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Home My WebLink AboutNew Hope Natural Media - 9/20/2008TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD, MA 02048 PERMIT TO OPERATE A MOBILE FOOD TEMP ESTABLISHMENT 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: NEW HOPE NATURAL MEDIA Whose Place of Business is: NEW HOPE NATURAL MEDIA (PENTON) @ THE COMCAST CENTER Permit expires September 20, 2008 License Number. MF-308T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH Dr. Raymond Martin, Chair an FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued 03 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: �- r ^ 2) Establishment Address: 445 m pry 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 046 . 5) Applicant Name & Title: 6)Applicant Address: ' O i 7) Applicant Telephone No.: 02, 24 Hour Emergency No.: Ocl , 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: Corporation 0A`1nAssociation An Individual ❑ A Partnership El Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. � eAA 11 " Ck�� N"r� )�� $ vl� lye t ,� B�'w2 � O 12 Person Directly Responsible For Daily Operations Owner, person in charge, Supervisor, Manager, etc. Name & Title: C7 Address: 'tp\ 1 Telephone No: _ 6jbj cjLIjo Fax: 770 CI, 6t'�&[d6 Emergency Telephone No: 13 District Or Regional Supervisor (rf applicable) Name & Title: Address: Telephone No: Fax: BLANK FOOD PERMrr APPLICATTON Food Establishment information 14.) Water Source 15) Sewage Disposal DEP Public Water Supply No: (if applicable): 0Ai 16) Days and Hours of Operation: 17) No. of Food Employees 18) Name of Person In Charge Certified in Food Protection Management: Dawn / i w, )� Re ulred as of 1011/2001 in accordance with 105 CMR 590.003(A) Please attach co of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): 20) Location: Co VV',(A ��0� 22) Establishment Type: ❑ Caterer ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Food Service -( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Bed & Breakfast Home Mobile (Dates) i-o 6 ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) ' SD cm 21) Length Of Permit: (check one) ❑ Annual ❑Seasonal/Dates �7 Temporary/Dates/Times �C 23) Food Operations: Definitions: PHF- Potentially hazardous food(timettemperatun: controls required) (check all that apply): ` Non-PHFs- non -potentially hazardous food (no fimeAemperature controls required) RTE -rea do -eat foods .Sandwiches, salads, muffins which need no further rocessin) Sale of commercially Pre- ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Holdin For Sin le Meal Service Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to , ❑ Vacuum Packaging/Cook Chill be Prepared b Consumer ❑ Reheating of commercially Customer Self -Service Use of Process Requiring A Variance and/or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service of Non ❑ Ice Manufactured and Packaged for . ❑ Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Only. ❑ Preparation of Non-PHFs Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Retail Sale Events or institutional Food Service El Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Other (Describe): ❑ Retail Sale of Salvage, Out-0f-Date or Total Permit Fee. Reconditioned Food Payment is due with application 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 htir- plicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.090-afd the �Food C�te. 24) Signature of Pursuant to MGL Ch.62C, sec. 49A, I certify uftde'r the penalties of perjury that I, to my best knowledge and belief, have filed all state returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: BLANK FDOD PERMIT APPLICA'nON 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. Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number 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. R:MmIthVane's DocumentMAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U1V www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: XNO(yc-r\ -6� �60 p, Phone #: Are you an employer? Check the appropriate box: Business Type (required): I. I am a employer with l2_ employees (full and/ __or 5. ❑ Retail TT part-time).* 6. ❑ Restaurant/Bar/Bating 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. g• ❑ 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] * I I Health Car'el 4. ❑ We are a non-profit organization, staffed by volunteers, nce with no employees. [No workers' comp. insurareq.] •❑ 1 12.KOther �v `eli *Any applicant that checks box #I 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. I am an employer drat is pro vidingaworkers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address: City/State/Zip: a IAN Policy # or Self -ins. Lie. # U ?,s 4, w 16 ` Expiration Date: 2' 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#y against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations.of the: DIA for insurance qa erase verification. I do hereWW fy,lunder the pains phd penaltjis ofperjury that the information provided ybove P true and correct. Official use only. Do not write in this area, to be completed by city or town officlal. City or Town: Permit/License # 1-71U-f 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 i afe Exam F-aa No.4342 01W. No. 676n3a ServSafe` certification To SAMUEL B OWEN bnxwaMNttmWamaapelaMxbM foM bylhe NariarelamxneKAaarcWbnf0.ra(anW ruMelianralinaevaele®iwtl Rgml�Ma,aperCniliretlon Eremualim Date of Examination: 2/26/2008 Date Of ExptraGon: 2/26/2013 Lecana,pply. Ch dMh Yms pw.w...NaloryeBancV Hanonal gesawa....... zon torreeeMeaaon requirement. EDUMI-.AT1ONL, 47'r; 11-24 e AUN j 1210(0) forLD.: udeA1388 TO THE ORDER OF i FARGOBANK, N.A. ARL ST i- -R, CO 80302 WIRIES GALL (480) 394-3122 u•047722464011' 1:L210002481:486L 5057821" Sam Owen MIX Operations Manager direct 303.998.9539 cell 303.709.S503 fax 303939.9866 samuel.owen@penton.com **$25.00** deliciousliving magarine 1401 Pearl Street, Suite 200 Boulder, Colorado 80302 303.939.8440 Rnion