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Home My WebLink AboutFaith Fellowship United Methodist 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:. N. E. CONFERENCE OF THE UNITED METHODIST CHURCH Whose place of business is: FAITH FELLOWSHIP UNITED METHODIST CHURCH 9 NORTH MAIN STREET PERSON(S) IN CHARGE: �— 1 _:: b_ Permit Expires: ,June 01, 2010 License Number: FS-74 Food Fee: WAIVED Milk & Cream ❑O BOARD OF H 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 Crean This is to certify that. N. E. CONFERENCE OF THE UNITED METHODIST CHURCH having a place of business at: FAITH FELLOWSHIP UNITED METHODIST CHURCH 9 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 License FS-74 Sco L ' e, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Name: Address: /too 009a c %_ Sf Phone #: 5bd 3 3 J--6Gq D 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. ❑ 1 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. [No workers' comp. insurance required] g. �on-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]*'11.Health 4. [j�We are a non-profit organization, staffed by volunteers, Care with no employees. (No workers' comp. insurance req.l 12.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **]f 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 Nat Insurer's Address: 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 insurance coverage verification. I do hereby certify, under the pains and penalties ofterjury 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 Person: Phone www.mass.gov/dia 00 •d O •'1 a N a � 6 o Z Z W F f a 0 U LL LL � f Q C� K W IY U O 00 �: M CD a C X w N 0 N � F r Q o' n z S 6 s z At .. og az �v xd Z m E O N H a rq N 6 d Z !Z W i r a a' V 0 LL LL f. Q C� X W W V j FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS- FOOD ESTABLISHMENT PERMIT APPLICATION /dnnlicatinn mimt ha .cuhmitted at len.et .4n dnvc hefnre the nianned nnenino date) 1) Establishment Name: FAITH FELLOWSHIP UNITED METHODIST CHURCH 2) Establishment Address 9 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 9 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-6040 5) Applicant Name & Title: BERNIE ALLAIN REV. DAVID ARRUDA 6) Applicant Address 30 WEBB PLACE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (774) 719.2175 24 Hour Emergency No.: 8) Owners Name & Title N. E. CONFERENCE OF THE UNITED METHODIST CHURCH 9) Owner Address (If different from applicant): 9 N. MAIN STREET, MANSFIELD, MA 02048 10) Establishment Owned By: ❑ An Association ❑ A Corporation ❑ An Individual ❑ A Partnership 0 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: TOWN 15) SEWAGE DISPOSAL: SEPTIC DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:,,,• 1 p2, 17) DAYS/HOURS: VARIOUS COFFE HOURS ONCE A MONTH 7pm-9:30 pm 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. 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: 91 Permanent Location ❑ Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: ❑J Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 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 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution Meals/Day) bl�)CAIIE,guf/V &91919PO4 Clh ❑ 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 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-to-eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑J 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 Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended 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- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand 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 Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin CHURCH FAIRS ❑ 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: Payment is due with application ❑� waived I, the undersigned, attest to the accuracy of the information provided in this application and af0rm 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 cgpies of 105 CMR_59p;QOQand 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: 04-3058556 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: FAITH FELLOWSHIP UNITED METHODIST CHURCH ADDRESS: 9 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6040 FAX NUMBER: OWNER OF BUSINESS: N. E. CONFERENCE OF THE UNITED METHODIST CHURCH TELEPHONE OF OWNER: (508) 339-6040 FEDERAL ID/SS NUMBER: 04-3058556 FEE: $2.00 PERMIT NUMBER: FS- 1 SIGNATURE: DATE: (�