Loading...
HomeMy WebLinkAboutSmithfield Deli/Signature Mktng 8/30/2018Commonwealth 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: TEMPORARY RETAIL SNACK 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:. SIGNATURE MARKETING GROUP Whose place of business is: SIGNATURE MARKETING GROUP @ SMITHFIELD DELI MOBILE TOUR 390 WEST STREET PERSON(S) IN CHARGE: COLLIN KRUSE Permit Expires: August 30, 2018 Food Fee: $25.00 License Number: TRS-1 BOARD OF HEALTH Michae(McCtean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By, JUL 2 0 Temporary Food Establishment Pe►`niifApplication (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: 2) Establishment Address: CLwe S�- 3) Establishment Mailing Address (if different): 'M4k- �fi # LAv5 f 4) Establishment Telephone No: -�b CA 5) Applicant/Owner Name & Title: 6) Applicant/OwnerAddress: )3dti'�{C)CVX6KV0— 7) Applicant/Owner Telephone No: (--o 0� ",�° !yam _ OL0 _D ILA 8) Applicant/Owner Email address: K C 9) Person Directly Responsible For Onsite Operations: Name & Title: Address: Telephone No: —j O kA c 0 - 2 LV? Fax: Emergency Telephone No: —1 b Zy 10) Event Attending Date(s): Event Name: � 1,�/�.fi-��� Tx-lv Tv©Yj\�< --�OW Event Location: SV�fl/v-� SOtO We -SA- S+_ ,, -r-W A- 0'--OqF Event time: -v\ _ ` Y\'\ 11) Check one n Food Truck ❑ Caterer _11sitR Other: 1'eWL� �pC` SCo(C 12) Solid waste disposal plan: wuvltq� 13) Water Source: � g 0 L&T KcLSCJs 14) Sewage disposal plan: (i v1Cl�C t l 3 fg C Ni aj 1of,the food tobe served: 15 ) Please give a brief description 16 ) Food will be prepared: Onsite for Immediate consumption Onsite and held at proper holl cold holding temperatures Offsite and held at proper hot/ cold holding temperatures ❑ Offsite, cooled and reheated on site n Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: /� �� `. Food Safety Manager: _ , l,/4]�"(i'�, KV�t�t�� �,t Allergen Awareness: ` ` al, I, Iv- ice' �-�" 18) For caterers: CltylTown where food establishment permit is held. Please attach a copy of the caterer's permit: 01A For food trucks, please list additional communities,where a food permit is held and attach copies of the permits: NIN I, the undersigned, attest to the a establishment operation will con by the board of health on how to 19) Signature of Applicant: _ y of the information provided in this application and I affirm that the food h 105 CMR 590.000 and all other applicable law. I have been Instructed copies of 105 CMR 590.000 and the federal Food Code. Pursuant to MGI. Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 20) Social Security Number or Federal ID: L- 5 - � ?, (.4141- ( A 21) Signature of Individual or Corporate Name: Food Protection Questionnaire for Catered Events Date of Event: U % i �C- Event Time: SpNX— 1 p On Location of Event: (I',, 1'( ! 1(e 55 0 L� JP 5 *- S 1 r P eT CV1Gt dS ( Gt List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Food Manager Certification Person Trained On Site? ❑ Yes ❑ No Allergen Awareness Menu Label Present? ❑ Yes ❑ No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41 °F? How will the PHF be kept at or above 140°F? Time of PHF? Setup Served Removed List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) LAS— 127'34L-Au �l "*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. C:\Users\sloite\Desktop\Scolds Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Indiistrial'Accidents Office of Investigations 600 Washington Street U1V Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: 'A Qi 5 (A -,a i, W N Q_ 2, 2ZjO City/State/Zip: C ,V\-Lt ref C 2$ 83 Phone #: `) Ot-t - _�, ,� l -yy 6f' Are yqu an employer? Check the appropriate box: Business Type (required): 1. [Z I am a employer with ___ employees (full and/ 5. El Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* 1 l,❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12Q16ther *Any applicant that checks box # 1 must also rill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: N00\P �.A S1d k2Un �� V lZ VS Insurer's Address: : Po j3 V}c < i)sl 71 l City/State/Zip: h rtyA o44f C— Z Policy # or Self -ins. Lic. # Wi-0 to to 3" '3D _�Zll� 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, corder file pains and penalties ofpeijuty that the information provided above is trite and correct. Phone #' __ 7OLA — 7_� \ — QM�i- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone R U) ry z J O 124, M wl� 0 � � u � W-4 *M� � � w u (M� z *-.4 z .4 ■o � Un Un w z � � � � Cd \\` / / \ \ » \ \ ^ 0 : . 7 )!� � | ];I ) 41 } §)Zk am{a % � R \ 2 to \ ti � / 2018 Smithfield Supermarket Sampling Tour Standard Operating Procedure 1. The mobile tour manager assigned to each particular retail store location will arrive approximately 90 minutes prior to the scheduled start time of the event. 2. Tour Manager checks in with on -site Store Manager on where to set up. 3. Tour Manager checks in with Store Manager and Deli Manager to confirm product shipment arrived and everything is ready for the event. 4. Product is purchased a. Product to be sampled is purchased daily from each store location and immediately placed on ice in coolers. Note that product will not be placed on top of ice, but submerged (only when fully sealed) in the ice to cover on all sides. As a reminder, mechanical refrigeration is not used to store the product due to the fact that this is only a temporary (4 hour) event. Cooler will have a thermometer to show temperature. 5. Set Up a. Outside Assets include: 1. (1) 5 x 5 EZ-UP branded tent ii. (1) 2x4' table iii. Branded table covers and tent back wall iv. (2) Branded sail sign v. (2) GWP A -Frame signs placed at the entrance of the store. b. Inside Assets include: 1. (1) Branded Deli Kiosk with deli dome for cold -holding samples ii. (1) Branded Grab & Go Cooler iii. (1) 2x4' Branded table for product prep 6. Food Preparation/Sampling —all prep and sampling will take place inside the store a. Deli Meat and Cheese Preparation and Sampling I. Deli meat and cheese is sliced by the deli department and each slice is rolled up and cut into 5-6 bite -sized pieces. They will then toothpick each one and place in the covered deli dome with an ice -packed tray on the bottom. ii. A deli dome with an ice tray is used for sampling. Ice is replenished as needed, and a dome covers the sampling tray at all times (except when a sample is being retrieved). iii. Samples are disposed of every 15-20 minutes and replaced with fresh ones as needed. b. Pinwheel Recipe Preparation and Sampling I. Deli meat, cheese, mustard, and tortillas are purchased upon arrival to the store and immediately placed in an ice -packed cooler. ii. Deli meat and cheese is sliced by the deli department. iii. Using gloves, the tour managers will spread a quarter -sized dollop of mustard on a 6" tortilla. They will then place the meat and cheese on top of the tortilla and roll everything together. They will then cut the roll into 5-6 bite -sized pieces and stick each with a toothpick and place in the covered deli dome with an ice -packed tray on the bottom. 1. Tour managers have the option to garnish the pinwheels with a cherry tomato as wanted. iv. A deli dome with an ice tray is used for sampling. Ice is replenished as needed, and a dome covers the sampling tray at all times (except when a sample is being retrieved). v. Samples are disposed of every 15-20 minutes and replaced with fresh ones as needed. 7. Cleanup a. All leftover samples and product will be discarded appropriately at the conclusion of the event. b. All utensils and cooking supplies are washed, rinsed, and sanitized appropriately, and are cleaned after every use. c. Any wastewater and trash will be disposed of appropriately. The following items are part of the event setup: