HomeMy WebLinkAboutGreat Mansfield Cleanup - 5/3/2008TOWN OF MANSFIELD, BOARD OF HEALTH
SIX PARK ROW, MANSFIELD, MA 02048
PERMIT TO OPERATE A FOOD SERVICE 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:
BRUCE MONTGOMERY @THE TWEETER CENTER
Whose Place of Business is:
GREAT MANSFIELD CLEAN-UP @THE TWEETER CENTER
Permit expires May 3, 2008
License Number. FS-301T
Food Fee: WAIVED
Milk & Cream:
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
30 ( i
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: Y
1 Q
2) Establishment Address: :61 \
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
5) Applicant Name & Title:
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): N
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
An Association
A Corporation
V
❑ An Individual
❑ A Partnership
❑ Other legal entity
12) Person Directly Responsible For Daily Operations (Owner, person in charae. Supervisor. Manager, etc.)
Name & Title:
r
Address;
Telephone No:
Fax:
Emergency Telephone No:
q
!+.
a ✓D 6�44
13 District Or Regional Su ervisor if applicable)
Name & Title:
Address:
Telephone No: Fax:
BLANK FOOD PERMIT APPLICATION
Food Establishment Information
14.) Water Source
16) Sewage Disposal
DEP Public Water Supply No: (if applicable):
, ��
J�(OVti
16) Days and Hours of Operation:
I v t
17) No. of Food Employees
16) Name of Person In Charge Certified in Food Protection Management:
Required as of 1 tdrl/2001 in accordance with 105
CMR 590, POW Please attach cn
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
❑ Food Service - Institution
❑ Residential Kitchen for Bed & Breakfast Home
19 Mobile (Dates)
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast
Establishment
❑ Frozen Dessert Manufacturer
Other (Describe)
21) Len( d.
heck one)
❑ Annual
❑Seasonal/Dates ? r
C�
❑ Temporary/Datesffir
23) Food Operations:
Definitions: PHF—Potenfially hazardous thod(Gmatemperature controls required)
(check all that apply):
Non-PHFs— non-potentlaily hazardous food (no timertemperature controls required)
RTE—
ready -to -eat foods Ex. Sandwiches, salads, muffins which need no lurther rocessfn )
❑ Sale of commercially Pre-
PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held for
Packa ed 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
Packa ed 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 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
Wlthin 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
U Offers RTE PHF in Bulk Quantities To be completed by the Board of Health
Other (Describe):
El Retail Sale of Salvage, Out -Of --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 other applicable law. I have been instructed by the board of health on how to
obtain copies of 105 CMR 590.0 a the federal Food Code.
r
24) Signature of Applicant: -- -- - -
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, t -�
returns and paid state taxes required under law.
25) Social Security Number or Federal ID: ,
I,ofllee R. Fish
26) Signature of Individual or Corporate Name: Director
BLANK FOOD PERhBT APPLICATION
D[AN4FiI,LD PARR k I21tCRS;AfK)N Bl?Pl: Prgµrnnu (50N)'2G1A&94
j Sx Park Ro,e OOicc; (SON) 85I43458
T G,nvlicld, MA 02(M 8 Puu: (508) 26 1 7435
cnm11: I dish0')mnnaidd nw.....
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 By: Corporate Officer (Mandatory, if Applicable)
---T®www C)4/�( c` cq
"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.
R:ViealthVane's DocumentATAX CERTIFICATION FORM.doc
iLN The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k1ri 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Business Type (required):
L ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity, S• ❑ Office and/or Sales (incl. real estate, auto, etc.)
[No workers' comp. insurance required] S. ❑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, 1 I.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*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 #1,
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. Lic. # 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 MOL 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 certkyfuVdier the pains and penaltles of perjury that the Information provided above is 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 #
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.gowma