HomeMy WebLinkAboutSmuckers Quality Beverages - 6/7/2008TOWN 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:
SMUCKERS QUALITY BEVERAGES @ THE TWEETER CENTER
Whose Place of Business is:
SMUCKERS QUALITY BEVERAGES @ THE TWEETER CENTER
Permit good June 7, 2008 only
License Number. MF-301T
Food Fee: $25.00
Milk & Cream: NO
BOARD OF HEALTH
Dr. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
SMUCKERS QUALITY BEVERAGES AT THE TWEETER CENTER
FOR THE PERFORMING ARTS
2) Establishment Address:
885 MAIN STREET, MANSFIELD, MA 02048
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
508-339-3333
5) Applicant Name & Title:
CATHERINE O'DONNELL, SALES MARKETING MGR.
6) Applicant Address:
GREATER MEDIA, INC., 55 MORRISSEY BLVD., BOSTON, MA
02125
7) Applicant Telephone No.: 617-822-6260
24 Hour Emergency No.: 973-476-7076
8) Owner Name & Title (if different from applicant):
SMUCKERS QUALITY BEVERAGES
9) Owner Address (if different from applicant):
37 SPEEDWAY AVENUE, CHICO, CA 95927-0369
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home
address of officers or partner.
CORPORATION
❑ An Association
❑ A Corporation
❑ An Individual
❑ A Partnership
❑ Other legal entity
12) Person Directly Responsible For Dailv Operations (Owner, person in charae. Supervisor. Manaaer, etc.)
Name & Title:
RHONDA FLECK, PRODUCT MANAGER
Address:
37 SPEEDWAY AVENUE, CHICO, CA 95927-0369
Telephone No:
530-899-5074 Fax: 530-891-6397
Emergency Telephone No:
13 District Or Regional Supervisor if applicable)
Name & Title:
Address:
Telephone No: Fax:
Food Establishment Information
14.) Water Source: TOWN
DEP Public Water Supply No: (if applicable):
15) Sewage Disposal TOWN
16) Days and Hours of Operation: 6/7/2008
17) No. of Food Employees
18) Name of Person In Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003 A Please attach copy of certificate
19) Person Trained in Anti -Choking Procedures (if 25 seats or more):
NO
20) Location:
22) Establishment Type:
❑ Retail ( Sq. Ft)
❑ Caterer
PERMANENT
❑ Food Service -( ) Seats
❑ Food Delivery
❑ Permanent
❑ Food Service - Institution
❑ Residential Kitchen for Retail Sale
® Mobile (Dates) 617/08
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast Home
Other (Describe)
❑ Residential Kitchen for Bed & Breakfast
SAMPLING AT THE TWEETER
Establishment
CENTER FOR THE PERFORMING
ARTS
❑ Frozen Dessert Manufacturer
21) Length Of Permit: 1 DAY
23) Food Operations:
Definitions: PHF— Potentially hazardous food(time/temperature controls required)
Non-PHF's —non-potentially hazardous food (no
time/temperature controls required)
check all that apply):
RTE—
ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no further processing)
❑ Sale of commercially Pre-
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
Package 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
El Reheating of commercially
El 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
El 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
❑ 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 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 ,590.000 and the federal Food Code.
24) Signature of Applicant: OZLMI�(�M &21 /KXX/�
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 returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 94-1748248
26) Signature of Individual or Corporate Name: SMUCKERS QUALITY BEVERAGES
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)
"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:\HwIth\Jane's DocumentATAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of lndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Pleillso Print Lei 1
Business/Organization Name: nDNQ(-I'(g,V QJA\N\'1 &,\IeVA6-e;S
�,7
City/State/zip: � V1\ (', V � �J ob" 1 Q6 Phone
Are you an employer? Check the appropriate box;
Business Type (required):
1. ❑ I am a employer with employees (full and/
5. ❑ Retail
or pert -time),*
6. ❑ RestaurantBar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no
?, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
�[No workers' comp. insurance required]
S. ❑ Non-profit
3. We are a corporation and its officers have exercised
9. %EE ��tertaitiment
their right of exemption per c. 152, §I(4), and we have
�❑
10,p1Manufacturing
no employees. (No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
i
11,❑Health Cara
with no employees. [No workers' comp. insurance req.]
izE) Other
"Any applicant that checks box NI must also All out the section below showing their workers' compensation policy intbrmatioit:
"JI'the wrporate officers have exempted (hemSeiV0s, but the corporation has other employaes, a workers' oompensation policy is required and suchan
organization should check box NI.
■ms
tam an employer that is providbig workers' compensation tasurance for ruy employees. Below As t)ie policy informatlorl.
Insurance Company Name:
Insurer's Address:
City/state/Zip:
Policy N or Self -ins. Lie. 4 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 ofcrimimd 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. Do advised that a copy of this statement may be forwarded to the Office of
Invesdaatlons of the DIA for insurance coverage verification.
under
Official use only. Do not write its this area, lobe completed by etty or town ofjlciad
City or Town:
above Is tine and correct.
Issuing Authority (circle one);
1. Board of health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office
6.Other_
Contact
www.macs•gov/die
Phone