HomeMy WebLinkAboutSt. Mary's School - 7/14/2009Commonwealth 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: MOBILE 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:.
ST. MARY'S CATHOLIC SCHOOL
Whose place of business is:
ST. MARY'S CATHOLIC SCHOOL
330 PRATT STREET
PERSON(S) IN CHARGE
JULIE CARCHEDI
Permit Expires: July 14, 2009
RAIN DATE 7/15/2009
License Number: MF-11T
Food Fee: WAIVED
BOARD OF HEALTH
' -- - --- -
Dr f: ym nd Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Appiica ion must e submitted at leastdays before the planned opening date)
1) Establishment Name: J C,
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2) Establishment Address ?j ?yO
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3) Establishment Mailing Address (if different)
JUL 1 3 Z009
4) Establishment Telephone No:
3 " c
5) Applicant Name & Title: G, , I d
U(A�d _f . __ Al
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6) Applicant Address t
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7) Applicant Telephone No.:
24 Hour Emergency No.:
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8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
• An Association
or partner.
• A Corporation
Name
Title Address
El An Individual
0 A Partnership
11 Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
---- - E-mail:
--
Alt E-Mail:
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13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
14) WATER SOURCE:
Food Establishment Information
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:
If more than 3 individuals are certified, complete list is on file.
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):
20) Location:
❑ Permanent Location
Moblie Mobile Start
Date:
Mobile End
Date:
Mobile Comments:
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
- Temporary
e porary Start Date:
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Temporary End Date:
l/ll
Temporary Time:
Rain Date:
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i
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
Food Service up to 201 +
or 25'+ PHF display $125
Food Service- Institution
t
( L Meals/Day)
D Bakery $25
Caterer $25
Food Delivery $25
Milk & Cream $2
❑ Mobile Food & Consession $50
El Mobile Food Temporary $25
Ei Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25 # of Pushcarts:
Residential Kitchen $25
Retail Food $50
Retail Snack Food $10
Tobacco Products No Fee
23) Food Operations `� De/idllions: PHF - Potentially hazardous food(timellemperature controls required)
Non-PHFs - non -potentially hazardous food(no t0xv$emperature controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno fudherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service
For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
of Non-PHFs
Other Food Operations }
r
0
to be Prepared by Consumer
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
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
❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
r 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 ❑ 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 copies of 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant:
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: ZZ62Z
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Ulf 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization
Address: 3 ��
Are you an employer? Check the appfopriate box:
Business Type (required):
L ❑ 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. ❑ 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
10. ❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4We aAre a non-profit organization, staffed by volunteers,
.,[
h no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box #I 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.
Ian: 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, under the ppins and penalties ofperjury that the information provided above is true and correct.
City
only. Do not write in this area, to be completed by city or town official.
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 Person: Phone #:
www.mass.gov/dia