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HomeMy WebLinkAboutM&M Concessions/Fanelli - 5/1/2008TOWN 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: MARK FANELLI Whose Place of Business is: M&M CONCESSIONS Permit good May 1-4, 2008 License Number. MF-152T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH r Dr.�,R�ypond Martih, Chairman 04/23/2008 WED 9140 PAX Date Received Q0> 0/0> 4 1cd t BOARD OF Date Inspected TH Approved By Permit # Issued 111 F 2--F FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: M&M CONCESSIONS 2) Establishment Address: P.O.BOX 249 RINDGE, NH 3) Establishment Mailing Address (if different) P.O. BOX 249, RINDGE, NH 4) Establishment Telephone No: 5) Applicant Name & Title: MARY FANELLI 6) Applicant Address: 216 PROSPECT STREET, LEOMINSTER, MA 01453 7) Applicant Telephone No.: 978-537-1428 24 Hour Emergency No.: 508-962-7372 8) Owner Name & Title (if different from applicant): MARK FANELLI 9) Owner Address (if different from applicant): 216 PROSPECT ST„ LEOMINSTER, MA 01453 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. PARTNERSHIP MARY FANELLI 216 OR 244 PROSPECT ST., O An Association LEOMINSTER, MA 01453 nIndividual rCorporation Partnership ther legal entity 4Cl Oarenn !)iron#Iv l7ccnnncihla Fnr!hilt, rinwnfinnc rrlu.oar nprenn in rhnrna Si mpnilanr UnnAnP. PAr. I Name & Title: Address: Telephone No: Emergency Telephone No: 421n' I?aninnpl 4h inavicnr lir pnnllnphlal Name & Title: — Address: f -�7 Telephone No: ax: 04/23/2008 WED 9140 FAX Food Establishment Information @�ott/ota 14.) Water Source: TOWN 15) Sewage Disposal TOWN DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: MAY 1ST -MAY 4TH 2O08 17) No, of Food Employees 2 PER 18) Name of Person In Charge Certified in Food Protection Management: Re uirad es of 10111200f in accordance with 105 CMR 590.003 A Please attach copy of certitioate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): I NO 20) Location: 22) Establishment Type: ❑ Retail ( Sq. Ft) ❑ Caterer TEMPORARY ❑ Food Service - ( ) Seats O Food Delivery [] Per anent �� [� obile Dates r1 —�/ ( )- ❑ Food Service - Institution ( Meals/Day) ❑ Residential Kitchen for Retail Sale ❑Residential Kitchen for Bed & Breakfast Home Other (Describe) ❑ Residential Kitchen for Bed & Breakfast / Establishment ❑ Frozen Dessert Manufacturer 21) Length Of Permit MAY 1ST-4TH 23) Food Operations: Do Onl ions: PHF— Potentially hazardous food(time/temperature controls tequired) Non-PHFs- non -potentially hazardous food (no timehemperature controls required) check all that apply): RTE- ready -to -eat foods (Ex. Sandwiches, salads, my lns which need no Podhorpro cessing) Sale of commercially Pre- © PHFCooked To Order Hat PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Pre- Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs cold Holding For Single Meal Susceptible Population Facility Service El Delivery of Packaged PHFs Lj Sale of Raw Animal Foods Intended Vacuum Packaging/Cook Chili to be Prepared by Consumer ❑ Reheating of commercially ❑ Customer Self -Service EJ Use of Process Requiring A Variance Processed Foods For and/or HACCP Plan (including bare hand Service Within 4 Hours. contact alternative, time as a public health control Customer Self -Service of Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Non PHF and Non- Retail Sale Animal Origin P fishable Foods Only, reparation of Non-PHFs LJ Juice Manufactured and packagedLJ Prepares Food/Single Meals for Catered for Retail Sale Events or institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the board of Health Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Total Permit Fee: $26.00 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 other applicable law. I have been instructed by the board of health on how to obtain cciMep of 105 CMR4g"P"nd the federal Food Code. 24) Signature of Applicant: Pursuant to MOL Ch.62C, sec. 49A, I certify Aer the penalties of perjury that I, to my best knowledge and belief, have filed all state returns and paid state taxes required under law. c��{ r, 25) Social Security Number or Federal ID: O T223 9v D 7 �' 6 0'� r, 26) Signature of Individual or Corporate Name: TOWN 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: MARK FANELLI Whose Place of Business is: M&M CONCESSIONS Permit good May 1-4, 2008 License Number. MF-153T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH l � Dr. Ralond Martin, dhairlpan 4/23f3005 WED 909 FAX ®ooa/ala 41- POP(0)CA, C hop--;, �-owl fi�"� TH USE ONLY Date Received Date Inspected Approved By Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at feast 30 days before the planned opening date) 1) Establishment Name: M&M CONCESSIONS 2) Establishment Address: P.O.BOX 249 RINDGE, NH 3) Establishment Mailing Address (If different) P.O. BOX 249, RINDGE, NH 4) Establishment Telephone No: 5) Applicant Name & Title: MARY FANELLI 6) Applicant Address: 216 PROSPECT STREET, LEOMINSTER, MA 01453 7) Applicant Telephone No.: 978-637-1420 24 Hour Emergency No.: 508-962-7372 8) Owner Name & Title (if different from applicant): MARK FANELLI 9) Owner Address (if different from applicant): 216 PROSPECT ST., LEOMINSTER, MA 01453 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. PARTNERSHIP MARY FANELLI 216 OR 244 PROSPECT ST., ❑ An Association LEOMINSTER, MA 01463 ❑ A Corporation ❑ An Individual O-A Partnership ❑ Other legal entity 171 Porenn niraMly RaannnQihia Rnr nnii%, innarntinna fnwnar narcnn In nharna SI1hfbrvignr. MAnmoer. etc.1 Name & Title: Address: Telephone No: j l Z Fax: Emergency Telephone No: A41 N.frl } rlr Ranlnnnl Ri,nan,icnr Rfnnnlicahial Name & Title: Address: 7 2- Telephone No: Fax: A 04/23r.2008 WED 909 FAX Food Establishment Information 0009/014 14.) Water Source: TOWN 15) Sewage Disposal TOWN DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: MAY 1ST -MAY 4TH 2O08 17) No. of Food Employees 2 PER 18) Name of Person in Charge Certified in Food Protection Management y(7� ) /7 ,r v �/ C6 y) '/�-�-- Re uired as of 10/0001 in accordance with105 CMR 590.003 A Please attach cn of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): NO 20) Location: 22) Establishment Type: ❑ Retail ( Sq. Ft) ❑ Caterer TEMPORARY ❑ Food Service- ( ) Seats ❑ Food Delivery ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Retail Sale [2,IOfobile (Dates) 4( Day) ❑ Residential Kitchen for Bed & Breakfast Home Other (Describe) (Describe) ❑Residential Kitchen for Bed & Breakfast I /) Establishment ❑Frozen Dessert Manufacturer Frozen 21) Length Of Permit: MAY 1ST-4TH 23) Food Operations: DOfirntionsr PHF- Potentially hazardous food (lime/lomporature controls required) Non-PHF's - non -potentially hazardous food (no b'me/lempareture controls mqulmd) (check all that a I J; RTE- matly-to-eat foods (Ex. Sandwiches, salads, muffins which noed no further procassing) ET Sale of commercially Pre- ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service ❑ Sale of Commercially Pre- Ll Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs cold Holding For Single Meal Susceptible Population Facility Service Delivery of Packaged PHFs Sale of Raw Animal Foods Intended El Vacuum Packaging/Cook Chill to be Prepared by Consumer LJ Reheating of commercially ❑ Customer Self -Service D Use of Process Requiring A Variance Processed Foods For and/or HACCP Plan (including bare hand Service Within 4 Hours, contact alternative, time as a public health control ❑ Cust mer Self -Service of Ice Manufactured and Packaged for Offers Raw Or undercooked Food Of N 6 PHF and Non- Retail Sale Animal Origin aerishable Foods Only, Preparation of Non-PHFs Juice Manufactured and packaged ❑ Prepares Food/Single Meals for Catered for Retail Sale I Events or institutional Food Service. ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health Retail Sale of Salvage, Out -Of -pate or Reconditioned Food Total Permit Fee: $25.00 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 106 CMR 590.0no and all other applicable law. I have been Instructed by the board of health on how to obtain cop' f 106 CMR 5 .00 and the Feder ood Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A. I certify and the penalties of perjury that i, to my best knowledge and belief, have filed all state returns and paid state taxes required under law.,} U Q 9 D 1 (p 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: li 04/23/2008 WED 9:41 FAX Q012/014 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. "Social Security No. (Voluntary) 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. RAHcalWancs DocumenuTE MIT APPLICATIONSUAX CERTIFICATION FORM.doc 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 pplicant Information Please Business/Organization Name: #: q7�- 3 7- Are y an employer? Check the appropriate box: Business Type (required): 1. EV I am a employer with f[ 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 (me]. 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 10.0 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 req:] 12.® )M,/)L Other / t /%t *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 #l. I am an employer that is providing rgorkers' compensation insurancedor my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. a (D �7 1d 0/pKtion Date: 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 c/ertrf , under thethe pai and perm tiieees ofperjury that the information provi�de/d above is truce 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 Phone www.mass.gov/dia TOWN 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: MARK FANELLI Whose Place of Business is: M&M CONCESSIONS Permit good May 1-4, 2008 License Number. MF-150T Food Fee: $25.00 Milk & Cream: NO BOARD OF HE Dr. RayTOd Martin, Chairman 04/23/2008 WaD 9135 FAX Date Received FOR BOARD OF Date Inspected Approved By 11 Permit # Issued H r- i FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: M&M CONCESSIONS 2) Establishment Address: P.O.BOX 249 RINDGE, NH 3) Establishment Mailing Address (if different) P.O. BOX 249, RINDGE, NH 4) Establishment Telephone No: 5) Applicant Name & Title: MARY FANELLI 6) Applicant Address: 216 PROSPECT STREET, LEOMINSTER, MA 01453 7) Applicant Telephone No.: 978-537-1428 24 Hour Emergency No.: 508.962-7372 9) Owner Name & Title (if different from applicant): MARK PANELLI 9) Owner Address (if different from applicant): 216 PROSPECT ST., LEOMINSTER, MA 01453 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or Partner. PARTNERSHIP MARY FANELLI 216 OR 244 PROSPECT ST., ❑ An Association LEOMINSTER, MA 01453 © Corporation ❑ An Individual A Partnership Other legal entity 121 person Directly Resnonaihla Fnr Daiiv nnerations tOwnpr. nersnn in nhnrne_ Sunervisor. Manaoer. etc.l Name &Title: Address: Telephone No: _/ Pax: Emergency Telephone No: 6 2- 73 7 -3--- 131 nistrirt Or Roninnal Sunarvisnr /if annlinahlal Name & Title: ' Address: y Telephone No: ��0 Z 7 04/23/2008.wao 9s35 FAX fQ003/014 14,) Water Source: TOWN DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: MAY 1ST -MAY 4TH 2O08 18) Name of Person In Charge Certified in Food Protection Management: It 14rllj 17) No. of Food Employees tA.-q— /laa A-1 _. 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): NO 20) Location: 22) Establishment Type: ❑ Retail ( Sq. Ft) ❑ Caterer TEMPORARY ❑ Food Service - ( ) Seats [] Food Delivery ❑ Permanent E] Food Service - Institution ❑ Residential Kitchen for Retail Sale ❑ Mobile (Dates) I . ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Home Other (Describa) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer 21) Length Of Permit: MAY 1ST-4TH 23) Food Operations: Definitions:PHF — Potentially hazardous food(time/temperature controls required) Non. F's—non-potentially hazardous load (no BmeRemperature controls fequired) check a!I that a 1 -readyto-eat foods (Ez. sandwiches, soled$, muffins which need no Nriherprocessing) LJ Sale of commercially Pre- PHFCooked To Order Hat PHF Cooked and Cooled or Hot Held Packaged Non-PHFs for More Than a Single Meal Service ❑ Sale of Commercially Pre- ❑ Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs cold Holding For Single Meal Susceptible Population Facility Service Delivery of Packaged PHFs Sale of Raw Animal Foods Intended Vacuum Packaging/Cook Chill to be Prepared by Consumer ❑ Reheating of commercially LJ Customer Self -Service U Use of Process Requiring A Variance Processed Foods For and/or HACCP Plan (including bare hand Service Within 4 Hours. contact alternative, time as a public health control Customer Self -Service of ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Non PHF and Non- Retail Sale Animal Origin Perishable Foods Only. EJ Preparation of Non-PHFs Juice Manufactured and packaged El Prepares Food/Single Meals for Catered for Retail Sale Events or institutional Food Service LJ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Total Permit Fee: $25.00 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 ith 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtai co ' s of R 590 000 and the federal Food Code. 24) Signature of Applicant: ILI Pursuant to MOL Ch.620, sec. 4gA, I ce i under the penalties of perjury that I, to my best knowledge and belief, have filed all state returns and paid state taxeErrequired under law. Iltl 26) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: TOWN 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: MARK FANELLI Whose Place of Business is: M&M CONCESSIONS Permit good May 1-4, 2008 License Number. MF-151T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH Dr. Raymppd Martin, Cha man 04/23/2008 WED 9136 _ FAX U� Date Received Date Inspected 0004/014 USE ONLY Approved By Permit # Issued M r- /S/ T- FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: M&M CONCESSIONS 2) Establishment Address: P.O.BOX 249 RINDGE, NH 3) Establishment Mailing Address (if different) P.O. BOX 249, RINDGE, NH 4) Establishment Telephone No: 5) Applicant Name & Title; MARY FANELLI 6) Applicant Address: 216 PROSPECT STREET, LEOMINSTER, MA 01453 7) Applicant Telephone No.; 978-637-1428 24 Hour Emergency No.: 508-962-7372 8) Owner Name & Title (if different from applicant): MARK FANELLI 9) Owner Address (if different from applicant): 216 PROSPECT ST., LEOMINSTER, MA 01453 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. PARTNERSHIP MARY FANELLI 216 OR 244 PROSPECT ST., Ej An Association LEOMINSTER, MA 01463 ❑ A Corporation ❑ / n Individual LU/A Partnership ❑ Other legal entity 1�1 n_.___ nb....if.. 0------ lkL. C-, M-11.. n--fl .nc In ... — .. n 6 rkh . Cuh6RliCnf hA9RAflP.r aic 1 Name & Title: — Address: Telephone No: Fax; Emergency Telephone No: 7 j 13 District Or Regional Supervisor if a licable Name & Title:__. -- Address: Telephone No; 04/23/2008 WED 907 _FAX Food Establishment Information 0005/014 14.) Water Source: TOWN 15) sewage Disposal TOWN DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: MAY t5T-MAY 4TH 2O08 17) No. of Food Employees PER 18) Name of Person In Charge Certified in Food Protection Management: n OA — co Required as of f0/f200f in accordance with 105 CMR 590.003 A Please attach copy of cedificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): I NO 20) Location: 22) Establishment Type. ❑ Retail ( Sq. Ft) ❑ Caterer TEMPORARY ❑ Food Service — ( ) Seats ❑ Food Delivery ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Retail Sale ❑ Mobile (Dates.) U., MealsfDay) ❑ Residential Kitchen for Bed & Breakfast Home Other (Describe) ❑ Residential Kitchen for Bed & Breakfast Establishment DIY/�j,�{, ❑ Frozen Dessert Manufacturer 21) Length Of Permit: MAY 1ST-4TH 23) Food Operations: De Hiltons: PHF—Potentially hazardous food (urneRemperature contin required) Non-PHFs— non•potentially hazardous rood (no 6'meRemperature controls squired) check all that apply): RTE,- ready -tout foods (Ex. Sandwiches, salads, mums loh need no further processing) Sale of commercially Pre- PHFCooked To Order Hot PHF Cooked and Cooled or Hot Hold Packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Pre- Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs cold Holding For Single Meal Susceptible Population Facility Service Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended Vacuum Packaging/Cook Chili to be Prepared by Consumer ❑ Reheating of commercially ❑ Customer Self -Service Use of Process Requiring A Variance Processed Foods For and/or HACCP Plan (including bare hand Service Within 4 Hours. contact alternative, time as a public health control Customer Self -Service of U Ice Manufactured and Packaged for Offers Raw Or undercooked Food Of Non PHF and Non- Retail Sale Animal Origin Perishable Foods Only. ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged El Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Board of Health Retail Sale of Selvage, Out -Of -Date or Reconditioned Food Total Permit Fee: $25.00 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 other applicable law. I have been instructed by the board of health on how to obtain copies of 10 CMR 590.0 a federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under t penalties of perjury that 1, to my best knowledge and belief, have filed all state returns and paid state taxes required u der law. , 9 �� 25) Social Security Number or Federal ID: O 26) Signature of Individual or Corporate Name: