at the ",,zQJ I {f. 0%� 1 f, �� 't,. 4sf ,f�, ,rJ�a'�,Xl� rs .�Om or b`y, 6, lits . their t l �- iileratJ-8..44 l� d'rf f t ' \ l s tb s}ti �sltce dti 5"1