HomeMy WebLinkAboutMansfield H.S. Cheerleading -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:.
Whose place of business is:
MANSFIELD HIGH SCHOOL CHEERLEADING - FAMILY FUN NITE
250 EAST STREET
PERSON(S) IN CHARGE
STACY M.LYNCH
Permit Expires: ,July 14, 2009
RAIN DATE 7/15/2009
License Number: MF-10T
Food Fee: WAIVED
BOARD OF HEALTH
4
Dr. Raymo artin, Chairman
FOR BOARD OF HEALTH USE ONLY
Eateceived: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be subm—Itte-drdat least 30 days betore the planned opening date)
1) Establishment Name: MO i l _ `}r ��� f, I CACP, leat1111rL_
2) Establishment Address
.7 r:,' i lr t LIJ Crt ✓0 1C
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: - J (/
5) Applicant Name &Title: '5j ex e(, , C cr; C
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6) Applicant Address -
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
U An Association
El A Corporation
El An Individual
0 A Partnership
O Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
)- Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
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I
Telephone No:
5 7, 3-�
i7
24 Hour Emergency No: i
FAX:'
E-mail:
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Alt E-Mail
5 FCi C V I L
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13) District Or Regional Supervisor (if applicable)
Name & Title:
`
Address:
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ry Ci �, 1 < S % � 4 ... � .
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Telephone No:
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24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL: Vf/
DEP Public Water Supply No: (If applicable) ��,�
PPY PP ) 16) No. of Food Employees:
17) DAYS/HOURS: ; rti
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file.
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) [ /V//l
20) Location: [ Permanent Location 22) Establishment Type
[/l Mobile Mobile Start Date: v1y /`� i°' Retail ( Sq. Ft)
Mobile End Date: .,)o'! �`i
i Food Service up to 100 or
Mobile Comments: r/.,.. , _ 1-. n., _ /` l f up to 10' PHF display $75
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary Start Date: 'j), iy I
Temporary End Date: JJYH
TemporaryTime: t°ifo�
Rain Date: J,, ) y / 5
Food Service up to 101 -200
or up to 25' PHF display $100
E] Food Service up to 201 +
or 25'+ PHF display $125
Food Service - Institution
Meals/Day)
Q Bakery $25
Q Caterer $25
E] Food Delivery $25
[' Milk & Cream $2
Mobile Food & Consession $50
Mobile Food Temporary $25
n Manufacture Frozen Desserts/Ice Cream
$5/freezer
Pushcart $25 # of Pushcarts:
Residential Kitchen $25
Q Retail Food $50
[I Retail Snack Food $10
n Tobacco Products No Fee
23) Food Operations Definitions:PHF - Potentially hazardousfood (timefiemperatune controls required)
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 -Packaged Non-PHFs [ PHFCooked To Order 0 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
Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
nj Sale of Raw Animal Foods Intended Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer EJ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non- Customer Self -Service
U Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Perishable Foods Only Ice Manufactured and Packaged for
contact alternative, time as a public health
Preparation of Non-PHFs Retail Sale
control)
Other Food Operations Juice Manufactured and Packaged for
E] Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
Offers RTE PHF in Bulk Quantities
❑ 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 [ 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: J „" ) Xi- 7t-e'A
Pursuant to MGL Ch.62C, sec. 49A, I ceA under the Wienalties 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:
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.
>'Signatuof Indio ual or
CorporaName (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
0,3 �- JLi- 7iy(,
** 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 620, 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
City/State/Zip: m /i Phone #: SU 7 - / 7J Y O
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. ❑ 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. g, 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]*
4. ❑ We are a non-profit organization, staffed by volunteers, I I. ❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑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 #l.
I are an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy 9 or Self -ins. Lie.
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 CIA for insurance coverage verification.
I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct.
/ r % ?
Sianahtre.• . ��i.('T..f ..n t / i . Y11%- Date. �J 0 r�l
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
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 M
www.mass.gov/dia
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ST•L ,MASSACHUSETTS DEPARTMENT OF REVENUE
CERTIFICATE OF EXEMPTION
Cartfflcallon Is hereby made that the organization herein named is an exempt purchaser under General Laws, Chapter 6/H, Sections 6(d)
and (a). All purchases of tangible personal property by this organization are exempt from taxation under said chapter to the extent that
such property Is used In the conduct of the business of the purchase(- Any abuse or misuse of this cedIficate by any tax-exempt
organization or any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation.
Yllilful misuse of this Certificate of Esempl(on Is subject to c(im(aal sanctions of up to t year in pdson and S10,W0 (S50,000 for
eomoalions) In lines. (Sea (averse side).
TOWN OF MANSFIELD
SO WEST STREET.
MANSFIELD MA 02048
NOT ASSIGNABLE OR TRANSFERABLE
EXEMPTION NUMBER E
046-001-209
ISSUE DATE
01/04/89
CERTIFICATE EXPIRES ON
NONE
COMMISSIONER OF REVENUE
STEPHEN_W. KIDDER