HomeMy WebLinkAboutJennerational Salon - 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:.
JENNIFER MCDONALD
Whose place of business is:
JENNERATIONAL SALON
112 NORTH MAIN STREET
PERSON(S) IN CHARGE
Permit Expires: July 14, 2009
RAIN DATE 7/15/2009
License Number: MF-15T
Food Fee: WAIVED
BOARD OF HEALTH
DqRaymoMartin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
pp ica ion mus a su mi e a e>as ays a ore e p anne opening a e
1) Establishment Name:
2) Establishment Address
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:: 3� L�
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No.S 24 Hour Emergency No.:
8) Owners Name & Title
9) Owner Address (If differe rom applic nt): S
10) Establishment Owned By:
11 An Association
11 A Corporation
n Individual
Ll A Partnership
El Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
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:
AIt E-Mail:
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:
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/l/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
Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
21) Length of Permit:
Annual
Seasonal
Seasonal Dates:
Temporary Start Date: '--/t - Qy
Temporary End Date:
Temporary Time: /
Rain Date:
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
( Meals/Day)
El Bakery $25
Caterer $25
Food Delivery $25
El Milk & Cream $2
Mobile Food & Consession $50
Mobile Food Temporary $25
Ei Manufacture Frozen Desserts/Ice Cream
$5/freezer
Q Pushcart $25 # of Pushcarts:
Residential Kitchen $25
Retail Food $50
Q Retail Snack Food $10
Tobacco Products No Fee
23) Food Operations Definitions:PHF - Potentially hazardous food(timeRemperature contmis required)
Non-PHFs - non -potentially hazardous food(no timeRemperature controls required)
(Check all that apply): RTE -ready-to-eal foods (Ex, sandwiches, salads, muffins which need no fudherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
El Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Other Food Operations
a���r1
TJr V
PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
LJ Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
i] Juice Manufactured and Packaged for
Retail Sale
Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
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 / Cook Chill
El Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
or Reconditioned Food I I To be completed by the Board of Health
Total Permit Fee:
--/1 Payment is due with application ❑ waived
I, the undersigned, attest to th accurac f the iniormali provided in this application and affirm that the food
establishment operation will co ply wi 1 5- MR 590.0 0 and it other applicable law I th been instructed by the
board of health on how to obtain c of CM R ¢90.0 an the federal Food C e.
24) Signature of Applican Uml )
Pursuant to MGL Ch.62C, a 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: 0 r 000 7 0
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.
Jn dxe,Qk
Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
7G 0077�e(Q
** 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
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Address: / /,�) t-P .W e l_
City/State/Zip: Waj� & j r Q P Phone #: 0 5 �s tj
1=) 0_ �
Are y an employer? Check the appropriate box:
Business Type (required):
1. Eff
I am a employer with 41_�___ 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 (me]. 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 a 152, § 1(4), and we have
10.❑ Manufacturing
no employees, [No workers' comp. insurance required]*
I I ❑ Health Care
4, ❑
We are a non-profit organization, staffed by volunteers,
with no employees. INo workers' comp. insurance req.]
12.❑ Other
*Any applicant that checks box NI 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 NI.
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 Date:
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
Phone # \J 0Z 33 l a6c-�O
the Information provided above is true and correct.
"— t r . J1 Q
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
6. Other
Contact
Permit/License
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
www.mass.gowdin
Phone