Loading...
HomeMy WebLinkAboutCanoe River C.G. - 6/1/2010Commonwealth of Massachusetts Town of Mansfield Board of Health to Operate a Food Service Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. JOSEPH GONSALVES & FAMILY Whose place of business is: CANOE RIVER CAMPGROUND 137 MILL STREET License Number: FS-6 Permit Expires: June 01, 2010 BOARD OF HEALTH Food Fee: $75.00 Milk & Cream C7 Dr. Raymond Martin, Chairman Permit for the Sale of Tobacco Products 1 Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: CANOE RIVER CAMPGROUND 137 MILL STREET License Number: FS-6 Permit Expires: June 01, 2010 BOARD OF HEALTH Dr. Raymond Martin, Chairman 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: JOSEPH GONSALVES & FAMILY having a place of business at: CANOE RIVER CAMPGROUND 137 MILL 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.: FS-6 Scott Leite, 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 9 Issued FS-6 FOOD ESTABLISHMENT PERMIT APPLICATION (Annlication must be submitted at least 30 days before the olanned ooenino date) 1) Establishment Name: CANOE RIVER CAMPGROUND 2) Establishment Address 137 MILL STREET ). 2009 3) Establishment Mailing Address (if different) 137 MILL STREET MANSFIELD, MA 02048 By 4) Establishment Telephone No: (508) 339-6462 5) Applicant Name & Title: MARK BURMEISTER, MANAGER 6) Applicant Address 137 MILL STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-6462 24 Hour Emergency No.: (508) 339-8684 8) Owners Name & Title JOSEPH GONSALVES & FAMILY 9) Owner Address (If different from applicant): 137 MILL STREET, MANSFIELD, MA 02048 10) Establishment Owned By: ❑ An Association ❑O A Corporation ❑An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of or partner. Name Title Address =7�}n�Ll.� in1C _- officers M.A2K-[3cu�MEts�2 PRC--�006>v i /37 Mtt-L- 5"� �_ r1 to J5Fr c i_� (4, 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Fm�An K 9tAkAle`752�2- Address: 7 3 -7 M t L-L. 5F F. M/fN5r-1 Telephone No: S O&,_ 3 31 - 6 y6 � 24 Hour Emergency No: 5�� _ 7 e FAX: so,? - 33i - s7,;� 37- 13) District Or Regional Supervisor (if applicable) Name & Title: A) 114 Address: Telephone No: 24 Hour Emergency No: FAX: - — - Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 6 17) DAYS/HOURS: JUNE-SEPTEMBER 18) Name of Person In Charge Certified in Food Protection Management: MARK BURMEISTER If more than 3 individuals are certified, complete list is on file. STEVEN J. GONSALVES Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate PHILIP CARROLL 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: ❑d Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 22) Establishment Type ❑ Retail ( Sq. Ft) CJ 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 ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 Tobacco Products No Fee 21) Length of Permit: ❑� Annual J Seasonal ❑ Seasonal Dates: JUNE-SEPTEMBER ❑ Temporary Temporary Start Date: Temporary End Dale: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑J 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 Susceptible Population Facility ❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) ❑ Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑d 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: $75.00 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 5,90.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies g 105 C 590.90q and the federal„FooA Code. 24) Signature of Applicant:Pursuant to 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: 04-2375571 II _ 26) Signature of Individual or Corporate Name: .�-' 2LI'`� I'�� �b0. CA-A)L' Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: CANOE RIVER CAMPGROUND ADDRESS: 137 MILL STREET TELEPHONE AT LOCATION: (508) 339-6462 FAX NUMBER: (508) 339-5237 OWNER OF BUSINESS: JOSEPH GONSALVES & FAMILY TELEPHONE OF OWNER: (508) 339-8684 FEDERAL ID/SS NUMBER: 04-2375571 FEE: $2.00 PERMIT NUMBER: FS-6 SIGNATURE: DATE: v // 6 /O Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: CANOE RIVER CAMPGROUND LOCATION OF SALE OF TOBACCO PRODUCTS: 137 MILL STREET TELEPHONE AT LOCATION: (508) 339-6462 OWNER OF BUSINESS: _JGSEP—- ff6- Go2v,kL-Ve"S ): 4AM (L ADDRESS OF OWNER: 137 MILL STREET, MANSFIELD, MA 02048 TELEPHONE OF OWNER: (508) 339-8684 FAX NUMBER: (508) 339-5237 If a corporation or partnership, give name, title, and home address of officers or partner. FEDERAL ID/SS NUMBER: 04-2375571 PERMIT NUMBER: SIGNATURE:C�, DATE: 6 w 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: 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. 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 Applicant Information Please Print Legibly Business/Organization Name: �9 l Ll , i -mac Act. C ¢'Ur C ✓2 i V�2 C,4q/°G-/e ©GGU Z�) City/State/Zip: 137 Mit-L S'% NI f+A) _`i; -1 C Z j ,5-08 3 -5 i — 6 1-16 �t Are you an employer? Check th�ropriate box: Business Type (required): 1 1 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 (incl. real estate, auto, etc.) employees working for me in any capacity. g El 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, §l (4), and we have 10. ❑ Manufacturing no employees. [No workers' comp, insurance rcquked]* I I. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers', comp. insurance req.] 121;�Other CAM/'6:- tcl ct,/� *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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: = L121 Ct4 —AM M U-,� i C, 4 /%-) Insurer's City/State/Zip: 0 Policy # or Self -ins. Lie. �. l3a�c l-I°i6 y 3a8va- ZZGIA._ c1S71-114cia3 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 e. 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of I do hereby certify, under t pgins eya�[ties ofperJ that the Rionnhrre•. A Phone#: S(78"33C� —6 Y6 I)L Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License above is true and correct. /c /o 9 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone in c co N OO Z 1 W N Q V M LL W U wj 91 E m w m N N S ai Jo sa °F' elm 0 e o_ tz 0 F mop z uj CA M a 00 Ln Ln 3 Ln 0 Z W Q U FM U. M F W U lz NO t aJ 0 O m Z a a N N m U 3 1 E c a m E LL _ wc 0 4 o � � a r N `o U LL c m m o rn m c O � m o G m C O � N v U G _ o O Z > o > Z o 00 z CY) .r a 3 � N O ¢ X O a XU > N N W a co N II JZ 10 aIF o, m a ZIW 9 J S, o Z �= Se flo4 p t6 a J Q r D) n Vj }dy r M'ct '.m NN N M MN ¢U 3 P1 .J_I 4 0` n o a :,. Q y w E O�VV 9! 3 ma E t Y a i�avLi tcc w y 9u J a$ U y N C O fi N N l0• w c o o y.mc dt �o a" to a s gF Q m p1m Eu) '� m =2.oT «y o yg 3 3 z m .°-c._Emc m m� ESQ° y £ r I €� �O- 'o: En �.c �z moz'cy"' m '.�-.. m a° 5 iE d °a z Ec �f- z u EA 2E 2" Z "c w m h.x ///o/'�fmw A" °o CZO �'r O�"jO 01 LW,H C fn NC�N�CJ �1 qu �6 z- tW Wv.En o m°yoin L°�O ._ mD c:9odrn �L'.c t o�mo 41 �§ o oo!am D mx'aa n,aim(ryEx jmm?� Eg�'�mm°�°_'a°ii m'� �3 i°w©e Vi z$ N V W w N S C N W W O 6. (i 8 LL U LL d F- i o LL = v N p $u m W p g 0 0 (^D MaO �NNMMN Pai c 1'\ % fi mn m Q O 0-5 {1) N N ° � a 5 o '^ d« a Q Z El i ,� 5 m O M E N G o�n Z O000 EE W M1°��NNNM - w�c �i Q m a E ii E �, 'yam N�vau�G W, 0F ci uj a Z ` U N J n � / o=j� � O p cc C�' oIOF k lei` iq e � c o E a'2 O zLL d N ywi1Y'�0 _>'E zz m E Z ,C O Z zOY4O Oc mNy%.rn pYp�aT O t�w ozS E 1i5 u w wO -DIM - V1���y,yyryyrypJrrn �y` ®Ey,P_gACg+ 0 0 0 p oQ "E r minU) N DO r D) n f0 }1�j ill O d vU 3 em -E W p. n e g Fr� 8 amo �� �c Off' Ad Q� Y 0iiOvv iiOv� O E 't 'O 8 r Mul ��NN NM MN uo Q m c Q v v 2 Wm /Z t: �a_aJo m �cc'E me Eu) E 900 �y 70 � �° 9' 2 3 ei m FozE ° wz E z c 5 z a � s°°dd c a°oEEE Ei^ano$°Kd m m w c UL' tL S_utwb❑�w zg w Uwn1-Q=�wH ag o 0