HomeMy WebLinkAboutFlint Farm Ice Cream - 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 1
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:.
DONALD FLINT
Whose place of business is:
FLINT FARM ICE CREAM
789 EAST STREET
PERSON(S) IN CHARGE:
DONALD FLINT
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS -28
BOARD OF HEALTH
Nichae(Heatey, 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: v�� �o c M Lu C r epMnJ _
"\O'C'
Establishment Address:
Establishment Mailing Add ress(if different): --N'bt,G ��5� �j��Q�
DEC 14 2018
j"�
Establishment Telephone No.: 5
Applicant Name & Title:
Applicant Address: cu 5\ &) x"A�t�no�tQ`0 rnQ
agencyNo.:
Applicant Telephone No.: ��-1J�jG�.�\\�j 24 Hour Ern 15
Applicant E-mail:
Owner Name & Title (If different from applicant):^\�
1
Owner Address: i�� �uy� S Cf�G� ��Gv�o�t\+� \t'\ n'\A
V
Own er Telephon e No.: vj%%
Owner E-mail: \p �\r\ Aa(� C�awv ClrSt , h
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
9 An Association
partner.
Ell A Corporation
Name Title Address
X An Individual
E0 A Partnership
D Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: �`b� �e ,� CN, `kc\
Telephone No: Ap) 24 Hour Emergency No:
FAX:
�\iE-mail: \ns • I\4�
Alt E -Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: p ^
DEP Public Water Supply No: (If applicable)
SEWAGE DISPOSAL: Co IN L
No. of Food Employees: KA t t rf'u
DAYS/HOURS: q (, \_31-c\pm
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):
Location: U+St Permanent Location
€3 Moblie Mobile Start Date:
Mobile End Date:
Mobile Comments:
Establishment Type
,,�_1 Retail ( Sq. Ft)
IhZI Food Service up to 100 INCLUDING
'-I FOOD TRUCKS $175.00
Qr_---. Food Service up to 101 -200 $250.00
Q Food Service up to 201 + $300.00
0 Supermarkets $400
El Caterer $35.00
Milk & Cream $10.00
'❑'1 Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Q Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Q Pushcart $50.00 # of Pushcarts:
E] Residential Kitchen $100.00
Retail Food $125,00
0 Retail Snack Food $50.00
Length of Permit:
Annual
Seasonal
Seasonal Dates(\Q,��� Y•
Ll Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food O eratlens
P
(Check all that apply):
Definitions:PHF - Potentially hazardous food(6meRemperature controls required)
Non-PHFs - non -potentially hazardous food(no finrMemperaturs controls required)
RTE - ready -lo -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing)
"•❑J-- Sale of Commercially Pre -Packaged Non-PHFs
PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
4:=3 Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Q PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
F3 Reheating of Commercially
Processed Foods for Service Within 4 Hours
Q Vacuum Packaging / Cook Chill
lg Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
"r=."i Customer Self -Service of Non PHF and Non-
Perishable Foods Only
Q Customer Self -Service
EJ Ice Manufactured and Packaged for
Retail Sale
l:] Preparation of Non-PHFs
Q Offers Raw Or Undercooked Food Of
Animal Origin
Other Food Operations
®
_
Q Juice Manufactured and Packaged for
Retail Sale
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 H waived
I, the undersigned, attest to the accuracy of the
establishment operation will comply with 105 Cl
board of health on how to obtain copies of 105 1
Signature of Applicant:
provided in this application and affirm that the food
anVII other a plica law. I have been instructed by the
o Ani
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury
and paid state taxes required under law.
Signature of Individual or Corporate Name:
Social Security Number or Federal ID: a 16 `a\'0Af0 \ bJ 5
have filed all state tax returns
it
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 December 31st of each year.
NAME OF BUSINESS: �\cv\\ �b„n.N 7'—cu C`C "
ADDRESS:
TELEPHONE AT LOCATION:
FAX NUMBER:
OWNER OF BUSINESS: \--z, GVH -\v- ' I\�
TELEPHONE OF OWNER:
FEDERAL ID/SS NUMBER:
FEE: $10.00
PERMIT NUMBER:
SIGNATURE:
1 �P
DATE: \a \ \\\\ D
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.
�\t 4A q_� M) _Is� mm�
Signature of Individual or Corporate Name
a,\) -aAJa�)\ 13 15,
**Social Security No. (Voluntary) or Federal
Identification Number
r
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.
C:\Users\sleite\Desktop\Scott's Docoments\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth ofMassachusetls
Department oflndustrialAccidents
Office of Investigations
n 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address: �\ "1;3
City/State/Zip
`AQ
Phone #
Are you an employer? Clieck the�ppropriate box: Business Type (required):
1. r� I am a employer with a employees (full and/ 5. ❑ Retail
or part-time).* aj 2 G 5� b nw� 6. [ ; RestaurantBar/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 required]** 11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no emolovees. 1No workers' coma. insurance reci.l 12.0 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 am an employer that is pr vfding, workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:o�am �avv�\s
Insurer's Address: \A N�& qv, � i 4! c_ \Sw i4
City/State/Zip: )\, t) J va u U 1 U"
Policy # or Self -ins. Lie. # ���^J �� \,9d—� 5 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pain ' na t s of jury h t the information provided above is true and correct.
Signature: Date:
Phone 9: �� `�tiJ� '�5 COJ
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
www.mass.gov/dia
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evideno� of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation acid should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Farm
IF Fairly
Casualty lnsurance Company
��envionq Ne..Y—k AGENT NO 1710 OFFICE NO 1710
FRANCIS E BINGHAM
Farm Faintly Casualty his. Co. 1408 PROVIDENCE HWY # S-130
NORWOOD MA, 02062-4652
NCCI COMPANY NO. 16721
j- i!MINSURED AND MAILING ADDRESS:
FLINT FARM ICE CREAM LLC
789 EAST ST
MANSFIELD, MA 02048-3458
THE INSURED IS LLC
Workplaces covered by, this policy:
ST WP NO. ADDRESS OF WORKPLACE
DIA 1 789 EAST ST
MANSFIELD MA 02048-3458
781-255-2002
POLICY NO 2003W6255
Endorse
EFFECTIVE 04/14/2018
FEIN #: 20-264815
RIG.BUR NO. INTRASTATENO.
The policy period is from 04/14/2018 to 04/14/2019 12:01 A.M. Standard Time at the insured's mailing address.
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state 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 nuclei- Part Two are:
Boday Injury By Accident llodily Injury By Disease potty Injury By Disease
s 100,000 each accident 5 500,000 policy limit S 100,000 each employee
C. Other States Insurance: Part Three of the policy applies tothe states, if any, listed here: All states except the states designated in
item 3.A. of the information page and ND, OR, WA, and WY ii
D. This policy includes these endorsements and schedules:
WC00o0a1A
Copyright 1997 Naaonal Council
on Cmnnemnnon hnnrnnce
NC 0000 o1
Issuing Office -PO Box 656 • ALBANY, NEW YORK12201-0656
PROCESSED 03/07/2018
2003W6255 0307-2010 09:06:50.00
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