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HomeMy WebLinkAboutJust Born - 5/31/2008TOWN 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: ROSS BORN & DAVID SHAFFER, CO -OWNERS Whose Place of Business is: INC @ THE TWEETER CENTER Permit expires May 31, 2008 nse Number: MF-204T Food Fee: $25.00 Milk & Cream: NO EALTH Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Date Inspected Approved By Permit # Issued fF '-�0� FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1)Establishment Name: '�wS�.C—HOC 2) Establishment Address: n.. Y-Y—p `c-A 2)e�,� 1 ,; (.� `Y� 3) Establishment Mailing Address (d different) 4) Establishment Telephone No: 75 & S 5) Applicant Name & Title: _ S 6) Applicant Address: _ 7) Applicant Telephone No.: 24 Hour Emergency NO.: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of COofficers - C,WI�C�� or partner. ❑ An Association ❑ A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal entity - 121 Person Directly Resnonsible For Daily Operations (Owner. nerson in charne. Sunervisor. Mananer. etc.1 Name &Title____ l Mr. Q ^ \C t' �y Address: .W `- Telephone No: Fax: Emergency Telephone No: 13) District Or Regional Supervisor ff applicable Name & Title: Address: Telephone No: Fax: ©LANK FOOD PERMIT APPLICATION Food Establishment Information 14.) Water Source 15) Sewage Disposal DEP Public Water Supply No: (if applicable): 16) Days and Hours of Operation: 17) No. of Food Employees 18) Name of Person In Charge Certified in Food Protection Management: Required as of IW1/200f in accordance with 105 CMR 590.003 A Please attach cb of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): 20) Location: 22) Establishment Type: ❑ Caterer ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Food Service -( ) Seats ❑ Residential Kitchen for Retail Sale Permanent Mobile (Dates) —K ❑ Food Service - Institution ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Home ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: (check one) ❑ Annual ,'seasonal/ ates c ' - M Temporary/Dates/Times 23) Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required) (check all that apply): Non-PHFs- non -potentially hazardous food (no time/temperature controls required) RTE-read -to-eat foods Ex. Sandwiches, salads, muffins which need no furtherproceasing) ❑ Sale of commercially Pro- ❑ 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 Holding For Single Meal Service Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill be Prepared by 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 Wfthin 4 Hours, alternative time as a public health control Customer Self- Service of Non El Ice Manufactured and Packaged for Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Onl . ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Retail Sale Events or institutional Food Service ❑ Offers RTE PHF in Bulk Quantities Other (Describe): To be completed by the Hoard of Health ❑ Retail Sale of Salvage, Out -Of -Date or Total Permit Fee: C'A 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��0 and all other ap cable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 690.000 agdthe federal Food bb i r `J 24) Signature of ApplicantI- i Pursuant to MGL Ch 2C, s . 49A, I c rtify under . e 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: '�?L4 n LQ S2❑�� r- 26) Signature of Individual or Corporate Name: �vSti C 1J .�h1C BLANK FOOD PEMTAPPLMn0N 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. ature of Indio' ual or Corporate Name "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. RMezlthVane's DownentsWAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwminass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: USAti C t� tJC - . Address: Phone #: t,) (0 - &_)-1 - �) (cZ Are an employer? Check the appropriate box: Business Type (required): 1 ,Ron 1 am a employer with 0r5 o0 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. 8• ❑ 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.❑ Other *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 91. 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. Lie. Expiration 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 certir , under the p, ins and penalties ofperjury that the information provided above is true and correct. _. V �7 �_I , I �r Q6kAoo 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: Phone www.mass.gov/dia FAX COVER SHEET Town of Mansfield Board of Health DATE:° TIME: )0` FROM: Town of Mansfield Board of Health Phone: 508-261-1366 Six Park Row Fax: 508-261-7343 Mansfield, MA 02048 TO: FAX#: � J c� 9 .7 C Type of Form: Number of Pages: (Including this sheet) If you do not receive all of the above pages, contact the Mansfield Board of Health. MESSAGE: 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: ROSS BORN & DAVID SHAFFER, CO -OWNERS Whose Place of Business is: JUST BORN, INC @ THE TWEETER CENTER Permit expires May 31, 2008 License Number. MF-204T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH i Dr. R mo Martin, Chairman