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Home My WebLink AboutChildren's Enrichment Center - 6/1/2010Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD 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:. BRENDA BARRETT Whose place of business is: CHILDREN'S ENRICHMENT CENTER 754 EAST STREET PERSON(S) IN CHARGE: BRENDA BARRETT, DIRECTOR Permit Expires: June 01, 2009 License Number: FS-350 Food Fee: $10.00 BOARD OF HEALTH Dr. Dymond Martin, FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Ap JLIIC-ar10r1 lrllAJl ue suuuuuc� aloam ..,. uwr� •��•�•--_r•--.---•-- - Establishment Name: Q, Establishment Address -7-5 E&f CT, establishment Mailing Address (if different) stablishment Telephone No:p applicant Name & Title: Applicant Address 5D f Applicant Telephone No.:,— ��-%�� 24 Hour Emergency No.: �� — �� -� j iJ 2>Wners Name &Title '.. wner Address (If different from applicant): Establishment Owned By: 11) if a corporation or partnership, give name, title, and home address of officers ro An Association or partner. Name Title Address [Q,K�Corporation Il An Individual O A Partnership C] OtJapr legal Entity 'Ll.• C,.. n a„ n..nrotinnc (NAmar nPrSnn In enaree. suuumbui. Illalloqu, a—i bull Ulm, Y r : 24 Hour Emergency No: FAX: 1 ,vi nintrint Or Regional Supervisor (if applicable) Name & Title Address: Telephone No: 24 Hour Emergency No: FAX: Food Establishment Information 14) WATER SOURCE: '76 16) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employee 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: Required a, of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate u 19) Person Trained in Anti -Choking P�Spedures (If 25 Seals or more) ❑�,.„„ .� 20) Location: Lt'I Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21) pgth of Permit: 2ual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time Location 22) Establishment Type [� Retail ( Sq. Ft) 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 EF Food Service up to 201 + or 25'+ PHF display $125 ¢.- ood Service - Institution ( I Meals/Day) MA£ H Bakery $25 El Caterer $25 Food Delivery $25 0 Milk & Cream $2 Q Mobile Food & Consession $50 Q Mobile Food Temporary $25 E] Manufacture Frozen Desserts/Ice Cream $5/freezer Pushcart $25 If of Pushcarts: Residential Kitchen $25 Q R tail Food $50 (tail Snack Food $10 n Tobacco Products No Fee 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Check all that apply): Non-PHFs - 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 Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- F)'erishable Foods Only Other Food Operations PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer S Ice Manufactured and Packaged Retail Sale El Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health Juice Manufactured and Packaged for I [I 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 ro be completedby/ the Board of Health Total Permit Fee: `� •'/ Payment is due with application n 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. 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: 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. * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) _ 1 q- e5-1339 ** 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 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: (-ku I6v-effn lit— Address: _5_4 ec-2L 69-' City/State/Zip: Are you an employer? Check the appropriate box: 1. EgTm a employer with 12-- employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] the #: Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 I.❑ Health Care 12.t_1 ether ��n Any applicant that checks box 01 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 01. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Address:%L6 City/State/Zip: Miat1Slu_ V�"lam" Policy # or Self -ins. Lie. # 60 (— D o ( '?`3 & Expiration Date: / J 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 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 Phone Www..... .IVY/ula ERTIFIEA. i D&vcrvH.wnc NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS CERTIFIES ZOUHOURR SAMROUTT HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR -CERTIFIcATE No: TEST FORM THE FOOD SAFETY MANAGER CERTIFICATION EXAMINATION PRESIDENT: 15W� Lawrence J. Lynch EH000189567 ISSUE DATE: EHB June 3, 2004 This,enifime is no, slid for more than five years from dam of issue.