HomeMy WebLinkAboutMansfield Youth Soccer - 7/14/2009Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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:.
MANSFIELD YOUTH SOCCER
Whose place of business is:
MANSFIELD YOUTH SOCCER - FAMILY FUN NIGHT
50 PLYMOUTH STREET
PERSON(S) IN CHARGE:
KENT BONGARZONE
Permit Expires: July 14, 2009
RAIN DATE 7/15/2009
License Number: MF-13T
Food Fee: WAIVED
BOARD OF ALTH
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Dr. Raymond 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 opening date)
1) Establishment Name:
�%N t O U
�CL�yil
2) Establishment Address: ] y� /
3) Establishment Mailing Address (if different): p (%� u�( / d 7 %yi J % i t/ ( O d (7 %
4) Establishment Telephone No: S 0 9 -- 3 ` r ✓ D ?5 .
5) Applicant Name & Title:
kr o .�
6) Applicant Address: I'
y�� �y �}
S vr(( D i � tf1-7f '(1' �'/14 0 )o ve
7) Applicant Telephone No:
0 8 - a t /' l S 24 Hour Emergency No
8) Owner Name & Title (if different from applicant): Mk n'(f 1 ( ro t�k t (G
9) Owner Address (if different from applicant): 0 l 4MA d (l
10) Establishment Owned By:
An association
A corporation
An individual
m A partnership�(
m Other legal entityKe
11) If a corporation or partnership, give name, title, and home address of
officers or partner.
Name Title Home Address
�J St
/'14 Or �tf U//�� fe ;ce(%il% - 3 S JA / ��� I "/d
54lu1i1&�hls Wdk(,y ke I��
/
KEN— jl vrPod- 'OrA
20sl(P ruN (-5"C✓S c A'W Lnhe Gh
12) Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager etc.
Name & Title:
t �" 7 D A Zt?NC' t 'd r ge (j t'CaA' o ✓!') F�iy,
Address:
U Cle Pe V ' 1-7 -//t
em
Telephone No:
f
So z / /�� �( Fax:
S U Q -
Emergency Telephone No:
13 District Or Regional Supervisor if applicable)
Name & Title:
Address:
Telephone No:
Fax:
ivuappucat ono-Z.aoc
Food Establishment Information
14)
Water Source:
15) Sewage disposal:
DEP Public Water Supply No: (if applicable)
16)
Days and Hours of Operation: Tv I j tl fA 5 om 7 9 v"
17) No. of Food Employees:
18)
Name of Person In Charge Certified in Food Protection Management:
Required as of 101112001in accordance with 105 CMR 590.003(A)F�easo onacn co orcortlricare.
19)
Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes
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
Mobile
❑ Food Service - Takeout
❑ Residential Kitchen for Bed and Breakfast
❑ FoodService- Institution
Home
( Meals/Day)
❑ Residential Kitchen for Bed and Breakfast
Establishments
Other (Describe)
❑ Frozen Dessert Manufacturer
21) Length Of Permit:
(check one)
❑
Annual
❑
Seasonal/Dates:
ai Tempgrary/DatesfTime:
IV l D 0
.ttions:
Dann 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
❑ Hot PHF Cooked and Cooled or Hot Held
Packaged Non-PHFs
for More Than a Single Meal Service.
❑
Sale of Commercially Pre-
❑ Preparation Of PHFs For Hot And
❑ PHF and RTE Foods Prepared For Highly
Packaged PHFs
Cold Holding For Single Meal
Susceptible Population Facility
Service.
❑
Delivery of Packaged PHFs
❑ Sale Of Raw Animal Foods Intended
❑ Vacuum Packaging/Cook Chill
to be Prepared by Consumer.
❑
Reheating of Commercially
❑ Customer Self -Service
❑ Use Of Process Requiring A Variance And/Or
Processed Foods For Service
HACCP Plan (including bare hand contact
Within 4 Hours.
alternative, time as a public health control
❑
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.
❑
Preparation Of Non-PHFs
Juice Manufactured and Packaged
❑ Prepares Food/Single Meals for Catered
for Retail Sale
Events or Institutional Food Service
❑ Offers RTE PHF in Bulk Quantities
Other (Describe): To he completed by the Board of Health
❑ Retail Sale of Salvage, Out -of Date Total Permit Fee:
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 106 CMR 590.000 and all other applicable law. I have been instructed by the board
of health on how to obtain copies 105 CM 90.000 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certif ruder the penalties 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: 0 &/ - 3 V W L1 T
26) Signature of Individual or Corporate Name: INS � a 0 j V/
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 Individual or Corporate Name
**Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (M1fcVfory, 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.
C\Users\Adnrinis(rator2\AppData\Local\Microsoft\Windows\Temporary Internet Files\OLK441 B\TAX CERTIFICATION
FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization N
Address: P V F)v l U 5
i h $ V i (lO / p) A Phone #: ('5-b 6 l 33 q — ) ::)� -5 7
Are ,you an employer? Check the appropriate box:
Business Type (required):
I. ❑
1 am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. ❑
1 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.allon-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
4/�i /
We are a non-profit organization, staffed by volunteers,
l /
with no employees. [No workers' comp. insurance reg.i
12.0 Other
*Any applicant that checks box # 1 must also till 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.
Iran an employer that is providing workers' compensation insurance for my employees. Below is the policy inftn'nratioa.
+h Insurance Company Name:
IInsurer's Address:
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
tine 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 D1A for insurance coverage verification.
1 do hereby cergfy, under fAii4 rains and penalties of perjury that fire information provided above is trite and correct
//0
Phone #: ' S O g �% S 3 ^' S� �—d �- c�/7" J
Official use only. Do not write in this area, to be completed by city or Iowa 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.ntass.gov/dia