HomeMy WebLinkAboutLithuanian Folk Group - 4/27/2008TOWN 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:
RUTA MICKUNAS
Whose Place of Business is:
LITHUANIAN FOLK DANCE GROUP OF BOSTON
Permit expires April 27, 2008
License Number. FS-162T
Food Fee: $25.00
Milk & Cream: NO
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Dr. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
r-S-16 aT
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
LITHUANIAN FOLK DANCE GROUP OF BOSTON
2) Establishment Address:
65 WOODS CROSSING
3) Establishment Mailing Address (if different)
65 WOODS CROSSING
4) Establishment Telephone No:
5) Applicant Name & Title:
ROTA MICKUNAS
6) Applicant Address:
65 WOODS CROSSING, HOLLISTON, MA 01744
7) Applicant Telephone No.: 508-893-9892
24 Hour Emergency No.: 508-735-6244
8) Owner Name & Title (if different from applicant):
RUTA MICKUNAS
9) Owner Address (if different from applicant):
65 WOODS CROSSING HOLLISTON, MA 01746
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home
address of officers or partner.
INDIVIDUAL
❑ An Association
❑ A Corporation
❑ An Individual
❑ A Partnership
❑ Other legal entity
12 Person Directly Responsible For Daily Operations Owner, person in charge, Supervisor, Manager, etc.)
Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No:
13 District Or Reclional Supervisor(if applicable)
Name & Title:
Address:
Telephone No: Fax:
Food Establishment Information
14.j Water Source: TOWN
DEP Public Water Supply No: (if applicable):
15) Sewage Disposal TOWN
16) Days and Hours of Operation:
17) No. of Food Employees 0
18) Name of Person In Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.0030Please 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
TEMPORARY
❑ Food Service - ( ) Seats
❑ Food Delivery
❑ Permanent
❑ Food Service - Institution
❑ Residential Kitchen for Retail Sale
❑ Mobile (Dates)
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast Home
Other (Describe)
❑ Residential Kitchen for Bed & Breakfast
Establishment
❑ Frozen Dessert Manufacturer
21) Length Of Permit:
23) Food Operations:
Definitions: PHF— Potentially hazardous food (time/temperature controls required)
Non-PHPs — 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
Packaged Non-PHFs
for More Than a Single Meal Service
❑ Sale of Commercially Pre-
❑ Preparation Of PHFs For Hot And
LJ 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
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
❑ 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'
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: 048-50-4133
26) Signature of Individual or Corporate Name:
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 (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
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
Applicant Information Please Print Legibly
Business/Organization Name:.
Address: `" E C ` t ; r; •r ; < j
City/State/Zip: ; 2. t a al r , c Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ I am a employer with ernployaes (full rnd/
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
W ❑ 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.]
12.0 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 #I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
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 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 certify, under the pails and penalties of perjury that the information provided above is true and correct.
Offlcial 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
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