HomeMy WebLinkAboutOrange Leaf Frozen Yogurt - 12/31/2019Commonwealth 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 ESTABLISHMENT
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:.
MARIO COSTA, PRESIDENT
Whose place of business is:
ORANGE LEAF FROZEN YOGURT
321 SCHOOL STREET, UNIT A-120
PERSON(S) IN CHARGE:
DEBRA FITZSIMMONS
Permit Expires: December31,2019
Food Fee: $175.00
License Number: FS-60
BOARD OF HEALTH
NichaeCHeatey, Chairman
Milk & Cream
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
Establishment Address
Establishment ail\ g Address (if different)
6o [ A C �44\ C vCQ�v
Establishment Telephone No
Applicant Name & Title: (r)AC ip \ ce 5'CV0jk
Applicant Address lQto �A c�.���a C,J��z IvUcwCXx� (YID U��a
Applicant Telephone No.: -7�\. GC.(U. 24 Hour Emergency No.: -III
Applicant Email GtiL but F�%rhA� cc�
Owner Name & Title (If different from applicant)
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NOV'2 2m
(oqb-1 uSg
Owner Address
i
Owner telephone number f
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
An Association partner.
XACorporation Name ` - Title \ \ Address
An Individualir�f,�
r ! A Partnership - 0,u, Cam\ al (2�- O(x,1
A Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: Sy
Telephone No: '7 71 . -7 (e 24 Hour Emergency No:
FAX: —
E-mail:OCr�tise�er�� Mr�Ns�e�C]POu.(;o
Alt E-Mail:
„ District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
M
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE: SOURCE: SEWAGE DISPOSAL: Taw J
DEP Public Water Supply No: (If applicable)No. of Food Employees
DAYS/HOURS: S _.5 -Zt - -
Name of Person In Charge Certified in Food Protection Management:
If
more than 3 individuals are certified, complete list is on file.
Person Trained in Anti -Choking Procedures (If 25 Seats or more):Ell
jll�
Location: ❑ Permanent Location I Establishment TYe: J Caterer $35 00
Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
Length of Permit:
Annual
Seasonal
Seasonal Dates:
_I Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
P
El R ail ( Sq. Ft)
[-' Food Service up to too INCLUDING
FOOD TRUCKS $175.00
it Food Service up to 101 -200 $250.00
--- -_ ❑ Food Service up to 201 + $300.00
[.,,I Supermarkets $400
Milk & Cream $10.00
Mobile Food Consession
N,OrPHF PREPARED ON SITE $100.00
V? anufacture Frozen Desserts/Ice Cream
$25.00/freezer
Ll Pushcart $50.00 # of Pushcarts:
Residential Kitchen $100.00
Retail Food $125.00
Retail Snack Food $50,00
[] Tobacco Products $150.00
Food Operations:
P
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 (Ez sandwiches salads, muffins which need no furtherprocessmg)
J ] Sale of Commercially Pre -Packaged Non-PHFs
� %] PHFCooked To Order
i) 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
[] Delivery of Packaged PHFs - - {
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
-
"
--- ---- ----- -- --
❑ Sale of Raw Animal Foods Intended
Susceptible Population Facility
1 Reheating of Commercially
to be Prepared by Consumer
_
❑Vacuum Packaging /Cook Chill
Processed Foods for Service Within 4 Hours
___J Customer Self -Service of Non PHF and Non -
Perishable Foods Only
] Preparation of Non-PHFs
Other Food Operations
I, the undersigned, attest to the accuracy of the
establishment operation will com�pply with 105
board of health on how to obta(r✓cois45A
Signature of Applicant:
Customer Self -Service --- L- Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
Ice Manufactured and Packaged for contact alternative, time as a public health
Retail Sale ; control) I
I. Juice Manufactured and Packaged for I Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
' Offers RTE PHF in Bulk Quantities i ] Prepares Food/Single Meals for
I Catered Events or Institutional Food Service
I 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 applicationI waived
tion provided in this application and affirm that the food
000 and all other applicable law. I have been instructed by the
0.000 and the federal Food Code.
Pursuant to MGL Ch.62Q,7see/49Pf; I certify under Rie 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: �O�J
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix
To the Board gfHeafth at the Totmn of Mansfield:
In accordance with the provisions afsection 6511 ofC'hapter 94 of the General Lanrs, as most recently amended, and
the regulations made thereunder, the undersigned hereby applies fear a license for a WHOLESALEIRE7AIL
nnannfacture gffi-ozen desserts and ice cream mix and submits tfneJidlowing inlbrnation:
1. Full name of applec
2. Business address
3. /f applicant is an individual.
3a. If applicant is a parrt/tn1lersh y ,
3b. If applicant is a corporation.
Fall nume end address of
President-_rr�3'k'�n
TYeasure7
Clerk.
Full name:
Residence:
fndl nume and residence gfafl partners:
State of incorporation:_-___
Date of incorporation:
Principal office:
_,.
4. Locution of Plunts:
5. Names of brands and trade or corporation name, if any, under which the products are to be sold.
6. Number and capacity gff•eezers end fees: O Fee.' ($25.00 per freezer) $ #Typ(e!
7. Is the etc purchased? \fP li'so, from whom purchased?_Ot
8. Is the ni.r pasteurized?
%l
9. Number of gallons of ozen desserts and/or ice cream mix to be sold in Massachusetts during the licensing
period
10. Nunnher of ;gallons ofp ozen do sseris and or ice cream cmT sold in A lassachusett.s during the previous licensing period
11. Is the plant constructed and equipped as provided in the regulations`/
12. Is the water supple public or not?
13. Hcme you received a cop), of the regulations?
I hereby certify that the frozen desserts and/or ice cream mtx I sell in Massachusetts will be manufactured in compliance with aIllaw of
the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts
Department of Public Health ade thereunder and will be manufactured under sanitary c ndutio s. I attest that the information stated
in this appli ati i r d ccurate under the pains and penalties of per7uiy.
l l�aa-
ICo o v w offi is sianature) (DATE)
(Title) -w (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 Indivitrual or Corporate Name
L` 0 l t~ p a(CD
Social Security Number (Voluntary) or Federal
Identification Number"
By: Corporate Officer (Mandatory, IF Applicable)
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.
Jane Doucette
From: Debra Fitzsimmons <debfitz01@verizon.net>
Sent: Thursday, December 27, 2018 12:09 PM
To: Jane Doucette
Subject: Orange Leaf Serve Safe Certificate
Here is the serve sage certificate. I will find my Allergen one.
Thanks
Debra Fitzsimmons
Sent from my Whone
1
Jane Doucette
From:
Debra Fitzsimmons <debfitz01@verizon.net>
Sent:
Thursday, December 27, 2018 2:50 PM
To:
Jane Doucette
Subject:
Allergen certificate
Please let me m ow if you need anything else.
Thanks
Deb Fitzsimmons
Orange Leaf Mansfield.
Sent from my Whone
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
nnlicant Information _ P
Business/Organization
City/State/Zip:
Are you an employer? Check the appropriate box:
1. 0 I am a employer with �_ employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #: a)g 33,1 1001-6
Business Type (required):
5, ❑ Retail
6. M Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I l.❑ Health Care
12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy intormahon.
**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 am an employer that is providtn workers' compensation inlsurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
0
Policy# or Self -ins. Lic. # C SC �� looms Expiration Date: 01 M) el
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerko n t e ains and penalties ofperjury 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
6.Other -
Contact
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Phone
D,EQLARATION PAGE
v
N
r
0
0
F'
ONUINCY MUTUAL
Washington Street
O Quincy, MA 02169
WORKERS COMPENSATION POLICY
POLICY CHANGE EFFECTIVE 02/18/2018
AMENDING PAYROLL PER RECENT AUDIT
XXXXX5684
MA TAXPAYER ID NO:
NCCI NO: 32247
1621
1.CNC YOGURT INC
66 FAIRFIELD CIR
NORWOOD
GROUP
NAMAKSY-ZAMMITO INS
955 WASHINGTON ST.
MA 02062-5564 NORWOOD
(781) 762-6732
BILL TO: CUSTOMER
COMPANY
AGCY INC
MA 02062-3479
NAMED INSURED IS: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IF APPLICABLE.
FEDERAL ID NO: XXXXX5684 RISK ID NO:
2. POLICY PERIOD: FROM 02/18/2018 TO 02/18/2019
12:01 AM STANDARD TIME AT THE INSURED'S MAILING ADDRESS.
POLICY CHANGE EFFECTIVE: 02/18/2018
3.A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS
COMPENSATION LAW OF THE STATES LISTED HERE: MA
3.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 $100,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $500,000 POLICY LIMIT
BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE
3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,
LISTED HERE: ALL STATES EXCEPT ND, OH, WA, WY.
3.D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES:
FORMS FLAGGED WITH AN * CAN BE FOUND ON A PREVIOUS ENDORSEMENT OR POLICY. FORMS
NOT FLAGGED WITH AN * ARE ATTACHED.
*WC 00 00 00 C *WC 00 04 22 B *WC 20 03 02 A *WC 20 03 03 D *WC 20 06 01 A
*WC 20 QM 02 *WC 20 03 01 *WC 20 04 01 *WC 20 04 05 *WC 20 06 04
4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES,
CLASSIFICATIONS, RATES AND RATING PLAN. ALL INFORMATION REQUIRED BELOW IS
SUBJECT TO VERIFICATION AND CHANGE BY AUDIT:
PREMIUM BASIS RATE PER
TOTAL ESTIMATED $100 OF ESTIMATED
CLASSIFICATIONS CODE ANNUAL REMUNERATION ANNUAL
NO REMUNERATION PREMIUM
(SEE EXTENSION OF INFORMATION PAGE)
TOTAL ESTIMATED PREMIUM $1,204.00
DIA ASSESSMENT ( 4.560%) $43.00
TERRORISM RISK INSURANCE CHARGE ( 3.000%) 9740 $31.00
MINIMUM PREMIUM $216.00 TOTAL ESTIMATED COST $1,278.00
� EPggiT EMIUM $1,231.00
ERSIGNED BY AUTHORIZED REPRESENTATIVE: /r 03/20/2018
WC 00 00 01 C
CONTINUED ON NEXT PAGE
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