HomeMy WebLinkAboutFenway Sausage Works 5/17/2018Commonwealth 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:.
CORY HANKS
Whose place of business is:
FENWAY SAUSAGE WORKS - DISTRICT ART SHOW
MANSFIELD SCHOOL COMPLEX - EAST STREET
PERSON(S) IN CHARGE:
CORY HANKS
Permit Expires: May 17, 2018
Food Fee: $25.00
License Number: T-14
BOARD OF HEALTH
Michae(MCC(ean, Chairman
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Date Received Permit Fee Approved Bey Permit # Issued
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: /4->�t.a/ 517,4sg�e o�
2) Establishment Address: �'3 //9.iN�/vNt3/,.7 S
3) Establishment Mailing Address (if different):
4) Establishment Telephone No: LaF !
5) Applicant/Owner Name & Title: /,
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6) Applicant/Owner Address: 9�
7) Applicant/Owner Telephone No:
8) Person Directly Responsible For Onsite Operations: O
Name & Title:
Address:
Telephone No:
S� ®�S®O Fax:
Emergency Telephone No:
9) Event Attending
Date(s):
/7l
Event Name:
Event Location:
2-310 O
Event time:
10) Check one
>r, Food Truck
j Caterer
1 Other:
11) Solid waste disposal plan:
12) Water Source:
C17Y
13) Sewage disposal plan:
14 ) Please give a brief description of the food to be served:
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.
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Signature of Individual or Corporate Name By: Corporate Officer idatory, i Appli a le)
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"*Social Security No. (Voluntanj) 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.
Ct\Useis\sleue\Desktop\Scod's Documents\Fond Establishments- Temp\TAX CERTIFICATION F'ORM.doc
Food Protection Questionnaire for Catered Events
Date of Event: Z Event Time:
Location of Event:
List all foods that you will be chilling, holding, cooking, and/or re heating at the event location:
On ice/Refrigerated Cooking Reheating
c
WIM11.
Cii'PrS �
Food Manager Certification Person Trained On Site? Z X ❑ No
Allergen Awareness Menu Label Present? es 1 7 No
List all Potentially Hazardous Food (PHF) and the individual intended temperature required:
s�yprn/rrs S'
List the required temperature for each food as it leaves your preparation site:
How will the PHF be kept at or below 41 °F?,�j��O
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.
CLoG.�S
S'pw.�T/7iiP
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15 ) Food will be prepared:
�- 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:
16) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
-Food Safety Manager: G: ✓ /Py ZN k-<-
Allergen Awareness: ['cf )i'
17) For caterers: City/Town 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:
I, the undersigned, attest to the a
establishment operation will con
by the board of health on how to
18) Signature of Applicant: _
of the information provided in this application and I affirm that the food
105 CMR 590.000 and all other applicable law. I have been instructed
boles of 105 CMR 590.000 and the federal Food Code.
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.
19) Social Security Number or Federal ID:
20) Signature of Individual or Corporate Name:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
y Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:_
Address:-,)
City/State/Zip:
Phone
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2 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• ❑Noit-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]* I .❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12�2 Other / o I1 >
*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 #I.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's Address:
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 trite 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 Person:
www.mass,gov/dia
Phone
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COMMONWEALTH OF MASSACHUSETTS
Town of Foxboro
Board of Health
Fenway Sausage Works
NAME
23 Hammond Street New Bedford, MA 02745
NUMBER
BHP-2018-0615
FEE
$100.00
DATE ISSUED
January 27, 2018
ADDRESS
IS HEREBY GRANTED A MOBILE FOOD SERVICE, CANTEEN TRUCK
PERMIT
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires December 31, 2018 unless sooner suspended or revoked.
RESTRICTIONS: Contact BOH regarding future locations/events in 2018.
NOTES: MOMS Foxboro Winter Bash
Health Director
COMMONWEALTH OF MASSACHUSETTS
Town of Foxboro
Board of Health
Fenway Sausage Works
NAME
23 Hammond Street New Bedford, MA 02745
Board of
Health
NUMBER
BHP-2018-0615
FEE
$100.00
DATE ISSUED
January 27, 2018
IS HEREBY GRANTED A MOBILE FOOD SERVICE, CANTEEN TRUCK
PERMIT
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires December 31, 2018 unless sooner suspended or revoked.
RESTRICTIONS: Contact BOH regarding future locations/events in 2018.
NOTES: MOMS Foxboro Winter Bash
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Health Director
Board of
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