HomeMy WebLinkAboutMansfield Boys Varsity Soccer - 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:.
MANSFIELD BOYS VARSITY SOCCER TEAM
Whose place of business is:
MANSFIELD BOYS VARSITY SOCCER TEAM - FAMILY FUN NIGHT
PERSON(S) IN CHARGE:
ELISABETH GARBER-MILLER
Permit Expires: July 14, 2009
Rain Date July 15, 2009
License Number: MF-8T
Food Fee: WAIVED
BOARD OF HEALTH.,
Jf.
Dr. Raymond'martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMITAPPLICAT|ON
(Application must be submItted at least 3U-da—ys before the _pii!annJcTc—penJng date)
a It
2) Establishment Address
3) Establishment Mailing Address (if different)
9�4�_
4) Establishment Telephone No:
,
7) Applicant Telephone No.:
24 Hour Emergency No.:
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
WAn Association
or partner.
Ru A Corporation
Name
Title Address
MR] An Individual
Iff Other legal Entity
12) Person DirectIv Resoonsible For Dailv Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Telephone No:
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: 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.
Required as of 10/f/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): IN I
20) Location: O Permanent Location
22) Establishment Type
O Bakery $25
Mobile Mobile Start Dale: f', . ;,4
® Retail ( Sq. Ft)
® Caterer $25
Mobile End Date: '7 ; > Cj0(
® Food Service up to 100 or
® Food Delivery $25
Mobile Comments:
up to 10' PHF display $75
® Food service up to 101-200
® Milk & Cream $2
® Mobile Food & Consession $50
21) Length of Permit:
K% Annual
or up to 25' PHF display $100
® Food Service up to 201 +
IN Mobile Food Temporary $25
® Manufacture Frozen Desserts/Ice Cream
® Seasonal
or 25'+ PHF display $125
$5/freezer
Seasonal Dates:
® Pushcart $25 # of Pushcarts:
FBIFood Service - Institution
FBIResidential Kitchen $25
51 Temporary
Temporary Start Date: 7 t y r,, f
( Meals/Day)
® Retail Food $50
Temporary End Date: -7 i{ " ri
Retail Snack Food $10
Temporary Time:
® Tobacco Products No Fee
Rain Date:
23) Food Operations Definitions:PHF- Potentially hazardous food(time/temperature controls required)
Non-PHF's - non -potentially hazardous food(no tlme/temperature controls required)
(Check all that apply): RTE -ready-to-eat foods (Ex. sandwiches, salads, mums which need no further processing)
X Sale of Commercially Pre -Packaged Non-PHFs ® PHFCooked To Order ® Hot PHF Cooked and Cooled or Hot Held
Do Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service
IR Delivery of Packaged PHFs Cold Holding For Single Meal Service ® PHF and RTE Foods Prepared For Highly
ry Susceptible Population Facility
0 Reheating of Commercially ®Sale of Raw Animal Foods Intended
Processed Foods for Service Within 4 Hours to be Prepared by Consumer ®Vacuum Packaging /Cook Chill
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
Non PHF and Non- I IMI Customer Self -Service
Ice Manufai
Retail Sale
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
I® Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Out -Of -Date
or Reconditioned Food To be completedby the Board offfeafth
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 copiest6f-105'CMR,590.000 and the federal Food Code. rr ,.,,
24) Signature of Applicant: '"tl`V�b=e"c��•"'N"�'�-`^'�'-/l1 x_.i�'�
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 stale 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.
r
�< tjr IYt�•l„
J;
* Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
** 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 62C, Section 49A.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Anplicant Information Please Print Letribly
Business/Organization Name: tYi,�li^ t,-t' t -�� i s I itt V l 1 j r C r P v �f rr. r� : } i ri" S
Address:
<''-6
City/State/Zip:
4 (axe')
�_l,- C
2C'4G Phone#:
G9,
Are you an employer? Check the appropriate 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 y. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
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]* l l ❑ Health Care
4.(' We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12,E] Other 1 <l a r r r (i r E e r c ic'
*Any applicant that checks box #1 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.
I am 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.
do hereby certify, under the pains and penalties of perjury that the information
n
ivnature• ; i'((a ru< ,,� t'. �jlL Da
Phone it:
is true and correct
Official use only. Do not write in this area, to be completed by city or town 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 Person: Phone #:
www.mass.gov/dia
Mansfield Board of Health
Date ` > t i
r __
�fl/@, ! 1"ti' � t c �t i'rE�C (r� ' �%� tf� ; u�rzt'. i4� '��'Y'� "r t' (E EiYI _ fGQUBSt a waiver Of the
r<r,
Food Service Permit Fee for the following reason
Thank you,
Signature
Tide