HomeMy WebLinkAboutLavender Country/Folk Dancing - 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:.
CHRIS RICCIOTTI
Whose place of business is:
LAVENDER COUNTRY & FOLK DANCING (LCFD) NEFFA
393 UNION STREET
PERSON(S) IN CHARGE:
CHRIS RICCIOTTI
Permit Expires: April 26, 2009
License Number: FS-5T
Food Fee: $75.00
BOARD OF HEALTH
P
i
Dr. Raymond Martin, Chairman
FOR HOARD OF HEALTH USE ONLY
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: Lavender Country & Folk Dancing (LCFD) Italian & Kid Friendly Food Booth
2)
Establishment Address: 393 Union Street Rockland, MA 02370-1729
3)
Establishment Mailing Address (if different): Same
4)
Establishment Telephone No: HOME: (781) 982-8042 Cell: (617) 852-4042, (508) 545-1594
5)
Applicant Name & Title: Chris Ricciotti (Original Organizer and Founder of LCFD) — Food Booth Manager
6)
Applicant Address: 393 Union Street Rockland, MA 02370-1729
7)
Applicant Telephone No: (781) 982-8042, (617) 852-4042 24 Hour Emergency No: (617) 852-4042, (508) 545-1594
8)
Owner Name & Title (if different from applicant): Same
9)
Owner Address (if different from applicant): Same
10) Establishment Owned By:
x An association
m A corporation
m An individual
m A partnership
m Other legal entity
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
Name Title Home Address
12
Person Directly Res onsible For Daily Operations (Owner, Person in Charge, Supervisor, Manager etc.
Name & Title:
Chris Ricciotti & Sam Arfer Food Booth Managers)
Address:
393 Union Street Rockland, MA 02370-1729
Telephone
No:
Home: 781 982-8042 Cell: 617 852-4042, 508 545-1594 Fax: 781 982-1812
Emergency Telephone No:
Cell: 617 823-1203
13
District Or Regional Supervisor (if applicable)
Name & Title:
N/A
Address:
N/A
Telephone No:
NIA Fax:
)9oappucatlon6-z.doc
Food Establishment Information
14) Water Source: Town of Mansfield, MA
15) Sewage disposal:
DEP Public Water Supply No: (if applicable)
Town of Mansfield, MA
16) Days and Hours of Operation: Friday, April 20 6:OOpm-11:OOpm
17) No. of Food Booth Volunteers:
Saturday, April 25", B:OOam-11:OOpm
Approximately 32
Sunday, April 261", 8:OOam - 6:OOpm
18) Name of Person In Charge Certified in Food Protection Management: Chris Ricciotti
Required as of 101112001 in accordance with 105 CMR 590.003 A Please attach co o/certifica(e.
19) Person Trained In Anti -Choking Procedures (if 25 seats or more): X 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
X Mobile
❑ Food Service -Takeout ❑ Residential Kitchen for Bed and Breakfast
X Food Service - Institution Home
TEMPORARY
( 500 Meals/Day) ❑ Residential Kitchen for Bed and Breakfast
Weekend Food Booth Setup
Establishments
❑ Frozen Dessert Manufacturer
Other (Describe)
21) Length Of Permit:
(check one)
X Annual
❑ Seasonal/Dates:
❑ Temporary/Dates/Time:
Darinitions: PHF- potentially hazardous food(time/temperature controls required)
23) Food Operations:
Non-PHFs- 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-
❑ PHF Cooked To Order
X Hot PHF Cooked and Cooled or Hot Held
Packaged Non-PHFs
for More Than a Single Meal Service.
❑ Sale of Commercially Pre-
X Preparation Of PHFs For Hot And
❑ PHF and RTE Foods Prepared For Highly
Packaged PHFs
Cold Holding For Single Meal Service.
Susceptible Population Facility
X Delivery of Packaged PHFs
❑ Sale Of Raw Animal Foods Intended
❑ Vacuum Packaging/Cook Chill
to be Prepared by Consumer.
X Reheating of Commercially
❑ Customer Self -Service
❑ Use Of Process Requiring A Variance And/Or
Processed Foods For Service Within
HACCP Plan (including bare hand contact
4 Hours.
alternative, time as a public health control
X 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.
X Preparation Of Non-PHFs
❑ Juice Manufactured and Packaged
❑ Prepares Food/Single Meals for Catered
I
for Retail Sale
Events or Institutional Food Service
X 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:-
$75.00
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 59 0 other applicable law. I have been instructed by the board
of health on how to obtain copie o 5 CMR 5 of er I Food Code.
r
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certi under the penalties of perjury that I, to my best knowledge and belief,
have filed all state tax returns and paid sta a taxes required under law.
25) Social Security Number or Federal ID: 03�
26) Signature of Individual or Corporate Name
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 IndiviAual or Corporate Name
038-40-2278
**Social Security No. (Voluntary) or Federal
Identification Number
(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.
EAMy DocumentANEFFA\Food Booth 2009\NEFFA'I'empFoodEstmemo\Completed Form- TAXCERTIFICNI'IONFORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
u,p
600 Washington Street
Boston, MA 02111
wivivanass.govIdia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address: A 1? 2� Onto
Are you an employer? Check the appropriate box:
LEI ❑ I am a employer with employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
1.Cit7D
1ne#: �T7/� l(CK— p"gz-
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. MNon-profit
9. ❑ Entertainment
10.❑ Manufacturing
1 LE] Health Care /
12.XOther _�rCr
*Any applicant that checks box #1 nnust also fill out the section below showing their workers' compensation policy inlermation.
**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 ant att employer that is providing ivorlrers' contpe»sation insnrnnce.for my employees. Belot, is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. # 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 cerpXir, under the
perjury that the information provided bov is true and correct.
Date �►7� ?
Mlow"
Of use only. Do not write in this area, to be completer) 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
Phone
www.raoss.gov/dia
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Chris Ricciotti
393 Union St.
Rockland MA 02370-1729
April 26, 2007
Dear Chris:
PO Box 180446 Boston MA 02118 Phone:(617)445-1647 Fax(617) 427-7890
Congratulations! I am pleased to send you the ServSafe Certificate of Completion for Serving Safe Food. You
scored 77% on the exam you took on April 11, 2007. This certificate is recognized nationally and is valid for
five years. The certificate belongs to you and not your employer so if you move, take the certificate with you
to your new job in food service.
Please feel free to call me if I can be of further assistance. I can be reached at (617) 445-1647. In the
meantime, take care and good luck with all of your future endeavors.
Sincerely,
Lisa M. Berger, MPH, CFSP
enclosure
www.servingsafefood.com info@servingsafefood.com
4 F..
0
",
P.O. Box 180446 Boston, MA 02118 (617) 445-1647 Fax 427-7890
Chris Ricciotti
393 Union St.
Rockland, MA 02370
April 12, 2007
To Whom It May Concern:
This is to confirm that Chris Ricciotti has completed the Food Protection Certification
Exam on April 11, 2007. Results of the exam will be available in approximately three
weeks.
If you have any questions, please feel free to contact me at (617) 445-1647.
Sincerely,
a L. 44,-oU
Cynthia L. Judd, CFSP