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HomeMy WebLinkAboutA.J. Bruno Concessions - 6/1/2010Commonwealth 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; PUSHCART 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:. ROBERT J. BRUNO & ANTHONY J. BRUNO Whose place of business is: A.J. BRUNO CONCESSIONS 100 SOUTH MAIN STREET PERSON(S) IN CHARGE: ROBERT BRUNO & ANTHONY BRUNO Permit Expires: June 01, 2010 License Number: P-94 Food Fee: $250.00 Milk & Cream BOARD OF HEALTH Dr. Nyrh6nd Martin, Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: ROBERT J. BRUNO & ANTHONY J. BRUNO having a place of business at.- A.J. BRUNO CONCESSIONS 100 SOUTH MAIN STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 No.: P-94 Scott Leith Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued P-94 FOOD ESTABLISHMENT PERMIT APPLICATION tAnnliratinn must he submitted at least 30 days before the olanned onenino date) 1) Establishment Name: A.J. BRUNO CONCESSIONS 2) Establishment Address 100 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 100 SOUTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 962-9989 5) Applicant Name & Title: ROBERT J. BRUNO & ANTHONY J. BRUNO 6) Applicant Address 100 SOUTH MAIN STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 962-9989 24 Hour Emergency No.: (508) 261-7198 8) Owners Name & Title ROBERT J. BRUNO & ANTHONY J. BRUNO 9) Owner Address (If different from applicant): 100 SOUTH MAIN STREET, MANSFIELD, MA 02048 10) Establishment Owned By: ❑ An Association ❑ A Corporation V An Individual ❑ A Partnership ❑ 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: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: Food Establishment Information 14) WATER SOURCE: MOBILE 15) SEWAGE DISPOSAL: MOBILE DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 1 117) DAYS/HOURS: SEASONAL 18) Name of Person In Charge Certified in Food Protection Management: ANTHONY J. BRUNO If more than 3 individuals are certified, complete list is on file. ROBERT BRUNO 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): ❑d 20) Location: Permanent LLocation 22) Establishment Type ��.a4 ❑d Mobile Mobile Start Date: 5/ /2008 ❑ Retail ( Sq. Ft) Mobile End Date: Moblie Comments: PUSHCARTS 21) Length of Permit: ❑� Annual 0 Seasonal Seasonal Dates: CONCERT DATES J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ 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) ❑ Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 ❑ Milk & Cream $2 ❑ Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑d Pushcart $25 # of Pushcarts: 10 ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 ❑ Tobacco Products No Fee 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready-fo-eat foods (Ex sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑ 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 OV Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $250.00 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 co es --Q,CMR-690t00(tWd the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.620, sec. 49A, I certify and paid state taxes required under law. the penalties of perjury that I, to my best knowledge and belief, have filed all slate tax returns 25) Social Security Number or Federal ID: 011-54-6117 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 * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ob i _I { (— ** 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, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information p Please Print Legibly Business/Organization Name. Address: City/State/Zip: �ad=i - ��<v. Phone#: vs,- Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. P-ei'am a sole proprietor or partnership and have no y, ❑ Office and/or Sales (me]. 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 I to.❑ Manufacturing 4. ❑ no employees. [No workers' comp. insurance required] * We 11 ❑Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers', comp. insurance req.] I 12.❑ Other *Any applicant that checks box pl must also till 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 41. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Nat Insurer's Address: 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 hereby certify, under the pains andpena/ties 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 off chd 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.govtdia Phone #: 4 Student Name ROBERTBRUNO Class Number 745900 Exam Date 4/27/2009 Expiration Date 4/27/2014 Instructor Name NANCY HANEY Sponsor Name Tri-County Reg Voc Tech High Schoo Exam Location MA Exam Form Name 4460 Overall Point Score 67 Overall % Score 83 Passing % Score 75 Status PASSED - Perfect Your Point Point Score Score 80 67 Domain Names I. Foods 36 29 II. Clean/Sanitize/Maint. 9 6 III. Facilities 6 6 IV, Monitoring Food Personnel 12 9 V. Temp. Measuring Devices 2 2 VI. Allergens 3 3 VIL High -Risk Populations 1 1 - VIII. Legal/Regulatory Issues 4 4 IX. Facility Layout/Design 2 2 X. Training Employees 5 5 4A1 0 0 To have a certificate reprinted, complete a Certificate Request Form on our Web site at t ..ServSafe.com (click on Customer Care/Help). �J" NATIONAL! RESTAURANT ASSOCIATION m ©2009 National Restaurant Associates Educational Foundation. NI rights reserved. 08121/02 v.0903 Exam Form No. 4460 `. ! NATIONAL C& IAY A %SECtrS0f0 IDN Cart. No. 6430307 ServSafe ` Certification To`ROBERT BRUNO foreareeurlheseAefmA the cmMzNc utfenh by the themes foulaenl Anedwion Fau,,00.1 f smalionrmaa sa,l efia real Kenew ManaAercenifikoioe Eussalsie. Date of Examination: 4/27/2009 Date of Expiration: 4/27/2014 ���+www±±.aa Local lnwv apptyCM1edwnhyour local requlamryagencytorrecenilication requLemono. a ®2W9 National Peclamant Ascooiation Edecetionel Foundation. All ri,lutoaerved. M55