HomeMy WebLinkAboutJohn's Dream Ice Cream - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit # Issued' -
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FOOD ESTABLISHMENT PERMIT APPLICATION ?.
(Application must be submitted at least 30 days before the planned opening date) 19
Establishment Name �J`h�S tDCeii,, Iae
Establishment Address -7 �� ; �St/ (LD. r
Establishment Mailing Address (if different)
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Establishment Telephone No 5 D� /
Applicant Name & Title: �� (fir I V� k' 6Juf _
M/Y U�DY
Applicant Address -7U YO�f1S� �� l�'YnISr GW
Applicant Telephone No.: j� c1� yd 24 Hour Emergency No.:
Applicant Email J t7 Hn15 fi(L� AM 6-R-449A4 L = Lr7iv�
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
Ll An Association partner.
El Corporation Name Title Address
An Individual
El A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: L� 1% I1D c
Address: 7 0 _ CZDr
Telephone No: 5 d �613,5 24 Hour Emergency No: `�U& ,
FAX:
E-mail: -�'OhNS176cdAM(Cc Czi-OYA06(vr 81L, Caws
AltE-Mail: C- J? () d P� 11 Wvuj>j9 (0 6 pr\A)L, C�w�
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management
Name of Person(s) In Charge Certified in Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. I_1 Yes
Does this establishment require a FOG permit? If yes, please attach the FOG permit application.
Length of Permit: Establishment Type:
L✓ Annual ❑ Retail Food $125.00 n Mobile Food Consession
[_l Temporary ❑ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream
Temporary Start Date: $25.00/freezer
Food Service up to 101 -200 $250.00
Temporary End Date: El Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts:
Temporary Time:
Supermarkets $400 ❑Residential Kitchen $100.00
Rain Date:
❑Milk &Cream $10.00 El Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food filme/femperalure 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)
[I Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
El Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
El Preparation of Non-PHFs
Other Food Operations
PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
El 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
Sale of Raw Animal Foods Intended
Susceptible Population Facility
to be Prepared by Consumer
❑ Use of Process Requiring A Variance
El Customer Self -Service
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Ice Manufactured and Packaged for
control)
Retail Sale -
Offers Raw Or Undercooked Food Of
Juice Manufactured and Packaged for
Animal Origin
Retail Sale
El Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for
Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service
or Reconditioned Food
I, the undersigned, attest to the accuracy of the information provided in is application and affirm that the food
establishment operation will c9mp(yjwithl�CMR 59 ..000 a all of r applicable law. I have been instructed by the
board of health on how to fl at Pies 1 0.0(0 and th ederal Food Code.
Signature of Applicant: Lw — kJ ('- V — 4X'/ a I
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. C)r L r , />
Social Security Number or Federal ID: q �j
Signature of Individual or Corporate Name: 7'W
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.
- 9 V
Signature of Indi al or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
070 �381),?
"Social Security No. (Voluntary) or Federal
Identification Nrunber
*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.
C:\Useis\sleile\Desktop\Scott's Docaments\Food Eslablishmenls- Temp\l'AX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 'Jd N,A 'S ►�( Ahn � Le c lie flf"t
Address: 7 o
f itl)/Ctn tP/7in-
I�p't9si�
M A 03'D Yid Phone M � vg 71,E 5 t/d) S
Are you an employer? Check the appropriate box: Business Type (required):
LR I am a employer with employees (full and/ 5. ❑ Retail
2. dor part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (inel. 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.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, 1 L❑ Health Cate
with no employees. [No workers' comp. insurance req.] 12. `f Other r V !� 6Z iN I
*Any applicant that checks box 41 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 #I.
I arm an employer that is providing workers' compensation insurance for my employees. Below is the policy uafontuation.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. # 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
Investieations of the DIA for insurance coveraac verification.
I do hereby cer ' rd r th p Its and ennitie ofp� etjwy that the information provided aboa is true and correct.
Phone #' SD (e q L6—
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 Cleric 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone M
www.mass.gov/dia
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date ?i I )'o
We, DRdAev\ (c� el(z6d6) (restaurant/ organization)
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization. *
[v/We are donating ALL proceeds earned directly to a 501(c)(3) organization.
Please list the organization: 14C W Z ,14GLrJi✓i�)
❑ We are not charging a fee for food/drink being served.
❑ We are a religious organization.
❑ Other:
Thank you, ` �YZZ/
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
— Approved
Denied Reason:
Signature: Date: