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HomeMy WebLinkAboutFlannel Cow Creamery - 12/31/2020O (% FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 1041411el 64� Establishment Address 9? C44bl- Establishment Mailing Address (if different) Establishment Telephone Noej// #'7F1'`/7f -VyZ1 fl7ly- #�57U-3.�V-0c),U jI _- - Applicant Name & Title: �Gth ri��Py, Applicant AddresobS /�(/A/� �� /t'i(ihfliW( A/F Applicant Telephone No.: VZS 24 Hour EmergencyNo.:SkltG ev �ei7"��% ofYf Cw' � ApplicantEmail l2�CuwC �Gta�Z✓7 @ysa�.Y-cam 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 n An Association partner. VA corporation U--- O Name I\ �itle �J%U/� Address An Individual �_Gt ❑APartnership Ll Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 4,, /{eeG6Gm 04- t — Address: 36 r MV l f/'- Mtw3 (a/4 Telephone No: _`7. q Zq 24 Hour EmergencyNo:94-c cC/7'�77�Id� FAX: E-mail: Alt E -Mail: r�4rGtPr(�J�ku�.� District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No: Food Establishment Information WATER SOURCE: 'Tfvl SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees /Z— 7_y— y"DAYS/HOURS: DAYS/HOURS: v-9 C Name erson(s) In Charge Certified in Food Protection Management: 41-01 Name of Person(s) In Charge Certified in Allergen Awareness Training fl , aa� Name of pest control company routinely inspecting the premises for evidence of pests ��y° /1C1` 4�enfjlw/ 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. [-]Yes /V11 ,leo' Does this establishment require a FOG permit? j If yes, please attach the FOG permit application. Length of Permit: Establishment Type: V/Annual ❑_ Retail Food $125.00 [� Mobile Food Consession [_] Temporary L✓ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 r°"I f'Manufacture Frozen Dessertslice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.001freezer Temporary End Date: 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 [] Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (fime/fempersture controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no timeAemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ( 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 U Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly U Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours El Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand E] Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only [ Ice Manufactured and Packaged for control) U Retail Sale P Preparation of Non-PHFs U Offers Raw Or Undercooked Food Of _ [.j J Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale F] Vacuum Packaging /Cook Chill �fCe El Offers RTE PHF in Bulk quantities ❑ Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Dale Catered Events or Institutional Food Service or Reconditioned Food 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. Signature of Applicant: Pursuant to MGL Ch.62C, 6ec. 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. Social Security Number or Federal ID: Signature of Individual or Corporate Name: I Town of Town of Mansfield - Board of Health 6 Park Rownsfield Mansfield, MA 02048 t t ), t; Mix In Conjunction t td Establiahment 7o the Board of Health at the Town of Mansfield: In accordance with the provisions of section 05H of Chapter 94 of the General Laws, as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license,for a WHOLL'SALFIRE7AIL mamtfacan•e qt frozen desserts and ice cream mix and submits the following btfot•malion: 1. Food Establishment Name In 1 2. Establishment Address: (_8 01 ta0 &-f 3. Location of Plants/ dessert machines: 4. Names of brands and trade or corporation name, if any, under which the products are to b 5. Number and capacity of freezers and f y_____-__. Fee: ($25.00 perfi-eezel) $ #Type! 6. Is the mix purchase !e f If so, from whom purchase r K"e 2L'os(�f _r Sly 7. Is the mix pasteurized? 6. Number of gallons of frozen de�s�se�rts and/or ice cream mix sold in Massachusetts during the previous licensing period (�,w� -^at `! 'fit 9w1 // 9. Is the plant/ dessert mcachine constructed and equipped as provided in the regulations �fj 10. Certified laboratory used for monthly testing A40 r( -J11 11. Regulations can be found at https://www.mass.gov/regulations/105-CMR-50000-good-manufacturing-practices- for-food. Please indicate if you would like a copy of the regulatis emailed to you 1 hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conditions. I attest that the information stated in this application is true and accura e under rt�the pains and penalties of perjury. (Company owner/officer's signature) (DATE) 06,✓IG (Title) (City or Town) 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) �7-q9'-x/372, "Social Security No. (Voluntary) or Federal Identification 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. C: Users\sleite\Desktop\Scolds Documenls\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth ofMassaehusetts Department oflndustrial 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 Name: f ha"I't - � C c - Address: U C � �J� AU City/State/Zip: Phone #: % V — �7j _ VF ZI Are you an employer? Check the appropriate box: Business Type (required): I.r/ I am a employer with _-6 employees (full and/ 5. ❑ Retail or p ra t_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• ❑ 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, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I run an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: 0V Hk�1g,-a //4 ?A City/State/Zip:&4%,-f , or v6/J— Policy # or Self -ins. Lie. # bZ /nJ ec- C A4 72 7 Expiration Date:s.L13A U 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 of perjury that the information provided above is true and correct. fl /Of Phone #: '7 91 —V j Y - 4 -PL 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 (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Accident and Indemnity Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: F 10448 Company Code: 5 .;..� 4 „.' Suffix LARS RENEWAL POLICY NUMBER: 02 WEC EK7727 Previous Policy Number: 02 WEC EK7727 1. Named Insured and Mailing Address: PASTURE PROPERTIES, LLC (No., Street, Town, State, Zip Code) 308 MAPLE ST MANSFIELD MA 02048 FEIN Number: 47-4952115 State Identification Number(s): The Named Insured Is: LLC Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 88 CHILSON AVE MANSFIELD MA 02048 2. Policy Period: From 08/13/19 To 08/13/20 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: CROSS INSURANCE INC RHODE ISLAND PO BOX 4830 EAST PROVIDENCE RI 02916 Producer's Code: 02090786 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 853-2582 Total Estimated Annual Premium: $992 Deposit Premium: Policy Minimum Premium: $270 MA (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by 07/05/19 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 07/05/19 Policy Expiration Date: 08/13/20 INFORMATION PAGE (Continued) Policy Number: 02 WEC EK7727 3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $500,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium Total Standard Premium Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Estimated Annual Premium (before Surcharges) Total Estimated Surcharges *See the attached Schedule(s) of Operations for Location and State Level Premium Information Total Estimated Annual Premium: $992 Deposit Premium: Policy Minimum Premium: $270 MA (Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 722110 Labor Contractors Policy Number: SIC: 5812 $690 $250 $21 $961 $31 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 07/05/19 Policy Expiration Date: 08/13/20 e� EXTENSION OF THE INFORMATION PAGE - ITEM 1 - NAMED INSURED Policy Number: 02 WEC EK7727 Endorsement Number: Effective Date: 08/13/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PASTURE PROPERTIES, LLC 308 MAPLE ST MANSFIELD MA 02048 Item 1 of the Information Page is completed to include as named insured: Named Insured: PASTURE PROPERTIES, LLC State ID : Not Applicable FEIN : 47-4952115 DBA Name FLANNEL COW CREAMERY, LLC FEIN 474941373 Form WC 99 03 66 Printed in U.S.A. Process Date: 07/05/19 Policy Expiration Date: 08/13/20 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Address: J j C ty oa" 4�&' Mailing Address: S'a4t'[i Phone/Fax Number: 'M 4k2�. czyJ Ob 2j S/rs✓c� Contact Person/Title for Grease 0 Name of Company scheduled to pump internal grease trap(s) monthly: d"P"/�� c £� Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date Print Na Facility Operational Information Please answer all questions in this section. if an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): r 12, Normal Hours of Food Preparation/Service:'4lcwt,, SQL l " Z,'°., G) Monday Svuw/ 12 - ID Tuesday " Wednesday Thursday y Sunday /L—q " Friday Saturday /Z— y /D Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU V.S 3 compartment sink Z Q Handwashingsink FJ /V4 Commercial Dishwasher U Ail} Barsink 0 Mop Sink 4/4 Garbage Disposal a Ice Making Machines (' Fryolators C� Grills or Ovens Exhaust Hoods i1/1) Floor drains p Other: � VL How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? i/ Yes If yes, at what station/sink? 3 tic�j Y"� yt 9 RE Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes _�� No Size gallons Where is the existing outdoor GRU located? 1"V If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste /V4 Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: Please list fixtures attached to each grease trap Grease Trap 1 yk4L Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes _�� No Size gallons Where is the existing outdoor GRU located? 1"V If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste /V4 Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: