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Home My WebLink AboutGrampy's Popcorn Wagon - 7/14/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Perinit 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:. JACKI ROSE Whose place of business is: GRAMPY'S POPCORN WAGON 186 MAIN STREET PERSON(S) IN CHARGE WALTER ROSE Permit Expires: July 14, 2009 RAIN DATE 7/15/2009 License Number: MF-12T Food Fee: $25.00 BOARD OF HEALTH v Dr. Ra'Aond Martin. Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION pp Acafon must e submitted at leastays e ore e p�noe opening a e -- 1) Establishment Name:y r � 2) Establishment Address � o xzr 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 5) Applicant Name & Title: Illl 6) Applicant Addressr 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title By 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 11 An Association or partner. El A Corporation Name Title Address An Individual a q a� / e' t`ifl dS L. •.'S fi(r /�'t`k'`� li� L":r '-1 `}^' Partnership 4 2 L � � Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: r G:> JG ✓r ` > ' U' i' ,r, s ! r I I Telephone No: t — f 24 Hour Emrgency o: ` N e sZ; SLIs tt� r, FAX: _ E-mail: Alt E-Mail: -- -- 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 1 24 Hour Emergency No: I Food Establishment Information 14) WATER SOURCE: _5 r,1/ 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. as of 10/l2001 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 'Moblie Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: E] Annual Seasonal Seasonal Dates: Temporary Start Date: r Temporary End Date: 7 Temporary Time: r3 Rain Date: '15��6> f 22) Establishment Type Retail ( Sq. Ft) 0 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 254 PHF display $125 El Food Service - Institution Meals/Day) Bakery $25 El Caterer $25 Food Delivery $25 [] Milk & Cream $2 Q Mobile Food & Consession $50 12 Mobile Food Temporary $25 11 Manufacture Frozen Desserts/Ice Cream $5/freezer Pushcart $25 # of Pushcarts: Residential Kitchen $25 Retail Food $50 Retail Snack Food $10 El Tobacco Products No Fee 23) Food Operations Definitions:PHF- Potentially hazardous food(timeRemperature 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 furtherprocessing) I] Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ 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 Sale of Raw Animal Foods Intended Susceptible Population Facility El Reheating of Commercially to be Prepared by Consumer ] Vacuum Packaging / Cook Chili Processed Foods for Service Within 4 Hours ___-- Customer Self -Service of Non PHF and Non - Perishable Foods Only t:71♦201111011 Other Food Operations 750i)A Customer Self -Service U Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale I control) ] Juice Manufactured and Packaged for I ] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities i] Prepares Food/Single Meals for Catered Events or Institutional Food Service ( Retail Sale of Salvage, Out -Of -Date ___..__.-.. _..... _ r or Reconditioned Food To be completed by the Board of Health- cft,_ 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: Pursuant to MGL Ch.62C, sec. 49 , I ce and paid stale taxes required un 'r law. the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: _ 26) Signature of Individual or Corporate Name: TJ„J'�- `7i '� TAX CERTIFICATION FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. fJ"fit/'rt��t�' ` % ter}t`;t✓'' �/^��e��-� Signature of Individual or Corporate Name' "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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. R:\Health\Jane's Documents\PERMIT APPLICATIONWAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street a Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Address: Phone #: 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 7, ❑ Office and/or Sales (met. 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 WE] Manufacturing no employees. [No workers' comp. insurance required]*c'c{ 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑Health Care with no employees, [No workers' comp. insurance req.] 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 #1. I out an employer that is providing workers' compensation insurance for nay employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. Attach a copy of the w Expiration 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 ..................V aasuaat7 jo. 0 - � a` d � m � O� rEn w Oz �• z [O .Y �M ij.1• x Y � 0,0 c+ d7 It Wmo 2vvo y�0 o;gmvi H•" � �' .. 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