HomeMy WebLinkAboutPresto Strange O Coffee 8/30/2018Commonwealth 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:.
JESSICA CASE
Whose place of business is:
PRESTO STRANGE O COFFEE - QUALTER MIDDLE SCHOOL OPEN HOUSE
240 EAST STREET
PERSON(S) IN CHARGE:
JESSICA CASE
Permit Expires: August 30, 2018
Food Fee: $25.00
License Number: T-12
BOARD OF HEALTH
Michael wMcCCean, Chairman
,.--1 j-,a's.. .
1'VL\ UVAl\U Vl' LIIiALlll VJG VLY I.�I
Date Received Permit Fee Approved By Permit # Issued
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: rXe �0 r t:
2) Establishment Address: c✓, !�C' r\/ G'✓ i C� Zrc�
3) Establishment Mailing Address (if different):
4) Establishment Telephone No: t �f
5) ApplicanVOwner Name & Title:
Cf" C
6) Applicant/Owner Address:
7) Applicant/Owner Telephone No:
8) Applicant/Owner Email address: �
t/1� i� /'�O CJS G'/I C- � G . Cc`'-�/
9) Person Directly Responsible For Onsite Operations:
Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No:
10) Event Attending
Date(s):
569
Event Name:
� �% ( LarY e n/ 16
Event Location:
�Jf IC GC
Event time:
11) Check onri
Food Truck
❑ Caterer
❑ Other:
12) Solid waste disposal plan:
13) Water Source:
14) Sewage disposal plan:
15 ) Please give a brief description of the food to be served:
Food Protection Questionnaire for Catered Events
Date of Event: _7-- 130- /'7—
Event Time: 42
Location of Event: / N}'L ID
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? � Y eess ❑ No
Allergen Awareness Menu Label Present? l�'lles ❑ 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? vy E c' L s k GG 6
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.
❑ Onsite for immediate consumption
❑ Onsite and held at proper hot/ cold holding temperatures
❑ Offsite and held at proper hot/ cold holding temperatures
❑ Offsite, cooled and reheated on site
❑ Other:
17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
❑ Food Safety Manager: t/� ✓ ��
❑ Allergen Awareness:
18) For caterers: Cityrrown where food establishment permit is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the permits:
1, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law, 1 have been instructed
by the board of health on how to obt_* copies of 105 CMR 59"OO_And_tb&4ederal Food Code.
19) Signature of Applicant:
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 state taxes required under law.
20) Social Security Number or Federal ID:
21) Signature of Individual or Corporate Name: �_
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.
Si tore of Individual or Corporate Name
'Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
C:\Users\sleite\Desktop\Seott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORMdoc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Uf 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: G/��s✓o s�✓� �✓�C �o i're
Address: 26- o✓i lGi✓,�/�—
City/State/Zip: % Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. ❑ Retail
art -time).* 6. [1Restaurant/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] 8• ❑ 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]*
4. ❑ We are a non-profit organization, staffed by volunteers, I LE] fkalth Care
with no employees. [No workers' comp. insurance req.] 12. fl Other ' �'t =
*My applicant that checks box # I most 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. Lic.
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 welt 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 DtA for insurance coverage verification.
Ido hereby certify, under the pains and penalties of perms that the information provided above is true and correct.
Oficial use only. Do not write in this area, to be completed by city or tower official.
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
www.mass.gov/dia