HomeMy WebLinkAboutSt. Mary Septemberfest 9/16/2018Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type: TEMPORARY FOOD PERMIT
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:.
SAINT MARY PARISH
Whose place of business is:
SAINT MARY PARISH SEPTEMBERFEST
330 PRATT STREET
PERSON(S) IN CHARGE:
MICHAEL K. MCMANUS, PASTOR
Permit Expires: September 16, 2018
Food Fee:
License Number: T-71
WAIVED
BOARD OF HEALTH
Michael-%lcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY _ " calory
Date received: Date Inspected: Approved By:,':'( Permit # ISBi
FOOD ESTABLISHMENT PERMIT APPLICATION
pp rca ion mus a su mr e a eas ays a ore e p anne opening a e
1) Establishment Name
Saint Mary Parish SeptemberFest
2) Establishment Address 330 Pratt Street, Mansfield, MA 02048
3) Establishment Mailing Address (if different)
4) Establishment Telephone No 508-339-2981
5) Applicant Name & Title: Rev. Michael K. McManus Pastor
6) Applicant Address 330 Pratt Street, Mansfield, MA 02048
7) Applicant Telephone No.: 508-339-2981 24 Hour Emergency No.: same
8) Owners Name & Title Saint Mary Parish
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By:
11 An Association
El A Corporation
El An Individual
El A Partnership
[N 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.)
Name & Title:
Rev. Michael K. McManus
Address:
330 Pratt Street, Mansfield, MA 02048
Telephone No:
508-339-2981 24 Hour Emergency No: same
--- -- __.
FAX:-
E-mail:
office@stmarymansschool.org
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:
15) SEWAGE DISPOSAL:
16) No. of Food Employees: 0
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: September 16, 2018 11am to 4pm
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file. Cameron Symonds
Required as of 10/12001 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): El
20) Location: .XX Permanent Location
22) Establishment Type
❑ Caterer $25.00
Mobile Moblie Start Date:
0 Retail ( Sq. Ft)
❑ Milk & Cream $10.00
Mobile End Date:
Food Service up to 100 or
Mobile Food Consession
Mobile Comments:
up to 10' PHF display INCLUDING
FOOD TRUCKS $125.00
Food Service up to 101 -200
NO PHF PREPARED ON SITE $75.00
Ei Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
21) Length of Permit:
Annual
or up to 25' PHF display $150.00
❑ Food Service up to 201 +
or 25'+ PHF display $275.00
❑ Food Service - Institution
t Meals/Day)
❑Pushcart $25.00 # of Pushcarts:
El Residential Kitchen $100.00
❑Retail Food $100.00
0
Retail Snack Food $25.00
Tobacco Products $25.
--- -- -
Seasonal
Seasonal Dates:
® Temporary
Temporary Start Date: Sept 16, 2018
Temporary End Date: Sept 16, 2018
Temporary Time: 5 hours
Rain Date: none
23) Food Operations
(Check all that apply):
Definitions:PHF - Potentially hazardous food(time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/tempersture controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing)
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
El Sale of Commercially Pre -Packaged PHFs
Prearation of PHFs Cold Holding For SinglerHot And 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 di Variance
contact lemafweCCP a time as gag public heabare th
control)
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
❑ Customer Self -Service
Ice Manufactured and Packaged for
Sale
Preparation of Non-PHFs
Other Food Operations
8 Uft (sat 5
btlt �' fto(i i�
_Retail
Juice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of
Animal Odgin
pares Food/Single Meals for
❑Pre
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
('t.'L: 97L
Total Permit Fee:
Payment is due with application waived
1, 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 CMRj 590.000 and the federal Food Code.
24) Signature of Applicant: f1h,A�-�(wwt Il h�'t�^-!��'
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 state tax returns
and paid stale taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name: tb+
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, 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 (Mandatonj, 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.
C:\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Saint Mary Parish SeptemberFest
330 Pratt Street
City/State/Zip: Mansfield, MA 02048
Phone #:
508-339-2981
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
I am a employer with employees (full and/
5. ❑ Retail
orpart-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.
8• RI Non-profit
[No workers' comp. insurance required]
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]*
11.❑ Health Care
4.
We are a non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. rNo workers' comp. insurance req.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. # Expiration
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: h ( 1"n� Date:
y�
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6.Other
Contact
PermittLicense
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Phone
www.mms.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permitAicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Forth Revised 5-26-05
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date July 31, 2018
We, Saint Mary Parish SeptemberFest (restaurant/ organization )
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. *
Please list the organization:
❑ We are not charging a fee for food/drink being served.
M We are a religious organization.
❑ Other:
Thank you, j
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date:
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CWU) °° 3
DATE OF EVENT:
START/END TIME:
Town of Mansfield
6 Park Row, Mansfield, Massachusetts 02048
Board of Selectmen
APPLICATION FOR EVENT
September 16, 2018
I 1 am-4pm
GROUPS (S) INVOLVED: St. Mary's Parish
CONTACT PERSON: Rev Michael McManus, 508-339-2981
STREET(S) AFFECTED:
Pratt Street but Church has parking lot
APPROVED, BOS, CHAIRMAN
APPROVED, POLICE CHIEF Signed hard copy 8/3/18
APPROVED, FIRE CHIEF Signed hard copy 8/3/18
APPROVED, BOARD OF HEALTH With restrictions, APDP 8/7/18
APPROVED, BUILDING DEPT. No issues RIB 7/7/2018
APPROVED, DPW/HIGHWAY
APPROVED, PARK & REC
RESTRICTIONS:
Police and Fire- Keep road accessible for all emergency vehicles to
safely pass
Tents over 700 square feet require permits RJB
Food vendors must obtain permit 7 days before event.
IF propane is used for cooking, permits must be pulled at FD prior to
event. No charge for permit.
Phone (508)261-7372 Fax (508)261-7498 Emailselectnen@nyanfieldvna.com
XANSFIFL ID
SPECIAL EVENTS APPLICATION
Town of Mansfield
6 Park Row, Mansfield, MA 02048
Phone:508-261-7372 Pax:508-261-7498
www:mansfieldma.com
Upon receipt of this completed application, you will be contacted by the Secretary to the Board of Selectmen for the Town of
Mansfield, Tracey Whalen. This application can be downloaded at www.mansfieldma.com. This application must be
received 30 days prior to the event. Please note that submission of this application should in no way be construed as final
approval or confirmation of your request. Final approval will require sign -off by Public Safety Departments and possible
review and sign -off by the Board of Selectmen and does include filing of and payment for all required permits.
Date of Application
July 31, 2018
Saint Mary Parish
Applicant Information
330 Pratt Street
(name, address, phone number)
Mansfield, MA 02048
508-139-298
❑Block Party
❑Carnival
Event Category
❑Circus
(please check any and all that apply)
❑Concert/Performance
❑Farmers' Market/Sidewalk Sale or Fair (with multiple vendors)
❑Fine Arts Exhibits
❑Parades/Procession
❑Rental of a Public Building or Facility
❑Road race/Walk
other: SeptemberFest
Parish event including entertainment,
Event Detail
description)
children's games, raffles, petting zoo,
food.
Proposed Date and Location
September 16, 2018
Parish grounds
For road mcedwalks, plmse include stanifinishiontions end augh =P of mum.
11 am
Event Start Time
Your event may requim pre -inspection by Town staff on the day of the cvcnt.
Event End Time
4 pm
Rev. Michael K. McManus
Event Contacts
330 Pratt Street
(include organizer's name, address, phone,
Mansfield, MA 02048
email and web -site if applicable)
508-339-2981 frmike@stmarymansschool.org
E VENT FEATURES
Please Answe That Apply
Will You Serve Or Sell Alcohol?
Y or If Yes, how man vendors?
Will You Serve, Sell Or Give Awa Food?
or N If Yes, how man vendors? our own eo 1
Will You Sell Or Give Away
Y or N If Yes, how many vendors? our own peopl
Merchandise?
Will Your Event Use, Close Or Block Any
❑Town Streets
Of The Following?
❑Town Sidewalks
❑Town Parking Lots
❑Town Commons
❑Town Rights Of Way
❑Town Fire Hydrants
Will Your Event Require Any Of The
C,�Tent/s
Following?
If Yes, how many? six
❑Electrical Services/Generators
If Yes, please provide name of vendor
❑Temporary Fencing
®Amplified Sound (live music or deejay)
❑Public Dance Floor
[]Stage
If Yes, what size
If Yes, please provide name of vendor
Will Your Event Include Any Of The
®Open Flames or Cooking/Propane
Following?
❑Carnival or Amusement Rides
❑Inflatable Amusements
®Games
®Live Animals
(ERaffle
❑Special Effects
❑Exterior Lighting
❑Pyrotechnics/Fireworks
Will you charge an admission fee? Y or N
Attendance
How many people do you expect to attend (per day)?
Will you event require signs or banners? Y or N
Publicity
Parking Plan
(please provide description)
On site parking
Clean -Up Plan
(include trash removal/clean-up plan, and
from 4 pm to 6: 30 pm
name of vendor, if applicable)
our own people
Upon review of your application, you may be required to use and
Event Security
pay additional fees for police officers and/or emergency medical
services personnel.
Insurance
Please note that you may require a Certificate of Insurance.
The application process begins when you submit this completed Special Events Permit Application to the Town
of Mansfield. Please note that submission of your application should in no way be construed as final approval or
confirmation of your request. Upon receipt of you application, the Town of Mansfield's Secretary to the Board of
Selectmen, Tracey Whalen will help guide you through the permit process. Copies of your application will be
forwarded and reviewed by the appropriate Town departments and divisions. You may be required to speak
before the Board of Selectmen to explain your event. If your event requires additional permits, licenses,
certificates, site inspections or police detail, you will be notified In some cases, costs are associated Upon
approval by the Board of Selectmen, you will receive a letter of approval.
NAME (please print):
SIGNATURE:
Rev. Michael R. McManus