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Home My WebLink AboutFirst Baptist Church - 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; FOOD SERVICE 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:. FIRST BAPTIST CHURCH Whose place of business is: FIRST BAPTIST CHURCH 52 NORTH MAIN STREET PERSON(S) IN CHARGE CHARLOTTE DILL Permit Expires: ,June 01, 2010 License Number: FS-20 Food Fee: WAIVED Milk & Cream V BOARD OF HEALTH Dr. kay6nd 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: FIRST BAPTIST CHURCH having a place of business at: FIRST BAPTIST CHURCH 52 NORTH 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.: FS-20 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 FS-20 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 da s before the tanned o enin date 1) Establishment Name: FIRST BAPTIST CHURCH 2) Establishment Address 52 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 52 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-7047 5) Applicant Name & Title: CHARLOTTE DILL 6) Applicant Address 160 N WASHINGTON STREET, NORTON, MA 7) Applicant Telephone No.: (508)2854639 24 Hour Emergency No.: 8) Owners Name & Title FIRST BAPTIST CHURCH 9) Owner Address (If different from applicant): 52 NORTH MAIN STREET, MANSFIELD 02048 10) Establishment Owned By: ❑O An Association ❑ A Corporation ❑ 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: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: VARIES 17) DAYS/HOURS: VARIES 18) Name of Person In Charge Certified in Food Protection Management: SUSAN M. SMITH If more than 3 individuals are certified, complete list is on file. 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: k6 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: W Annual ❑ Seasonal Seasonal Dates: J Temporary Temporary Start Date: Temporary End Date: Temporary Time: 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 ❑ 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 (Check all that apply): Definitions:PHF - Potentially hazardous food(time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which needno further processing) ❑ Sale of Commercially Pre -Packaged Non-PFHs 0 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 0 Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A 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 Ial Preoaration of Non-PHFs Other Food Operations SOUP KITCHEN ❑ Juice Manufactured and Packaged Retail Sale I I I Offers RTE PHF in Bulk Quantities I Retail Sale of Salvage, Out -Of -Date or Reconditioned Food ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service I I To be completed by the Board of Health Total Permit Fee: Payment is due with application 91 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 ,j?599 -000 and the fede/ra Food CC9 e. 24) Signature of Applicant: / .LryryJt T1/1/ J` .rl. 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: 04-3028252 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: FIRST BAPTIST CHURCH ADDRESS: 52 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-7047 FAX NUMBER: OWNER OF BUSINESS: FIRST BAPTIST CHURCH TELEPHONE OF OWNER: (508) 285-4639 FEDERAL ID/SS NUMBER: 04-3028252 FEE: $2.00 PERMIT NUMBER: FS-20 SIGNATURE: C��2�,J DATE: 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 City/State/Zip: 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 (incl. real estate, auto, etc.) employees working for me in any capacity. 8 Non-profit [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised 9. El Entertainment their right of exemption per c. 152, § I (4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required] * 11 ❑ Health Care 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers', comp. insurance req.] 12.❑ Other *Any applicant that checks box Nl 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 NI. I am 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. Lio, 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 insurance coverage verification. I do hereby certify, under thehains and penrjldq ofperjury that the information provided above is true and correct. Phone #: 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