HomeMy WebLinkAboutLithuanian Folk Dance Group - 4/26/2009Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Permit to Operate a Food Service Establishment
Type; FOOD SERVICE -TEMP
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:.
ROTA MICKUNAS
Whose place of business is:
LITHUANIAN FOLK DANCE GROUP OF BOSTON "SAMBURIS" NEFFA
65 WOODS CROSSING
PERSON(S) IN CHARGE:
RUTA MICKUNAS
Permit Expires: April 26, 2009
License Number: FS-8T
Food Fee: $75.00
BOARD OF HEALTH
Dr. RayQorjd Martin, Chairman
BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
T
Food Establishment Permit ApplicatiFAPR4
[ U d T
(Application must be submitted at least 30 days before the plannnidate)
2009
1) Establishment Name: Q ucki-Fers j` l*(48Ie C:1 O1�1
2) Establishment Address: mat) 1Qflt3`�ieI,4 mR
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
5) Applicant Name&Title: I_ikhuar%ion, Fotk< Ounce
Gfuu)p (34 Grea+er Qos4cx) "�xmbctr;s n
6) Applicant Address: (055 IUcoA s Crossi n
40 LIi S'*Ofl ) M A 0 L-7 (A
7) Applicant Telephone No: 50$ - -7'35— GQ q L{
24 Hour Emergency No: Sq vn e
8) Owner Name & Title (if different from applicant): �R V. jam,,
M t Gku fl a s
9) Owner Address (if different from applicant):
10) Establishment Owned By:
® An association
® A corporation
m An individual
® A partnership
m Other legal entity
11) If a corporation
officers or partner.
Name
or partnership, give name, title, and home address of
Title Home Address
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc.
Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No:
13 District Or Regional Supervisor if a #cable
Name & Title:
Address:
Telephone No:
Fax:
app icahon - oc
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 10/1/2001in accordance with 105 CMR 590.003(A) vie ajwh"pyofmffiafe.
19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes
®No
20) Location:
22) Establishment Type(check all that apply)
❑ Caterer
(check one)
❑ Retail ( Sq. Ft)
❑ Food Delivery
❑ Permanent Structure
❑ Food Service - ( Seats)
❑ Residential Kitchen for Retail Sale
Mobile
❑ Food Service - Takeout
❑ Residential Kitchen for Bed and Breakfast
❑ Food Service - Institution
Home
( Meals/Day)
❑ Residential Kitchen for Bed and Breakfast
Establishments
Vther (Describe) Sveci cm-(j
❑ Frozen Dessert Manufacturer
21) Length Of Permit:
(check one)
Li}hu4ntan Foos Cakes
❑ Annual
It
❑ Seasonal/Dates:
❑ Temporary/Datesfrime:
Definitions: PHF- potentially hazardous food(timettemperature controls required)
23) Food Operations:
I
Non-PHFs- non- potentially hazardous food (no timedemperature controls requireco
check all that a
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre-
14 PHF Cooked 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
❑ 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 And/Or
Processed Foods For Service
HACCP Plan (including bare hand contact
Within 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
❑ Prepares Food/Single Meals for Catered
for Retail Sale
Events or Institutional Food Service
❑ Offers RTE PHF in Bulk Quantities
Other (Describe): To be completed by the Board of Health
❑ Retail Sale of Salvage, Out -of Date Total Permit Fee:
or 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 CjiAR 590.000 and the federal Food Code.
24) Signature of Applicant: FL tJ LTCv
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all state tax returns and paid state taxes required under law.
26) Social Security Number or Federal ID: �� - � - `7 (3'3
26) Signature of Individual or Corporate Name: 46CD�
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
**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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Samburfs f�1K
Business/Organization Name: Lt'khuav%tan av,ee i�covp o$ Gct=ca+ea 1�. 08'1-or)
Address: & 5 Wooers
a
City/State/Zip: Vjol [ i s-bn MIA OYl q6 phone #: 50g- ? 3 5 - 6a 4 L1
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
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
7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. �j 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
WE ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
i l.❑ Health Care
4.�
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box # ]. 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 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, uu�nnd��er��the pains and penalties of perjury that the information provided above is true and correct
Signature: r`^'�r'V � Date:-Y11V09
Phone #: SO p- 7 3 5- �o.2 y t f
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
www.mass.gov/dia
Phone