Loading...
HomeMy WebLinkAboutColdstone Creamery - 12/31/2020Uj *14q- > t 1 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 C6ICA y4'� �I ' E� ('t 6 "�` IV,(� Establishment Address!- �c Establishment Mailing Address (if different) 0 Establishment Telephone No 1 % €_1 10 Applicant Name & Titles �� ° "� `` (' ` �`�� Applicant Address (t, LA21vt c,Z I` (r l,� a, r1r 'fit, Applicant Telephone No.: s �s t i I 24 Hour Emergency No.:'s'��i /�� g Applicant Email ! cjel 1 1 r e Y h'e ry r, 6 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 C7 An Association partner. A Corporation Name Title Address El An Individual (q� ' ( d t- K S i = c �_ ' r _ ..-- 0 A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: P } �\A L, (f�f1,c"- f13(t •.nib;,c , t,,c„ E--t•_'-Yi ,. f Address: — &zt Telephone No: S ' -_ �f [ 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATFR SOURCE: SEWAGE DISPOSAL: f DEP Public Water Supply No. (If applicable) �No. of Food Employees: d'j DAYS/HOURS: - f7frr Name of Perso (s) In Charge Certified in Food Prote�kctionp Management: -i.i ---------- Name of Person(s)((In Charge Certified in Allergen Awareness Training {-''`!. ixiv:-x t'v1{, ��€r'{�c;'17 j•.!�-, ti`tt(�5��'4i (i..r`�...;`L�. �..r&.: ;" Name of pest control company routinely inspecting the premises for evidence of pests 3 ' t'Ur-( i 11 Lc';" 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. 0 Yes; Does this establishment require a FOG permit? t S If yes, please attach the FOG permit application. Length of Permit: Establishment Type: l9 Annual H Retail Food $125.00 0 Mobile Food Consession Temporary Nj Pood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $176.00 t"'Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 lA Pushcart $50.00 # of Pushcarts: Temporary Time: El Supermarkets $400 0 Residential Kitchen $100.00 Rain Date: ^ilk & Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food fNme4emperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no timeRemperalum controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs 0 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 i Delivery of Packaged PHFs Cold Holding For Single Meal Service ry g PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand Customer Self -Service of Non PHF and Non - contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for ❑ g control ) Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 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 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 obta6 capigs of 105 CMR 590.000 and the federal Food Code. 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. _ 7 Social Security Number or Federal ID: Signature of Individual or Corporate Name. `1 �-� ' tcC- 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. Si lure of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "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. CAUsersUcite\Desktop\Scotts Docmnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth ofMassachuselts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: 9" 0 S C.Gv City/State/Zip: St eet- 04Iv, Lc C /Co>6ei.S6rvvc ('ret,+w1(--' Phone #: "7 L 71 `,r 13 1 Are you an employer? Check the appropriate box: Business Type (required): I. ❑—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. [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 requiredj*l 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 120 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 91. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: ty t, / Insurer's Address: t ' G City/State/Zip: W%i .> Policy # or Self -ins. Lic. # a (? G, '-4, _j `i — `i "" L i Expiration Date: &/ 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. 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 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: (e; 1A i �b'YtE v` s , Address: .. „ S: c. cJ i ey L'— 6 — L\ t ; S` 7'e Mailing Address: 6 Phone/Fax Number. /1 i Email: ('t I A. Ozn' "vy-\ Il6( -vv, ��tt � Contact Person/Title for Grease Traps: A0 (t``� iltIf A ,-' Name of Company scheduled to pump internal grease trap(s) monthly: r L u c Name of Company scheduled to pump external grease trap quarterly: J'n" k"a &J f 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. rj Print Name Date 11 pill-, r " 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): Normal Hours of Food Preparation/Service: N` �v� n ::= l � ., 4�fi ('? IV, " Monday Tuesday Wednesday Thursday Sunday Friday Saturday 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 f3 compartment sink -- Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? If yes, at what station/sink? 2 Yes Grease Traos and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 NZ� 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? 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: 'uki> I U = t IC, j9Mi Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste 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 3 a, m 4 > I s 9 w V j �i W m x n zi L F" » @\\) % \ \)] � )!% \ \\\( \ ?R$% 7\42 �\\/ \ ( ),0 ) Mal oo / (\(/ ; \ 0 ®^9«ƒd& .\ . § ^ � � � � � z � z 0 id ,Le 0 )M71 -�� SWEETOO-01 HALEY ,4CORo' CERTIFICATE OF LIABILITY INSURANCE DATE 011031201 YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the If SUBROGATION IS WAIVED, subject to the terms and conditions of PRODUCER INSURED Sweet Tooth, LLC dba Cold Stone Creamery 11 White Oak Way North Attleboro, MA 02760 must have ADDITIONAL INSURED provisions or be endorsed. certain policies may require an endorsement. A statement on t$ayl q:ZTrl:4I1d[rf_i I:1 I [IM 1 d q: 7 XTl[-[Q: B:III ill :]:I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AODL SUER POLICY NUMBER POLICY EFF POLICYEXPINSO MID UNITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X X BZS57709462 01/0112019 01/01/2020 EACH OCCURRENCE t1,000,000 DAMAGETORENTED ...PREMISES (€a_orE42ense)-__. 1�000�000 MED EXP (Any one emon $ 15,000 PERSONAL B ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO LOC GENERALAGGREGATE $ 2,000,600 PRODUCTS- COMP/OPAGG $ 2,000,000 EPLI 100,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accide IL_ 1,000,000 $ BODILY INJURY Per Person $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BZS57709462 01/0112019 01/01/2020 BODILY INJURY Per accident $ PerOacECRIEen DAMAGE _ $ X AUTOS ONLY Ix AUTOS MOO UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOVERS'LIABILrrY YIN ANY PROPREIIETORIPARTNERIEXECUTIVE gendatoIn BE E%CLUOED4 �' IDISEASE NIA UBOJ368779 01/0112019 01/01/2020 )( PER OTH- STATUTEER E L EACH ACCIDENT - EA EMPLOYE 1,000,000 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE. POLICY LIMB 1,000,000 A BIIEE BZS57709462 01101/2019 01/01/2020 ALS 12 Months A BZ857709462 01/01/2019 01/01/2020 Spoilage 10,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Kahala Franchising, L.L.C., Kahala Brands, Ltd., their subsidiaries, officers, directors, and employees, 9311 E..Via Oe Ventura, Scottsdale, Arizona 85258 are listed as additional insuredlgrantor of franchise in regards to covered locations: 280 School St, Mansfield, MA 02048- Business Personal Property amount of $312,120 174 S Franklin St., Holbrook, MA 02343- Business Personal Property amount of $306,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Kahala Brands, Ltd., Kahala Franchising,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 9311 E. Via its Ventura Scottsdale, AZ 85258 — AppppppUTHOR^^RED REPRRESENTATnVE ACORD 25 (2016103) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD