HomeMy WebLinkAboutUncle Jay's Chili - 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:
GAYOUS POWELL
Whose Place of Business is:
UNCLE JAY'S CHILI
Permit Good April 25-27, 2008
License Number. FS-159T
Food Fee: $25.00
Milk & Cream: NO
Am
rtin, Chairman
Date Received
Date Inspected
USE ONLY
Approved By Permit # Issued
r 5 - i 5 1 T
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
UNCLE JAY'S CHILI
2) Establishment Address:
5 SUZANNE DRIVE
3) Establishment Mailing Address (if different)
5 SUZANNE DRIVE
4) Establishment Telephone No:
5) Applicant Name & Title:
GAYOUS POWELL
6) Applicant Address:
5 SUZANNE DRIVE, NORTH OXFORD, MA 01537
7) Applicant Telephone No.: 508-987-7068
24 Hour Emergency No.: 508-987-7068
8) Owner Name & Title (if different from applicant):
GAYOUS POWELL
9) Owner Address (if different from applicant):
5 SUZANNE DRIVE, NORTH OXFORD, MA 01537
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 DIrBCtiv RasnnnAlhlP.. Fnr nnily rinorntinne rrlumcr pore in rh.rno 6 na .fo r RA. -- . -4- \
Name & Title:
'
Address:
Telephone No:
9� teC� Fax:
Emergency Telephone No:
fib; 7 70�-'.
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: y/J j - 4//97 ¢/nr - d P''4
17) No. of Food Employees 0
18) Name of Person In Charge Certified in Food Protection Management: 64_)0S Rwv
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
TEMPORARY
Food Service - ( ) Seats
N
❑ Food Delivery
❑ Permanent
Food Service - Institution
❑ Residential Kitchen for Retail Sale
159-Mobile (Dates) d - c 1 d 7
( Meals/Day)
❑ Residential Kitchen for Bed & Breakfast Home
Other (Describe)
❑ Residential Kitchen for Bed & Breakfast
$117 PA
Establishment
❑ Frozen Dessert Manufacturer
21) Length Of Permit:
23) Food Operations:
Definitions: PHF— Potentially hazardous food(time/temperature controls required)
Non-PHFs — non -potentially hazardous food (no
timeRemperature 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-
LA 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
❑ Customer Self -Service
0 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
U 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 195 CMR 590,000 and all other applicable law. I have been instructed by the
board of health on how to obtain copie 105 Cfyf 0.060 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: 200-75-4426
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.
* ture ofqndividual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
;; 1QQ "76-VL
** 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.