HomeMy WebLinkAboutMansfield Shelter Friends 9/29/2018Commonwealth 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:.
MANSFIELD SHELTER FRIENDS, INC.
Whose place of business is:
MANSFIELD SHELTER FRIENDS, INC. - CELEBRATION OF ANIMALS
SOUTH COMMON- MANSFIELD
PERSON(S) IN CHARGE:
SHARON BAKER, CLERK
Permit Expires: September 29, 2018
Food Fee:
License Number: T-34
BOARD OF HEALTH
.Michae(.McCtean, Chairman
Date received:
FOR BOARD OF HEALTH USE ONLY
Date Inspected: Approved By: M i VetmiF#Issued i
FOOD ESTABLISHMENT PERMIT
IOATIO N—_
(Application must be submitted at least 7 days prior to planned event) C EL it ARA I l(
1) Establishment Name: MPINSFI�-LJ INC — OF' RNIHRI.
2) Establishment Address
So wrH Cot1r10 N 11 A fJ- F I V I-b
3) Establishment Mailing Address (if different) P, 0, Q ox 25%175 IZu I-r S T-
Mr�Nsr-Ir;�� MR o2o1�
4) Establishment Telephone
No: 50% 2 C I - 73 3 q
5) Applicant Name & Title:
V R N G SS ()i G (A RI.t r r
6) Applicant Address
113 SAt10St'f AVE, Mr3INSF iI�LT), r lA 02oa
7) Applicant Telephone No.:
gC)$ .3 3- 24 Hour Emergency No.: � 3 �'
8) Owners Name & Title
M NS r , L1� S H In L'CE2 f%21 1J DS N L
9) Owner Address (If different from applicant): Po R oX 25, M R NS FI E L'b, n A 02-01-g
10) Establishment Owned By:
❑ An Association
9 A Corporation
❑ An Individual
El A Partnership
❑ 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.)
IN
Name & Title:
S H A RO M � MEI2 I C L L-K ll<
Address:
'20 }AARVk'SiW001 Lt1NEr MANSFIEL`b 11A 0206Fg
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
V0 (1 (7 G jnC6 : CD in
Alt E-Mail:
I Ms ( I cu\ S t t 1S
C' I tcr- O rcj
13) District Or Regional Supervisor (if applicable)
Name &Title:
Sm)(ZoN RR. LR. CLFRl< I 11NO IL E'LV)i PRGSIbc
Address:
-
2G ��ARUESrW00� LAW6. 11Rm\ n
ni�L� l R 020(-g
Telephone No:
24 Hour Emergency No:
FAX:
\1i
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL. TOWN
I
DEP Public Water Supply No: (If applicable) 16) N0. Of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management: DAVID P. GARUFI
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): !..
20) Location: '-, Permanent Location
22) Establishment Type
-._ Caterer $25.00
Moblie Moblie Start Date:
Retail ( Sq. Ft)
[j Milk & Cream $10.00
Moblie End Date:
I_-1 Food Service up to 100 or
f-.] Mobile Food & Consession $75.00
Moblie Comments:
up to 10' PHF display $125.00.
---i Manufacture Frozen Desserts/Ice Cream !,
21 Length of Permit:
-
$25.00/freezer
,Annual l
or up oe25' PHF display $1160.00
P P Y
-,
Pushcart $25.00 # of Pushcarts:
Seasonal
'', Food Service up to 201 +
! Residential Kitchen $100.00
Seasonal Dates:
or 25'+ PHF display $275.00
-,
l Retail Food $100.00
J Temporary nG1 p
G I SOT r't 0 to
Food Service - Institution
(
_ Retail Snack Food $25.00
Temporary Start Date:
Meals/Day)
Tobacco Products $25.00
Temporary End Date: 29 �`' I L�1
Temporary Time.
Rain Date:
23) Food Operations Definitions:PHF - Potentially hazardous food(time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no timekemperature controls required)
(Check all that apply):
I RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no lufther processing)
i
_.I Sale of Commercially Pre -Packaged Non-PHFs
PHFFCooked To Order
Hot PHF Cood and Cooled or
-_
Sale of CommerciallyPre-Packaged PHFs
Preparation of PHFs For Hot And
for More Than a Single Meal Servo eHeld
'Delivery of Packaged PHFs
Cold Holding For Single Meal Service
PHF and RTE Foods Prepared For Highly
.
- - - -
' Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially'.
to be Prepared by Consumer
I Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Nori
! - - - - - - - - -
Customer Self -Service
I Use of Process Requiring A Variance,,
and/or HACCP Plan (including bare hand
Perishable Foods Only
_. __ -- g _ -
Ice Manufactured and Packaged for
! contact alternative, time as a public health
P ,
Preparation of Non-PHFs
Retail Sale
control) _-...
Other Food Operations
I!._� Juice Manufactured and Packaged for
[-', Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
HAMBURGERS/HOT DOGS/BAKED GOODS
I--
- --- _--
I Prepares Food/Single Meals for
BEVERAGES/POPCORN, CHIPS
Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
F—To be completed by the Board of Health
I, the undersigned, attest to the accuracy of the formation prop
establishment operation will comply with 105 C R 590.000 and
board of health on how to obtain copies of 1j0 CM590.000 an
24) Signature of Applicant: f W, d`'
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties
and paid state taxes required under law.
25) Social Security Number or Federal ID: 31-1642680
26) Signature of Individual or Corporate Name:
d in this
other ap
(Xl
Total Permit Fee:
ii Payment is due with application! waived
oplication and affirm that the food
!cable law. I have been instructed by the
Food Code.
I?perjury t6t I, to
v
best knowledge and belief, have filed all state tax returns
Food Establishment Information
14) WATER SOURCE:
15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) _ 16) NO. Of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management: _bA v I D
If more than 3 individuals are certified, complete list is on file.
as of 101112001 /n accordance with 105 CMR 590.003(A) Please attach copy of certificate
GARU►'T
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): El
1
20) Location: 0 Permanent Location
22) Establishment Type
0 Caterer 25
0 Moblie Mobile Start Date:
Retail ( Sq. Ft)
0 Milk &Creaream $2
Mobile End Date:
'
Food0 Service to or
Mobile Food 8 Consessfon $50
Mobile Comments: �
up to di
up to 10' PHF displayy $75
0 Mobile Food Temporary $25
21) Length Of Permit:
Food Service up to 101 -200
0 Manufacture Frozen Dessertstice Cream
❑ Annual
or up to 25' PHF display $100
$5/freezer
0 Seasonal
0 Food Service up to 201 +
0 Pushcart $25
or 25'+ PHF display $125
0 Residential Kitchen $25
Seasonal Dates:
O Food Service -Institution
0 Retail Food $50 of Pushcarts:
Temporary I 214 20 i 6
Temporary Start Date:
( Meals/Day)
Retail Snack Food $10
Temporary End Date: � 2, ( / 2O I G
0 Tobacco Products No Fee
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions:PHF- Potentially hazardous food(Nme/lemporatun, Controls required)
Non-PHFs - non -potentially hazardous food(no lime/temperature controls required)
RTE-ready-to-eat foods (Ex. sandwiches, salads, mu/fins which need no fudherprecessing)
0 Sale of Commercially Pre -Packaged Non-PHFs
0 PHFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
Sale of Commercial) Pre -Packaged PHFs
❑ y g
0 Preparation of PHFs For Hot And
for More Than a Single Meal Service
0 Delivery of Packaged PHFs
Cold Holding For Single Meal Service
0 PHF and RTE Foods Prepared For Highly
El of Commercially
0 Sale of Raw Animal Foods Intended
Susceptible Population Facility
Processed
Processed Foods for Service Within 4 Hours
to be Prepared by Consumer
Vacuum Packaging / Cook Chill
0 Customer Self -Service of Non PHF and Non-
Customer Self -Service
Use of Process Requiring A Variance
Perishable Foods Only
andfor HACCP Plan (including bare hand
0 Ice Manufactured and Packaged for
contact alternative, time as a public health
0 Preparation of Non-PHFs
Retail Sale
control)
Other Food Operations
0 Juice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of
1fn't( nvAWRG�RS/ 01- Was/
Retail Sale
Animal Origin
D
Cl (��T IsG O�s 0 �UkRt� vt �St
❑ Offers RTE PHF in Bulk Quantities
❑ Prepares Food/Single Meals for
Catered Events Institutional Food
s� 1
A T�
C IA I e S 1. 0 R CO R M C H�,V
0 Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
or Service
To be
r
completed by the Board of Health
Total Permit Fee:
Payment is due with application 0 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 145,61MR 590.000 andlhe federAlFood Cade.
24) Signature of Applicant: V(a/[\p fn.
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties
and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
I, to my best knowledge and belief, have filed all stale tax returns
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.
4 LI�t�A/VJWQIJ
* Signature of Individual ofl
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: M NSF 1 L L i S H >r LTtR rk (E wbs
2wf ST
NSFIt; L.b
reW
Phone 5Qg-U I 73S9
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. ❑ 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] 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 ME] Manufacturing
— w employees. [No workers' comp. insurance required]* 11.0 Health Care
4. � We are a non-profit organization, staffed by voluntoers,
with no employees. [No workers', comp. insurance req.l 12.❑ Other
*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. 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 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, u�#er the pains a"penaldesf of perjury that the information provided above its true and correct.
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 #:
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date -21 AUG 13
We, O I' I N S I 1 ��� �-1 ��` �I� i �e�staturant/ 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:
Lg 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.
❑ We are a religious organization.
❑ Other:
Thank you,
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date:
0
c
(D
IRS
CD
mi
pr w
FOR BOARD OF HEALTH USE ONLY Permit # Issued T-34
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name MANSFIELD SHELTER FRIENDS, INC. - CELEBRATION OF ANIMALS
2) Establishment Address SOUTH COMMON- MANSFIELD
3) Establishment Mailing Address (if different) P.O. BOX 25/175 FRUIT STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 261-7339
5) Applicant Name & Title: VANESSA GARUFI
6) Applicant Address 113 SAMOSET AVENUE, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 337-6849 (508) 463-7347 24 Hour Emergency No.:
8) Owners Name & Title MANSFIELD SHELTER FRIENDS, INC.
9) Owner Address (If different from applicant) P.O. BOX 25, MANSFIELD, MA 02048
Owner's telephone number 5082617339
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: ISHARON BAKER, CLERK
I
Address: 20 HARVESTWOOD LANE, MANSFIELD, MA 02048
Telephone No: 24 Hour Emergency No:
FAX:
E-mail: VANG2D6C(qGMAIL.COM
- - --
Alt E-Mail: MSF(a.)MANSFIELDSHELTER.ORG
13) District Or Regional Supervisor (if applicable)
Name & Title SHARON BAKER, CLERK - ANA VILLELLA, PRESIDENT
Address: 120 HARVESTWOOD LANE, MANSFIELD, MA 02048
Telephone No: 24 Hour Emergency No:
i J
FAX: E-mail: