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Home My WebLink AboutChampagne Catering - 6/1/2010J/• Commonwealth 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: CATERER 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:. MICHAEL PRENTIS Whose place of business is: CHAMPAGNE CATERING 11 JOHN STREET PERSON(S) IN CHARGE MICHAEL PRENTIS Permit Expires: June 01, 2010 License Number: C-3 Food Fee: $25.00 Milk & Cream O BOARD OF HEALTH Dr. Raynipnd 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: MICHAEL PRENTIS having a place of business at., CHAMPAGNE CATERING 11 JOHN 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 License No.: C-3 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 C-3 FOOD ESTABLISHMENT PERMIT APPLICATION (Qnnhrntlnn Il' u.0 hP..QI1hmittP.I1 Pt )PP.Ct.'30 HRvs hAfn/P thp nlinnP(t nnP-nincy datP-) 1) Establishment Name: CHAMPAGNE CATERING 2) Establishment Address 11 JOHN STREET 3) Establishment Mailing Address (if different) 11 JOHN STREET MANSFIELD, MA02048 SUN 2 9 2009 4) Establishment Telephone No: (508) 337-8018 5) Applicant Name & Title: MICHAEL PRENTIS By --- 6) Applicant Address 11 JOHN STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 337-6208 24 Hour Emergency No.: (608) 337-6208 (508) 851.0672 8) Owners Name & Title MICHAEL PRENTIS 9) Owner Address (If different from applicant): 11 JOHN 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. ❑ A Corporation Name Title Address Cl An Individual ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: M Gi.sa EL ohs t 'S Address: I 3-0\�v, S4- Telephone No: 8 ® 33-7— 0 (8 24 Hour Emergency No: FAX:. --- _.. 13) District Or Regional Supervisor (if applicable) Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 1 17) DAYS/HOURS: VARIES 18) Name of Person In Charge Certified in Food Protection Management: MICHAEL PRENTIS If more than 3 individuals are certified, complete list is on file. Required 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 ❑ Bakery $25 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Caterer $25 Moblie End Date: ❑ Food Service up to too or ❑ Food Delivery $25 Moblie Comments: up to 10' PHF display $75 ❑ Food Service up to 101 -200 Milk & Cream $2 ❑ Mobile Food & Consession $50 21) Length of Permit: Q Annual or up to 25' PHF display $100 ❑ Food Service up to 201 + ❑ Mobile Food Temporary $25 ❑ g5)freeaZeore Frozen Desserts/Ice Cream ❑ Seasonal or 25'+ PHF display $125 Seasonal Dates: ❑ Pushcart $25 # of Pushcarts: ❑ Food Service - Institution ❑ Residential Kitchen $25 — ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Retail Food $50 Temporary End Date: ❑ Retail Snack Food $10 Temporary Time: ❑ Tobacco Products No Fee Rain Date: 23) Food Operations Definitions PHF- Potentially Non PHF's hazardous food (tlmellemperature controls - non -potentially hazardous food(no time/temperature required) controls required) (Check all that apply): RTE ready -to -eat foods (Ex sandwiches, salads, muffins which need no furtherprocessing) ❑d Sale of Commercially Pre -Packaged Non-PFHs ❑ PHFCooked To Order ❑J 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 "❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours __.__ _ ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand _...._. —_ ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only 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 ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date — To be completed by the Board of Health or Reconditioned Food Total Permit Fee: $25.00 --_"- --" Payment is due with application ❑ waived I, the undersigned, attest to the a rac of the informal' o ' in this application and affirm that the food establishment operation will ply wi 05 CMR 59 . 0 d herapplicable law. I have been instructed by the board of health on how t fain cop' s t 5 CM 9 op d the d al Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, se . 49A, I card under a 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 1 015-46-1124 26) Signature of Individual or Corporate Name: 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: CHAMPAGNE CATERING ADDRESS: 11 JOHN STREET TELEPHONE AT LOCATION: (508) 337-8018 FAX NUMBER: OWNER OF BUSINESS: MICHAEL PRENTIS TELEPHONE OF OWNER: (508) 337-8018 FEDERAL ID/SS NUMBER: 015-46-1124 FEE: $2.00 PERMIT NUMBER: C-3 SIGNATURE DATE TAX CERTIFICATION FORM 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. Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **Social Security No. (Voluntary) or Federal Ideniifi'cation Number *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\Jan&s DocumentAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 wwwanass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_ 0/1 Address: City/State/Zip: M Phone #: 5bkY - 33 7" / P__ Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail r part-time).* 6. ElRestauram/Bar/Eating Establishment 2 ,NrI am a sole proprietor or partnership and have no y, ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We 11.❑ Health Care are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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 We corporation has other employees, a workers' compensation policy is required and such an organization should check box #l. Into 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 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 ifwryangwcoverage verification. I do here eerd y under e and aloes of perjury that the information provided above is true and correct. C;�,„�n,�.,. it .. _.__ / 1-, le)�Y 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/aia 3q 3 13 l3(A c� (D �C /o (Aifs W lu (D -h m to l<rt Oa �• t V n O Z z a Al O lD 0- CD 0- 0 /y Pon C y rr tD ° O Mh n O 3 O