HomeMy WebLinkAboutMansfield H.S. Baseball - 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:
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:.
Whose place of business is:
MANSFIELD HIGH SCHOOL BASEBALL - NEFFA
250 EAST STREET
PERSON(S) IN CHARGE:
TIM GRAHAM, HEAD BASEBALL COACH
Permit Expires: April 26, 2009
License Number: MF-6T
Food Fee:
BOARD OF HEALTH
Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Annfication must be submitted at least 30 days before the planned o enin date
1) Establishment Name: 14 5 x,�,� �)<76/� �ffLtdC iii�L
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: 7Zq- Zyy- o/-1%
5) Applicant Name & Title: ..r 4 obiA V I�A2v iJI EBrJ �L 6'ter-/
6) Applicant Address 2�� /-/)5T �'T v7gNSFiF-Lr✓ ��
7) Applicant Telephone No.: 24 Hour Emergency No.:
77.E-2 y'y- 0/ 7 7 _ 77 Y- Z yy —OJ _7 7
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
11 An Association
EJ A Corporation
El An Individual
El A Partnership
11 Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
-
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
�--
T,y Gre' /fir-YrY+� , /,U ��/l�,� � .� r✓
Address:
�n �d) 5� si �7 5 `i FiLC� /'( ✓�
Telephone No:
I 4 / i 7 24 Hour Emergency No:
FAX:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
Food Establishment Information
14) WATER SOURCE: I 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: ❑ Permanent Location 22) Establishment Type
❑ Mobile Mobile Start Date: Retail ( Sq. Ft)
Mobile End Date: Food Service up to 100 or
Mobile Comments: up to 10' PHF display $75
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
LI Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time
23) Food Operations
Check all that apply):
Food Service up to 101 -200
or up to 29 PHF display $100
Food Service up to 201 +
or 25'+ PHF display $125
Food Service - Institution
( Meals/Day)
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
Retail Food $50
Retail Snack Food $10
Tobacco Products No Fee
Definitions., PHF - Potentially hazardous food (timeRemperature controls required)
Non-PHF's - non -potentially hazardous food(no fime/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
Sale of Commercially Pre -Packaged Non-PFHs I ❑ PHFCooked To Order
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Ice Manufactured and Packaged for
Retail Sale
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
Vacuum Packaging / Cook Chill
( Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
n Prepares Food/Single Meals for
Catered Events or Institutional Food Service
or Reconditioned Food I I To
Total Permit Fee:
Payment is due with application n 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 cegies of 1A5.CMRr5W.000 and the federal Food Code.
24) Signature of Applicant: � 0
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 tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
Mansfield Board of Health
Date { 3e
We, 111Eif S17VVL 611SOf5saK-1- request a waiver of the
Food Service Permit Fee for the following reason
,Sc l-1-00 C /-61AID d J-i S,:r2
Thank you,
Signature
Title