HomeMy WebLinkAboutGreat American Cleanup -5/2/2009Commonwealth 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: FOOD SERVICE TEMP
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:.
BRUCE MONTGOMERY @ THE COMCAST CENTER
Whose place of business is:
THE GREAT AMERICAN CLEAN-UP OF MANSFIELD @ THE COMCAST CENTER
BOARD
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
LORILEE FISH
Permit Expires: May 02, 2009
License Number: FS-301T
u=Ai ru
Martin, Chairman
Food Fee: WAIVED
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS-301 T
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned openinq date)
1) Establishment Name: GREAT AMERICAN CLEAN-UP OF MANSFIELD @ THE COMCAST CENTER
2) Establishment Address 885 SOUTH MAIN STREET
3) Establishment Mailing Address (if different)
885 SOUTH MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No:
508-851-6460
5) Applicant Name & Title: LORILEE FISH
6) Applicant Address SIX PARK ROW,
MANSFIELD, MA 02048
7) Applicant Telephone No.: 774-266-0010
24 Hour Emergency No.: 774-266-0274
8) Owners Name & Title
BRUCE MONTGOMERY @ THE COMCAST CENTER
9) Owner Address (If different from applicant):
SOUTH MAIN STREET, MANSFIELD, MA 02048
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
O A Corporation
Name
Title Address
❑ An Individual
_
❑ A Partnership
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
-
Lode,
--.._
Address:
/-
Telephone No:
Ca 1�- 24 Hour Emergency No:
FAX:
_ . —--
---
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
_. -- FAX:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
UlfBoston, MA 02111
tvww.tnass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Letaibly
Business/Organization
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.
8• rV 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
10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
11.0 Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.0 Other
*Any applicant that checks box # l 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 ant an employer that ispi
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic.
compensation insurance for my employees. Below is the policy information.
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 hereby cerdA,,lipiler 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
www.mass.gov/dia
Phone
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
1 17) DAYS/HOURS: MAY 2, 2009-11AM-2PM
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees:
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 101112001 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 22) Establishment Type
❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft)
Mobile End Date: ❑ Food Service up to 100 or
Mobile Comments: up to 10' PHF display $75
21) Length of Permit:
❑ Annual
❑ Seasonal
Seasonal Dates:
v
Temporary Start Date:
Temporary End Date:
Temporary Time: 11 am to 2 pm
Rain Date:
❑ 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)
❑ Bakery $25
❑ Caterer $25
❑ Food Delivery $25
❑ Milk & Cream $2
Mobile Food & Consession $50
LJ Mobile Food Temporary $25
❑ Manufacture Frozen Desserts/Ice Cream
$5/freezer
❑ Pushcart $25 # of Pushcarts:
Residential Kitchen $25
❑ Retail Food $50
❑ Retail Snack Food $10
❑ Tobacco Products No Fee
23) Food Operations Definitions:PHF- Potentially hazardous food(tlmeRemperatum controls required)
Non-PHF's - non -potentially hazardous food(no time/tempermure controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex, sandwiches, salads, muffins which need no furtherprocessing)
❑ Sale of Commercially Pre -Packaged Non-PFHs PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And
-- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
❑� Delivery of Packaged PHFs .__-.. Susceptible Population Facility
---e---- ------ ❑ Sale of Raw Animal Foods Intended
❑ Rheating of Commercially '.
Processed Foods for Service Within 4 Hours to be Prepared by Consumer ❑Vacuum Packaging
Cook Chill /
---- ---- --- --- ❑ Use of Process Requiring A Variance
❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service 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 ❑ 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 k waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comp) with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain c 1I ,of 105 CMR\590.000 and the federal Food Code.
24) Signature of Applicant: �. =--�1• _;—Y71 T�(a
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 state tax returns
and paid state taxes required under law.
25) Social Security Number or Federal ID: 04-6001209
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.
* Signa ure of Individual'or U
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.