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HomeMy WebLinkAboutCreedon & Co/Touch a Truck 9/22/2018Commonwealth 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:. JOHN CREEDON, PRESIDENT Whose place of business is: CREEDON AND CO., INC. - MANSFIELD TOUCH A TRUCK 265 FRUIT STREET PERSON(S) IN CHARGE: JOHN CREEDON, PRESIDENT Permit Expires: September 22, 2018 Food Fee: $25.00 License Number: T-79 BOARD OF HEALTH Michae(McCCean, Chairman UV FOR BOARD OF HEALTH USE ONLY 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: ciree d Q I ' OLh 00 , /1 I n ( . 2) Establishment Address: 3 -701 I l l a— V `l. d W 0 a n l c K M 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: n U — '/ q a— 3 I b Q pp ' V �y � 5) Applicant/ wner Name & Title: / f m �'�.h 11� Q o K `e I I lq! ^V "Q u 6 Applicant caner Address: 3q -,TDI rna 1100-.d O C10Jfo' /1 G)1 7) Applicant/Owner Telephone No: �' - G a. —3t 0 0 8) Applicant/Owner Email address: q m u� c j o tA a nd_ Cc) O O W 9) Person Directly Responsible For Onsite Operations: Cre e d opn bu i i e Ct-e e. do Name & Title: tt,�John John C e ``- d o n 1 r,e f ci Address: n-�- /�� , J o I m a lid . W o rC eS 1 er I j 1 I O I Lo D -I Telephone No: 5-D Q- r7 a— J 1 Q© Fax: J V -� 31 q qZ v Emergency Telephone No: 11 g� y '1 I — t 9t 3 10) Event Attending Date(s): Event Name: (`a mah6kif IJ 't -7 Duch a-rtLcIlt fthcifSS'I f Event Location: A) {' 'Q r'e — o) b u t + S- Event time: a i�}'� ' Qd o P m 11) Check one 12)) Solid waste disposal plan: Food Truck ern�(,�lqJ, - k back � Creeda(1 Caterer d L1-1 f 1 pkT - f-Y Other: 13) Water Source: N !Y - (�Ufifit ed we-FUc - 14) Sewage disposal plan: 5r&q h+- (oactz 1-rJ Cl-ep cON 15 ) Please give a brief description of the food to be served: 0oncQs5i onc- burgers, dogo, c to +h d.P,rs, Fries Ckq s d r (n � G, s a-Ut &9 0-, P (-sI ry DI (0d� & 0Y 16 ) Food will be prepared: Onsile for immediate consumption Onsite and held at proper hoU cold holding temperatures Offsite and held at proper hoU cold holding temperatures 'x 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: I .,p Food Safety Manager: J u I ��I ��1,nn a-e dye clo n Allergen Awareness: J 1A,� l.: t "� a 18) 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 accuracy of the information provided in this application and I 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 Iyop s of 105 CMR 590.00P-Ind the federal Fee q Code. 19) Signature of Applicant: 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. 20) Social Security Number or Federal ID: 21) Signature of Individual or Corporate Name: L/"'e5' '�— 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. 92�L UJI91 nature of Individual or Corporate Name 0�-ag9J'�_q3 "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:AUsers\sleileADesktopAScott's Documen( \rood Estoblishments- TempATAX CERTIFICATION FORNI.doc Food Protection Questionnaire for Catered Events Date of Event: 1 � Event Time: q a nn — /? P rn Location of Event: M G II 6 ��l e Id Ml CA() Q f} i }J KC List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Ye 2d Cooking Reheating eeF '�0.tt�t �co YljllbG!/rS fTU S Qk Chlu tend-ers Food Manager Certification Person Trained On Site? xycs L No Allergen Awareness Menu Label Present? Yes I I No List all Pete, ti lly Hazardous Food (PHF) and the individual intended temperature required: t/3. l M�-� 3 List the required temperature for each food as it leaves your preparation site: r t, How will the PHF be kept at or below 41 °F? ("� st TY t�E. ce-(,, ('tit h t How will the PHF be kept at or above 140°F? �` r �C p f 6 Time of PHF? Setup Served Removed C 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. ,` &r P. t ( ✓��9R �p6rP 6{ S P�E�++t�'S t n P" �. The Commonwealth of Massachusetts Department o f industrial Accidents Office of'Investigations 600 Washington Street Boston, MA 02111 wwty ntass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: N o rco e r AAA olWO CA Phone #: ` jM ' l qd '51d0 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. ❑ 1 am a sole proprietor or partnership and have no 7. Office and/or Sales (met. real estate, auto, etc.) employees working forme 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, 11. ❑ Health Care with no employees. [No workers' comp. insurance rep.] 121-1 Other nny npyucnut um, cuccrcS "., N, al.,,t aISO 1111 uul one Secllon neiow an Owl 119 the Ir workers' compensation policy in to] III lotion. **If the corporate officers have exempted themselves, but the corporation has other employees, it workers' compensation policy is requited and such an organization should check box #I. 1 rat an employer that is providing workers' compensation insurance for my employees. Below is the police information. Insurance Company Name: Te Y)' aA(S IF)6L14tr I n t5 (l,{ o—n ce 1q—a e__nr.0 Insurer's Address: City/State/Zip: 09 Sh" phi, o rc e J4--e,r M a c� Policy # or Self -ins. Lie. # 3"7 — Y? �3 q 3 S' 6 1 — o 1 Expiration Date: 3 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 a 152 can lead to the imposition of criminal penalties of a fine tip 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 andpenalties of perjury that the information provided above is true and correct. Signature: RWA I 10 li� I `eq Date: G' 19 l Phone #: `JV 4 ` U l l 0) — ­3 / &VU Official use only. Do not write in this area, to he completed by chy or tmvu official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectm70iffilice 6. Other Contact Person: Phone #: www.mass.goviota PIN: FM-17.1068 CITY OF WORCESTER, MA Department of Inspectional Services 25 Meade Street, Worcester, MA 01610 Phone:(508)-799-8539 k; FOOD ESTABLISHMENT PERMIT PERMIT EXPIRES: Mondav, December 31,_ 2018 EFFECTIVE DATE: Monday January 01 2018 PERMIT FEE: $250.00 2018 In accordance with Regulations promulgated under authority of M.G.L. c. 94, ss 305A: c. 111, ss. 5 123A, 105 CMR590.000 a Permit to operate a Food Establishment is hereby granted to: Name of Permit Holder JOHN W.S. CREEDON Address of Permit Holder 39 JOLMA RD. Name of Food Establishment CREEDON AND CO., INC. Address of Food Establishment 39 JOLMA RD OPERATIONS PERMITTED DURATION OF PERMIT Food and Drink Establishment 1 - 100 Occupancy Annual Comments: Restrictions: Common Notes: Renewal of Permit: An annual food establishment permit may be renewed by applying at least thirty(30) days prior to the expiration of the permit. Notification of Changes: This permit is non -transferable. A permit holder shall notify the DIS at least 30 days prior to any change. If this business is to close or there is a change in ownership, The DIS must be notified at least two weeks prior to closing and this permit must be returned to the DIS. Director of Housing and Health Inspections Post Conspicuously \t \\ \) t )0 / > \ ® )\ \ CD Z `= r O )} \ \ CD Z j} � ¥a O � �\ LLM W )\ » W \` / </ _ W \r CO k LLJ \ \ \ \ \ 3 / W-� CD W-4 � � � � � � � � \41 \ x \ \ \ a:\ { yyy2 w ~ ~ \ )Ul &