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HomeMy WebLinkAboutA. J. Bruno Concessions 12/31/2018Commonwealth. 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 PUSHCART 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:. ANTHONY J. & SHANNON BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - PUSHCART 1 - COFFEE PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-7 BOARD OF HEALTH Michae(McC(ean, Chairman Milk & Cream ❑O it FOR BOARD OF HEALTH USE ONLY Permit # Issued XP-7 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC - PUSHCART 1 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY J. BRUNO, OWNER 6) Applicant Address 996 CHARLES STREET, NORTH PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 OR 9985 24 Hour Emergency No.. (508) 261a198 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 1 0) 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 ANTHONY J. & SHANNON BRUNO 996 CHARLES STREET, NORTH PROVIDENCE, RI 02904 5089629984 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'ANTHONY BRUNO Address: 1996 CHARLES STREET, NORTH PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: (508) 261-7198 - FAX: 1 E-mail: - IAJBRUNOCONCESSIONS(qGMAIL.COM -- Alt E-Mail. 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: It1:4111[�: 00 SOUTH MAIN STREET, MANSFIELD, MA 02048 I74) 244-1089 24 Hour Emergency No: E-mail: 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO 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 SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): V1 20) Location: ❑ Permanent Location ,!]Mobile Mobile Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual Seasonal Seasonal Dates: CONCERT DATES i. Temporary Temporary Start Date: Temporary End Date: L, Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ 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 [.j Food Service up to 201 + or 25'+ PHF display $275.00 !J Food Service - Institution Meals/Day) ] Caterer $25.00 ❑J Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream ❑ $25.00/freezer jl Pushcart $25.00 # of Pushcarts: 1 [ _ Residential Kitchen $100.00 Retail Food $100.00 ❑I Retail Snack Food $25.00 [. I Tobacco Products $25.00 � 23) Food Operatiors Definitions: PHF- Potentially hazardous food (fimeltemperature controls required) Non-PHFs non -potentially hazardous food(no time/temperature controls required) (Check all that apply) RTE -ready to eat 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 -------- Sale of Commercially Pre-PackagedPHFs -- -- -HF-— --- j _J Preparation of Ps- For Hot And for More Than a Single Meal Service --- -- ----- ------ Cold Holding For Single Meal Service j JPHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs ----- ---- ---- - - -- ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility --Packaging-_ -- _ --- -- Reheating of Commercially - to be Prepared by Consumer j Vacuum /Cook Chill Processed Foods for Service Within 4 Hours ------ , Customer Self -Service of Non PHF and Non- - -_-- ---— ---- [_ ❑Customer Self -Service ] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for contact alternative, time as a public health I I Preparation of Non-PHFs Retail Sale control) Other Food Operations [_) Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service [_I Retail Sale of Salvage, Out -Of -Date or Reconditioned Food --- To be completed by the Board of Health _-- _-- _ -- _ _ - — — Total Permit Fee: $26.00 Payment is due with application waived !i 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 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. 25) Social Security Number or Federal ID: 36-4866352 _ n / 26) Signature of Individual or Corporate Name: `1�� hv� L l / el/A i e , / �s 4- Town of Town of Mansfield - Board of Health 6 Pak Ro ransfleld Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: A.J. BRUNO CONCESSIONS LLC - PUSHCART 1 - COFFEE ADDRESS: 885 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 962-9984 FAX NUMBER: OWNER OF BUSINESS: ANTHONY J. & SHANNON BRUNO TELEPHONE OF OWNER: 6089629984 FEDERAL ID/SS NUMBER: 36-4866352 FEE: $10.00 PERMIT NUMBER: XP-7 SIGNATURE: � DATE: 05/23/2018 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 PUSHCART 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:. 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN' DOTS 4 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-13 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 886 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6 Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 I ) PP 1 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association Cl A Corporation ❑ An Individual C 1 A Partnership i_Ci Other legal Entit 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: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONSPGMAIL.COM Alt E-Mail:. 13) District Or Regional Supervisor (if applicable) Name & Title: j Address: f No: 24 Hour Emergency No: ETelephone X: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 F 17) DAYS/HOURS: EVENTS F 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO 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 SHANNON BRUNO certificate f 9) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: [] Permanent Location 22) Establishment Type ❑ Caterer $25.00 Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 j Moblie 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 Desserts/Ice Cream $25.00/freezer 21) Length of Permit: [y_i 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: 0 ❑ Residential Kitchen $100.00 ElRetail Food $100,00 ❑ Seasonal Seasonal Dates; ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Dell, itions: PHF- Potentially hazardous food (timeAemperature controls required) Non-PHFs -non-potentially hazardous food(no timeltemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PHFs ❑J PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [VI Sale of Commercially Pre -Packaged PHFs ❑ 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 ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A 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 _ Pre [ J paration of Non-PHFs ❑ Customer Self -Service ❑Ice Manufactured and Packaged for Retail Sale _ ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food completed by the Board of Health FTobe Permit Fee: $125.00 ent 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 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. 25) Social Security Number or Federal to: 36-4866352 Qp 26) Signature of Individual or Corporate Name: A - � /' 17rur`c Con 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 PUSHCART 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN'S DOTS 3 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-12 BOARD OF HEALTH MichaeC-%1cCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued XF - f,g FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (608) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO I — 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (soe) ssz-sssa 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association CJ A Corporation F] An Individual A Partnership i—J Other legal Entit 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address —_ 19) Persnn Directly Resoonsible For Dailv Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONS(a)GMAIL.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 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 F 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO 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 SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 0 Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25,00 ❑Moblie Mobile Start Date: Retail ( Sq. Ft) ❑ Milk & Cream $10.00 j Moblie End Date: ood Service up to 100 or Mobile Food & Consession $75.00 Mobile Comments: p to 10' PHF display $125.00 ❑ Food Service up to 101 -200 anufacture Frozen Desserts/Ice Cream 25.00/freezer 21) Length of Permit: lyl Annual or up to 25' PHF display $150,00 ❑ Food Service up to 201 + or 254 PHF display $275.00 ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Dale: Temporary Time: Rain Date: 231) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timellemperature controls required) RTE- ready -to -eat 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 ❑ 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 ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑J Reheating of Commercially Processed Foods for Service Within 4 Hours ❑Vacuum Packaging /Cook Chill ❑ Use of Process Requiring A 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 ❑ Ice Manufactured and Packaged for Retail Sale [ J Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single 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: $125.00 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 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 fled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 36-4866352 Q �t LAIC 26) Signature of Individual or Corporate Name: ./ I - 7. G uno (bAC eS S:c��S LAIC 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 PUSHCART 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN' DOTS 2 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-11 BOARD OF HEALTH MicfiaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit #Issued XS FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1 Establishment Name A.J. BRUNO CONCESSIONS LLC 1/�P�ir� �VI✓ t� 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO I 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 6089629984 10) Establishment Owned By: ❑ An Association L�1 A Corporation ❑ An Individual 1 A Partnership _CJ Other legal Entit 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Dailv Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONS(cDGMAIL.COM Alt E-Mail:. 13) District Or Regional Supervisor (if applicable) Name & Title: j Address: 4 'Telephone; No: 24 Hour Emergency No: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN j DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 F- 17) DAYS/HOURS: EVENTS 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO 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 SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 Moblie Moblie Start Date: Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: ood Service up to 100 or ❑Mobile Food & Consession $75.00 Moblie Comments: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 C] Manufacture Frozen Desserts/Ice Cream $25.00/freezer 21) Length of Permit: r] 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: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 231 Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non-potentfally hazardous food(no ffouviemperature controls required) RTE - ready -to -eat 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 ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility - [j Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single 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: $125.00 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 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 fled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 36-4866352 26) Signature of Individual or Corporate Name: ✓ 1 -) 11 Yii^� �U �� rs�izn S ��� r 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 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC - TRAILER 1 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: UIUFRFRIT6 Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-28 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-28 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC -TRAILER 1 2) Establishment Address 885 SOUTH MAIN STREET { 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 '. 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10 Establishment Owned By: I Y 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. I A Corporation Name Title Address 1 An Individual I A Partnership Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO - Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone NO: (508) 962-9984 24 Hour Emergency No: FAX: E-mail: �AJBRUNOCONCESSIONS(d,)GMAIL.COM Alt E Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: - - Telephone No: 24 Hour Emergency No: FAX: 1 E-mail: -i 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: EVENTS Food Establishment Information L 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 6-10 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) j 20) Location: Permanent Location 22) Establishment Type �'. Moblie Moblie Start Date: [-I Retail ( Sq. Ft) .. Moblie End Date: !JI Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length Of Permit:-, -; Food Service up to 101 -200 . i ; Annual or up to 25' PHF display $150.00 j Seasonal I. _.', Food Service up to 201 + or 25'+ PHF display $275.00 Seasonal Dates: _-1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: ❑ Food Service - Institution ( Meals/Day) ANTHONY BRUNO SHANNON BRUNO Caterer $25.00 i -.] Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream - $25.00/freezer J Pushcart $25,00 # of Pushcarts: 0 l Residential Kitchen $100.00 _! Retail Food $100.00 ❑ Retail Snack Food $25.00 i- Tobacco Products $25.00 Rain Date: 23 Food Oerations Definitions: PHF - Potentially hazardous food (timeAemperature controls required) p i,. Non-PHFs- non -potentially hazardous food(no timeRemperature controls required) '.. '.(Check all that apply): RTE- ready -to -eat 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 VI Sale of Commercially Pre -Packaged PHFs 'I Preparation of PHFs For Hot And for More Than a Single Meal Service - ---- - Cold Holding For Single Meal Serviced Delivery of Packaged PHFs PHF and RTE Foods Prepared For Highly --- ---- -- --- j J Sale of Raw Animal Foods Intended Susceptible Population Facility J Reheating of Commercial) Sumer Vacuum Packaging / Cook Processed Foods for Service I of Process riance customer Self-Serviceof Non P'HP and Non- Customer Self -Service ce and/or HACCP PlaUse nbare c �u a (including hand Only 1 Y Ice Manufactured and Packaged for contact aiternahvla time as in public health Preparation of Non PHFs _ Retail Sale _ _ control) Other Food Operations i Jwce Manufactured and Packaged for,. ] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ' I 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 Total Permit Fee: $126,00 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 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: W!t r br o Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 36-4866352 _ �� 26) Signature of Individual or Corporate Name: • �• Qf'^ho - WOc.e� S„M� �, I-• • L 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. µµ66 /i--,T, �,". (s!esa�;vi.S f,L.( 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.\Health\J ne's Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Indushial 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 PERMITTING AUTHORITY. Applicant Information Please Print Lggibly Business/OrganizafionN�ame: f) 55 J Address: J ( Gx- "q w City/State/Zip: AA, S-f.e(r41 /A A 00'q j Phone #: el `t if y Are you an employer? Check the appropriate box: I. © I am a employer with J�- 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.] that checks box N must also fill out the Business Type (required): 5. ❑ Retail 6. RestaurantJBar/Fating Estabiishment 7. ❑ Office and/or Sales Joel, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10,❑ Manufacturing 11.0 Health Care 12.❑ Other compensation policy information. **If the wrpmate officers have cxempled themselves, but the coryorahoo has other employees, a worxecs compensauon poocy us requueo ma suca as organization should check box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informado$. Insurance Company insurer's City/State/Zip: Policy # or Self -ins. Lie. #- Expiration Date: 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 ��t``he pains anal penalties ofperjury (hat the information provided above is true and correct Sivature: Date: �Z -�'7._ 0)7 Phone #•—�6•Z ' `ietd'N 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 Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: _..__ Phone#: w .mass.gov/dia e 0 O Zo M W Z O Q �E LL Uu c c o o .� �a u �m a V 0 � C a'- < N C � O w O V Z LL Q c N N— w� LO � o S N _0_ C -"o Z Z `o c a o � E y Q �r =j a s M LO �o 0 O N s LO 4 3 w O W U w W W U V z h* z W z W P4 3 z w W Z m N _ _ o z U w z u Q Q h 0 d V w Gov w b O w 42 qa C o 6 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 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:. ANTHONY BRUNO Whose place of business is: A. J. BRUNO CONCESSIONS LLC - EMPLOYEE BARBEQUE 885 SOUTH MAIN STREET PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-31 BOARD OF HEALTH -%1ichae(McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS -.3( FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC — rA, )c, C pfl.r 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO I j 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508)96M984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association CJ A Corporation ❑ An Individual i j A Partnership j_LJ-Other legal Entit 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: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONS@GMAIL.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 15) SEWAGE DISPOSAL: TOWN I DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 F 17) DAYS/HOURS: EVENTS 1 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO 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 SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 [ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 j Moblie End Date: Food Service up to 100 or ❑ Mobile Food & Consession $75.00 Moblie Comments: 21) Length of Permit: up to 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/freezer (,jl 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: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Seasonal Seasonal Dates: ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: ! 23) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (timefiemperature controls required) Non-PHFs - non -potentially hazardous food(no tlmenemperature controls required) RTE- ready -to -eat 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 D./Sale of Commercially Pre -Packaged PHFs 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 ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer [j Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Prepares Food/Single 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: $126.00 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 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. 25) Social Security Number or Federal ID: 36-4866352 ((� / 26) Signature of Individual or Corporate Name: :- -J —r . VTi v' W-.4 0 w � � u � � � i LJ (4� z � z - NN 04 � � � z �14 z W-4 � � � � � /\V''0 \ \ / � � ) a!\ \ }+~» \ §}\§ a \+\} ) \ƒa® a � / z 0 LLM v oc W v z 0 - c VLLM I z 0 z z T ` vr J Oro Q x W N 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 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - LOT 9 - SHED 1 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: XFS-26 BOARD OF HEALTH MichaermcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued XFS-26 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address A.J. BRUNO CONCESSIONS LLC -LOT 9 S/,ecl 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 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 An Individual A Partnership Other_ legal_Entity __ - --- - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: FAX: I E-mail: AJBRUNOCONCESSIONS@GMAIL.COM Alt E-Mail: I 13) District Or Regional Supervisor (if applicable) FAX: E-mail: i 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS i 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): 1 -1 20) Location: [i Permanent Location I 22) Establishment Type 1 Moblie Moblie Start Date: [ Retail ( Sq. Ft) Moblie End Date: lam] Food Service up to 100 or Moblie Comments: up to 10' PHF display $125.00 21) Length of Permit: ❑ Food Service up to 101 -200 V Annual or up to 25' PHF display $150.00 Seasonal [ Food Service up to 201 + - or 25'+ PHF display $275,00 Seasonal Dates: -I Temporary Temporary Start Date: Temporary End Date: [; Food Service - Institution ( Meals/Day) ANTHONY BRUNO SHANNON BRUNO ❑ Caterer $25.00 ❑ Milk & Cream $10.00 J Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream -- $25.00/freezer [._ ] Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Temporary Time: Rain Date. --------- ---_-- ---_ ___.. -_... 23) Food Operations Definitions: PHF- Potentially hazardous food (timellemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) �I(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs V', Sale of Commercially Pre -Packaged PHFs _1 Delivery of Packaged PHFs j Reheating of Commercially Processed Foods for Service Within 4 Hours 1 Customer Self -Service of Non PHF and Non - Perishable Foods Only Other Food Operations [JI PHFCooked To Order 1 Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufactured and Packaged for Retail Sale it l 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 [] Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin j 1 Offers RTE PHF in Bulk Quantities 1 r I Prepares Food/Single Meals for _ J4 Catered Events or Institutional Food Service 1 ] Retail Sale of Salvage, Out -Of -Date —. -- ---- -- - or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $125.00 Payment is due with application-_ �i waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Lr'IING»��w'1 Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 36-4866352 ���CC / / 26) Signature of Individual or Corporate Name: �- T , vJ r�76 l/ Gnrr-5�".'7-/ Z_L� Y3 3 3 u E .o w a w a y y u E o r m c° m c m a m y m o o o Y m c e g a u LL a o o LL a o o Y o° o 0 y r LL m 'o N v O O g W W O O q W 9 LL m li. A V' O C d d O '-q'3105'e c ii LL'u.33 maa ?�?� m'�'t a,''o_i w ate.°• a c3� m3 w w m c v `w `w c° � c LL LL`w '^ a$ `w 3 3 o a a e m s i1 t� 2 'c c >> E ry a 3 3 3� 3 o u a� ( 5y 3>>�� m' 3 �� m" 9 9 m° ei N T R N 1L 1� W M N N N ei tn1 M d, N N N N N N N N N N M M M M M M M a e a o a I 8 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 PUSHCART 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLr 885 SOUTH MAIN STREET -PUSHCART 2 DIPPIN' DOTS PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-8 BOARD OF HEALTH 34ichaeCMcCCean, Chairman 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 PUSHCART 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:. ANTHONY BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - PUSHCART 2 - DIPPIN' DOTS PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-8 BOARD OF HEALTH MicfiaeCMCCCean, Chairman i l FOR BOARD OF HEALTH USE ONLY Permit# Issued XP 8 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC -PUSHCART 2 )Pe 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (608) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: i 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N PROVIDENCE, RI 02904 Owner's telephone number 5089629984 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 — -- 1 A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 1ANTHONY BRUNO Address: CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No I(508) 962-9984 24 Hour Emergency No: FAX: E-mail: :AJBRUNOCONCESSIONS(a)GMAIL.COM Alt E-Mail: i 13) District Or Regional Supervisor (if applicable) - - Name & Title: i 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: EVENTS Food Establishment Information 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 6-10 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) i 20) Location: [ Permanent Location 22) Establishment Type jl, Moblie Moblie Start Date: I ❑ Retail ( S Ft) Moblie End Date: Mobile Comments: 21) Length of Permit: �] Annual Seasonal ---- --- Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations iCheck all that apply): q ❑ 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 25'+ PHF display $275.00 Food Service - Institution ( Meals/Day) ANTHONY BRUNO SHANNON BRUNO ❑ Caterer $25.00 ❑ Milk & Cream $10.00 Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer L] Pushcart $25.00 # of Pushcarts: 1 j] Residential Kitchen $100.00 -] Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Definitions: PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs- non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat roods (Ex. sandwiches, salads, muffins which need no further processing) ] Sale of Commercially Pre -Packaged Non-PHFs IV 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 1J 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 Customer Self -Service Ice Manufactured and Packaged for Retail Sale [ ] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service I_J 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 ] 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 Salvage Out -Of -Date or Reconditioned Food �To be completed by the Board of Health 1 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 of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: (;ba1"" r.Y`M,ra 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: 36-4866352 A �7 Q 26) Signature of Individual or Corporate Name: f l.a - 0 r� r 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 PUSHCART 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:. ANTHONY BRUNO Whose place of business is: A. J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN' DOTS 1 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December31,2018 Food Fee: $25.00 License Number: XP-10 BOARD OF HEALTH MichaeCMcCCean, Chairman 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 PUSHCART 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:. ANTHONY BRUNO Whose place of business is: A. J. BRUNO CONCESSIONS LLC 885 SOUTH MAIN STREET - DIPPIN' DOTS 1 PERSON(S) IN CHARGE: ANTHONY BRUNO Permit Expires: December 31, 2018 Food Fee: $25.00 License Number: XP-10 BOARD OF HEALTH MicfiaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Permit# Issued 01f? ,gyp L. FOOD ESTABLISHMENT PERMIT APPLICATION I (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name A.J. BRUNO CONCESSIONS LLC ✓ 2) Establishment Address 885 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 31 OXFORD ROAD MANSFIELD, MA 02048 4) Establishment Telephone No (508) 962-9984 5) Applicant Name & Title: ANTHONY BRUNO I 6) Applicant Address 996 CHARLES STREET, N. PROVIDENCE, RI 02904 i 7) Applicant Telephone No.: (508) 962-9984 24 Hour Emergency No.: 8) Owners Name & Title ANTHONY BRUNO 9) Owner Address (If different from applicant) 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Owner's telephone number 5089629984 10) Establishment Owned By: ❑ An Association W A Corporation ❑ An Individual I A Partnership Li Other legal 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.) I Name & Title: ANTHONY BRUNO Address: 996 CHARLES STREET, N. PROVIDENCE, RI 02904 Telephone No: (508) 962-9984 24 Hour Emergency No: FAX: E-mail: AJBRUNOCONCESSIONS@GMAIL.COM Alt E-Mail:. 13) District Or Regional Supervisor (if applicable) Name & Title: Address: No: 24 Hour Emergency No: FTelephone AX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN FDEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-10 17) DAYS/HOURS: EVENTS -- F 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY BRUNO 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 SHANNON BRUNO certificate 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ 20) Location: ❑ Permanent Location 22) Establishment Type ❑ Caterer $25.00 [.', Moblie Mobile Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: ood Service up to 100 or ❑Mobile Food & Consession $75.00 Mobile Comments: 4 S u o 10' PHF display $125.00 ❑ Food Service up to 101 -200 ❑ Manufacture Frozen Desserts/Ice Cream $25.00/1reezer ! 21) Length of Permit: (y] Annual or up to 25' PHF display $150.00 ❑ Food Service up to 201 + Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Seasonal Seasonal Dates: or 254 PHF display $275.00 ❑ Retail Food $100.00 ❑ Food Service - Institution ❑ Retail Snack Food $25.00 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $25.00 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Definitions: PHF- Potentially hazardous food (tlmelemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous tood(no tlmenemperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs inV PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service [� Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring A Variance and/or HACCP Plan (Including bare hand �] Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service FoodsOly Perishable Foods Only contact alternative, time as a public health control) ❑Ice Manufactured and Packaged for Retail Sale ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $125.00 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 105 PMR 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. 25) Social Security Number or Federal ID: 36-4866352 26) Signature of Individual or Corporate Name: .� •-.�.l"dry CU/tiC5St•.j Lt�.e,