HomeMy WebLinkAboutMansfield Band Parents - 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:.
WAYNE SMITH
Whose place of business is:
MANSFIELD BAND PARENTS ASSOCIATION, INC.
FAMILY FUN NITE
PERSON(S) IN CHARGE
WAYNE SMITH
Permit Expires: ,July 14, 2009
RAIN DATE 7/15/2009
License Number: MF-7T
Food Fee: WAIVED
HEALTH
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 leastays a ore tne planned opening date)
1) Establishment Name: A� \ t
2) Establishment Address
3) Establishment Mailing Address (if different)
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4) Establishment Telephone No:
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5) Applicant Name & Title: tzclkw t
6) Applicant Address
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7) Applicant Telephone No.:
24 Hour Emergency No.:
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
XAn Association
El A Corporation
El An Individual
A Partnership
El Other legal Entity
11) If a corporation
or partner.
Name
or partnership, give name, title, and home address of officers
Title Address
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
1
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Address:
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Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
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Alt E-Mail:
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13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL: N
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 11%
17) DAYS/HOURS: �� s Q
ell
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): El
20) Location: ❑ Permanent Location
22) Establishment Type
❑ Bakery $25
Mobile Mobile Start Date:
i't 4� 0 c1
❑ Retail ( Sq. Ft)
❑ Caterer $25
Moblie End Date: 711 ,� to�1Ej
Food Service up to 100 or
❑ Food Delivery $25
Mobile Comments:
up to 10' PHF display $75
Milk & Cream $2
21) Length of Permit:
❑ Food service up to 101-200
❑ Mobile Food & Consession $50
Annual
or up to 26 PHF display $100
❑ Mobile Food Temporary $25
Seasonal
❑ Food Service up to 201 +
❑ Manufacture Frozen Dessertsilce Cream
or 25'+ PHF display $125
$5/freezer
Seasonal Dates:
❑ Pushcart $25 # of Pushcarts:
❑ Food Service - Institution
Residential Kitchen $25
[Temporary
Temporary Start Date:
% 1 `I,
O i
( Meals/Day)
❑ Retail Food $50
Temporary End Dale:
1' 1 5' 0`1
❑ Retail Snack Food $10
Temporary Time:
10
❑ Tobacco Products No Fee
Rain Date:
23) Food Operations
Definitions: PHF - Pbtenfieny hazardous food(davAemperatum controls required)
Non-PHFs - non -potentially hazardous food(no fimrltemperatum controls required)
(Check all that apply):
RTE-
raady4o-eat foods (Ex. sandwiches, salads, muffins which needno fudherpmcessing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Preparation of Non-PHFs
Other Food Operations
(q n d S
PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
to be Prepared by Consumer
Customer Self-service
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging I Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
bl' h Ilh
U Ice Manufactured and Packaged for
contact altematwe, bme as a pu rc as
Retail Sale
control)
Ej Juice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
❑ Prepares Food/Single Meals for
0 Offers RTE PHF in Bulk Quantities
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 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 R 510.000 and all other applicable law. I have been instructed by the
board of health on how to obtain cor 105 C 4000 and deral Food Code.
24) Signature of Applicant: Z
Pursuant to MGL Ch.62C, s . A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid slate taxes required under law. tP q to 3cl _
25 Social Security Number or Federal ID: (� ( 1 f� ` ./1
26) Signature of Individual or Corporate Name: MCANS r e-`` �r>�•v3� a'r`,y &S"c" 12 •> 1 Ac
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 (Mandatory)
By porate Officer
(Mandatory, if applicable)
iA t - 'a l a Ct � 3 0�
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the certit'ication 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
o- Boston, MA 02111
www.ntassgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:_
Address: Pi D, IRZ7k l y
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time). *
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. M We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
Phone #: `01 501- 33ri-1 305
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12.❑ Other
*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 #I. .,
Iant an employer that isproviding workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer'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
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 pains and penalties ofperjury that the information provided above 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
W
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Food Service Permit Fee for the following reason
Av
Thank you,
Date 7 W36j
O C `T Y" (-\SS Z) C , �-, "-
Title
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request a waiver of the