HomeMy WebLinkAboutDancing Smoothies - 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 - TEMPORARY
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.:.
MICHAEL & PAULA YOUNGMAN
Whose place of business is:
DANCING SMOOTHIES - NEFFA
65 CROSS COUNTRY ROAD
PERSON(S) IN CHARGE:
Permit Expires: April 26, 2009
License Number: FS-3T
Food Fee: $75.00
BOARD OF HEALTH
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 onenino date)
1) Establishment Name: }�
2) Establishment Address - S �` V% S
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: ?e,;
5) Applicant Name & Title:
6)Applicant Address 2x��CiLS- �-
7) Applicant Telephone No.: 24 Hour Emergency No.: k,,q - L✓�7 r � �
-S
8) Owners Name & Title �J2(
� 7
9) Owner Address (If different from applicant):
51"/L ..
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
19 An Association
or partner.
0 AA Corporation
Name Title Address
WAn Individual
A Partnership
O Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Telephone No:
� 2_ c _ --e 24 Hour Emergency No:
D
FAX:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address':
Telephone No:
24 Hour Emergency No:
FAX:
Food Establishment Information
14) WATER SOURCE: �J I 15) SEWAGE DISPOSAL: lyy(
DEP Public Water Supply No: (If applicable) ( 16) No. of Food EmDlovees
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management:
Required as of 10/1/2001 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): k-7
Location: [jg Permanent Location
Mobile Mobile Start Date:
Mobile End Date:'/
Mobile Comments:
21) Length of Permit:
Q Annual
Q Seasonal
Seasonal Dates:
22) Establishment Type
[] Retail ( Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $75
Food Service up to 101 -200
or up to 25' PHF display $100
Q Food Service up to 201 +
or 25'+ PHF display $125
Food Service - Institution
Bakery $25
Caterer $25
Food Delivery $25
Milk & Cream $2
Mobile Food & Consession $50
Mobile Food Temporary $25
Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25 # of Pushcarts:
Residential Kitchen $25
Temporary Start Dale: "q ( Meals/Day) [N Retail Food $50
Temporary End Date: 1 j (GFS Retail Snack Food $10
Temporary Time �Vezir� //� iM� [FA Tobacco Products No Fee
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Check all that apply): Non-PHF's - non -potentially hazardous food(no time/femperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PFHs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Perishable Foods Only
Preparation of Non-PHFs
0 PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
c9 Sale of Raw Animal Foods Intended
to be Prepared by Consumer
0 Customer Self -Service
0 Ice Manufactured and Packaged for
Retail Sale
0 Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Lt Vacuum Packaging / Cook Chill
#3 Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Other Food Operations Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF In Bulk Quantities r Prepares Food/Single Meals for
Catered Events or Institutional Food Service
® Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment Is due with application [g waived
I, the undersigned, attest to the accuracy of the information provided in this application and 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 co/p),es of 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: �7Z-`/9�t
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penaltles of perjury that 1, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID. C q 7/-'�'
26) Signature of Individual or Corporate Name: /"�- Y L G [ e L f-/-1.- -- --_
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 o
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
d47-,3,?-- L?3"
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
u,p 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: `✓ xlvc'lof '
e 4 V-6- OST?r Phone #: 82- - IaJ X
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. E/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.
[No workers' comp. insurance required] $• ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11 ❑Health Care
4. ❑ We are a non-profit organization, staffed by volgnteers,
with no employees. [No workers'.comp. insurance req.] 12.❑ Other L1 z SS10ii��� r
*Any applicant that checks box HI 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 Nat
Insurer's Address:
City/State/Zip:
Policy # or Self -ins, Lic.
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 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, tinder the pains and
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License
above is true and correct
l
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.mass.gov/dia