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HomeMy WebLinkAboutFirefly's BBQ - 5/17/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health r Comcast Temporary Food Permit 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:. STEVE ULISS Whose place of business is: FIREFLY'S BBQ @ THE COMCAST CENTER 885 SOUTH MAIN STREET Permit good fora MAY 17, 2009 & JUNE 14, 2009 9 AM TO 9 PM License Number: MF-2T Food Fee: BOARD OF HEALTH Dr. Raymond Martin, Chair Xn FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued COMCAST TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 48 hours prior to planned event) 1) Establishment Name: �C7 YYICCc�y C,��� 2) Establishment Address 9$3S cJ (min 1ans �y e (t� t / 7 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 5) Applicant Name & Title: i 6) Applicant Address Ili Vi*yl post, Pj, Eas+ M6601 OeL A_ h rn19 01 7) Applicant Telephone No.: JCIR- 355 7 &rag13 24 Hour Emergency No.: G ✓� 8) Owners Name & Title steU e Lk t SS ., DW✓►er Yha a w 9) Owner Address (If different from applicant): 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, El An Association and home address of officers or partner. 11 A Corporation �i/fift (]Gill �l�t A?" j iYv !tee An Individual /v MIAPartnership lnl('1 EI Other legal Entity o/ in .ldn A YJ'I7aL izl rerson urecuy Kesponsioie t-or uaq uperaflons (owner, person in charge, supervisor, manager etc.) Name & Title: -C&eo e U I t S $ — O LA,) t1 e—r— J Address: i I F'n�S�an �J©s+ FPS U Gtrl bye {M F} W Z 5 2 Telephone No: r �rJ 7 7�c� 3 I FAX: Emergency Phone 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: Emergency Phone 52 Food Establishment Information 14) WATER SOURCE: twin vja+e.r 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) Awn Sr�r— 16) DAYS/HOURS: % #m_ ClPm 17) No. of Food Employees: Q 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 copy of certificate 20) Location: 1,A nMl.,as51 l,t:/ W 22) Establishment Type Permanent Location [7] Mobile Food Temporary(Snack Size Sampling of Products,Comcast) $25 Temporary per day (for the event) with a cap of $100.00 Temporary Dates: 6117log 4611(4109 9165 R)(gers Rzsi-aSa.lad, GIJ�t-'I`�Y �1CL.I 21) LENGTH OF PERMIT: 5/17/Cc1 ., CD", cook -ifs, bf DW(Li 1 es, f pv f-a to n, f'J 23) Food Operations Definitions: PHF - Potentially hazardous food (timellemperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no timeitemperature controls required) RTE - ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Preparation of PHI s For Hot And for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Cold Holding For Single Meal Service 0 Reheating of Commercially Processed Foods LJ Juice Mam ❑ for Service Within 4 Hours Customer Self -Service Retail Sale 0 Customer Self -Service of Non PHF and Non- J Ice Manufactured and Packaged for Perishable Foods Only I Retail Sale K Preparation of Non-PHFs Other Food Operations To be completed by the Board of Health Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information��rovided in this application and affirm that the food establishment operation will comply vdth 105 CMR 590.0,pQ"and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 5 00 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Cl sec. 49A, I certl r returns and paid state taxes required un lain 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: of perjury that 1, to my best knowledge and belief, have flied all state tax OL4 ;y 9a14102, 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. Sign ivi r Corporate Name By: Corporate Officer-Wandatory, if Applicable) -L'-1 N7-2.(402 "Social Security No. (Voluntary) or Federal Identification Number *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. RMealthVane's Doeumants\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Fl rt? � ] �6_ r 5 6 t3 Q e r3Q, Address: ICI Oosfvn Post St- City/State/Zip: `v V,% `J � (711 J 2 Phone #: 5D fsi r357 (O 69 3 Art, ou an employer? Check the appropriate box: Business Type (required): 1 ✓✓✓ lam a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establ7auto,etc,) 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. 7, ❑ Office and/or Sales (incl, real 3. ❑ (No workers' comp. insurance required] We S. ❑ Non-profit are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10. ❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required]* We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. (No workers' comp. insurance req.] 12.0 Other *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 Nl. I am an employer that is providing workers' compensallon insurance for my employees. Below is the policy information. Insurance Company Name: 'rw iD Ba&Y K i 11 sy ra f] c e ai ro ma)M- l o Su rd o el? et) Insurer's Address: V il,Q/ Y� AA , City/State/Zip: N &) Y X K t %N 1 01(P i Policy # or Self -ins. Lic. #W C ci33(p5o oCj f; Expiration Date: 8 i —0 1 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 www.mws.gov/dia L tlM' N o z z W i F- a V O m LL LL a � x W W u LY ! �i r O co co 0 Z' Q" Y zF!.�� O ✓ RAU)A O nE F. F. T'd 46E9-LSE BOS 30I330 3lda0ddoo SA333?JI3 WHIZ:TT 600Z bT ReW Page 1 of 2 Jane Doucette From: Kerri Malizia @ Firefly's BBQ [kerri@freflysbbq.com] Sent: Thursday, May 14, 2009 7:08 AM To: Jane Doucette Subject: RE: 5117 & 6/14 request for Health Certificates Send them via fax please- 508-357-6397 Thanks! Kerri Malizia I Catering Sales Manager Firefly's Bodacious Bar-B-Que & Beyond 181 Boston Post Rd I Marlborough 101752� Phone 1 508.357,6393 Fax 1 508.357.6394 www.fireflysbbq.com --- On Wed, 5/13/09, Jane Doucette <Jdottcette ntmtsfretrLna.corn> wrote: From: Jane Doucette <Jdoucette@mansfreldma.com> Subject: RE: 5/17 & 6/14 request for Health Certificates To: "Kerri Malizia a Firefly's BBQ" <kerri@6reflysbbq.com> Date: Wednesday, May 13, 2009, 7:44 PM Hi Kern, I received the forms today. I can fax the permit to you or mail it to you - however you want. Jane From: Kerri Malizia @ Firefly's BBQ [mailto:kerrl@fireflysbbq.com] Sent: Wednesday, May 13, 2009 2:38 PM To: Jane Doucette Subject: RE: 5/17 & 6/14 request for Health Certificates 1 sent back the forms and payment via mail You should have received them by now. When should I expect a copy of the permits? Will I receive them via email, fax or mail? If it's via fax can you fax it to 508-357-6397 Thanks! Kerri Malizia I Catering Sales Manager Firefly's Bodacious Bar-B-Que & Beyond 181 Boston Post Rd I Marlborough 101752 Phone 1 508.357,6393 Fax 1 508.357.6394 wwwAreflysbbq.com --- On Wed, 5/6/09, Jane Doucette < doucette@,tttmrsfteldiva.codt> wrote: From: Jane Doucette <Jdoucettc a mansfleldma.com> Subject: RE: 5/17 & 6/14 request for Health Certificates To: "Kerri Malizia" <kerri@fireflysbbq.com> Date: Wednesday, May 6, 2009, 11:31 AM Hi Kerri, here are the application forms. If you need anything else or have any questions, please let me know. Have a nice day. From: Kerri Malizia [mallto:kerri@freflysbbq.com] Sent: Wednesday, May 06, 2009 9:35 AM To: Jane Doucette Subject: RE: 5/17 & 6/14 request for Health Certificates No problem, you can always fax them if that is easier. 508-357-6397 Kerri Malizia I Catering Manager 5/14/2009 Page 2 of 2 Firefly's Bodacious Bar-B-Que & Beyond 181 Boston Post Rd I Marlborough 1 01752 Phone 1 508,357.6393 Fax 1 508.357.6394 www.fireflysbbq.com --- On Wed, 5/6/09, Jane Doucette </doucelfe@rnnnsfreldnen.conr> wrote: From: Jane Doucette <Jdoucettc@mansfieldma.com> Subject: RB: 5/17 & 6/14 request for Health Certificates To: "Kerri Malizia" <kerri a fireflysbbq.com> Date: Wednesday, May 6, 2009, 8:04 AM Hi Kerri, I tried e-mail them to you yesterday but there was a problem with the data base. As soon as it is fixed today, I will send it out to you. Sorry about the delay. From: Kerri Malizia [mailto:kerri@flreflysbbq.comj Sent: Tuesday, May 05, 2009 4:25 PM To: Jane Doucette Subject: 5/17 & 6/14 request for Health Certificates Hi Jane - We are catering two events at the Comcast Center May 17th and June 14th. We will need to gel a BOB certificate for those dates. Could you email me out the forms? Regards, Kerri Kerri Malizia I Catering Manager Firefly's Bodacious Bar-B-Que & Beyond 181 Boston Post Rd I Marlborough 1 01752 Phone 1 508.357.6393 Fax 1 508.357.6394 www.fireflysbbq.com 5/14/2009