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HomeMy WebLinkAboutFlannel Cow Creamery - 12/31/2019q Commonwealth 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: 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:. RYAN J. HEEDEN Whose place of business is: FLANNEL COW CREAMERY, LLC 88 CHILSON AVENUE PERSON(S) IN CHARGE: RYAN HEEDEN, OWNER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-27 BOARD OF HEALTH Nichae(HeaCey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned openin date Establishment Name: f !L A jt j Coca C/t°a-Pt` er�y i I X C, Establishment Address: g$ (� )JOA J ( AN IU; Establishment Mailing Address(if different): ' Establishment Telephone No.: SS/ v ` 5-V) _ j j y - tv} 3 D� Applicant Name & Title: gj, �W�r Applicant Address:3n plc to Sf- iMa"'dkoll-, Applicant Telephone No.: '751 '` W_ 'z4Y Z I 24 Hour Emergency No.: 5a K� Applicant E-mail: (-jo'n eed @ Ali- � W 7477 -Ole) Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. L1 A Corporation Name /�,, Title Addressss"" �/" An Individual 4 &w^_/_,�- WAQ/ log / «y'Y V. A Partnership &z.- NQP.Gf (o - e/ 11a o s k1eV _ hof 6Lb'�'!i' El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �� ,,V, Address: tt Telephone No: 24 Hour Emergency No: FAX: E-mail: 7 � Alt E-Mail: ,Flan& ' (,0" ot" Aq +td � o,+ ("q , c.— - - I --- 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: '%7.j� /0--25 DAYS/HOURS:F}ff`il-0(': 7tilx� t2-y;"5- h. L-5- P*3" 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): ❑ W/7 -X/0 ji�a % 3 Location: Permanent Location Establishment Type ❑Caterer$35.00 ❑Moblie Moblie StartDate: [lJ Retail ((e Sq. Ft) 0Se0`AJ Pq Milk& Cream$10.00 Mobile End Date: i G Food Service up to 100 INCLUDING ❑Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 I�f Manufacture Frozen Desserts/Ice Cream i $25.00/freezer Length of Permit: Annual --------- ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: �J Seasonal Seasonal Dates: I"l�rlit' I SH Gtvfi%� r ❑Supermarkets $400 Residential Kitchen $100.00 Novevwa'l Retail Food $125.00 Temporary ❑ Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions :PHF - Potentially hazardous fond(tlme/troperalwo controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessmill Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs El Preparation of PHFs For Hot And for More Than a Single Meal Service Delivey Packaged of PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility -- ------ ❑ Sale of Raw Animal Foods Intended _ ❑Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- El Customer Self -Service LJ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for _ ____ Catered Events or Institutional Food Service 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 ❑ waived 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 obtaiyf ies of 105 R 690.000 and the federal Food Code. Signature of Applicant: �// 2l r. u 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. Signature of Individual or Corporate Name: �n'�G / (yw �ilel�/L+�' l Social Security Number or Federal ID: 17,_ L] f 7 W 2 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. /=ldilit l 60t,) G(, 4� Ik66"6 Signature of Individual or Corporate Name By: Corpo ate Officer (Mandatory, if Applicable) q j-�q`11373 "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:\Userslsleile\Desktop\Scolt's Documents\Food Establishments- Temp\TAX CERTIFICATION FORMAoc The Commonivetilth bfMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UlfBoston, MA 02111 tvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: Phone #: .0 / - / 7 ' 7 g Z f Are you an employer? Check the appropriate'box: Business Type (required): 1. I am a employer with Z®"Zy employees (full and/ 5. ❑ Retail or part -lime).* 6. (P 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. 8• ❑ Non-profit [No workers' comp. insurance required] 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]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp, insurance req.] *Any applicant that checks box #I 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 am an employer that is providing workers' compensation insurance for my employees. Below is the polic information. Insurance Company Insurer's Address: i 0 13€l K I e City/State/Zip: or Policy # or Self -ins. Lie. # 0 Z, -1J & ( _C IL i 7 7 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 a 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 $250.00 a day against the violator. Be advised that a copy of this statement may betforwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ffy, under �he pains and penalties of pery'rery that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mass.gov/dia A� o® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 11/09/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). PRODUCER CONTACT Karen Clemente NAME: Cross Insurance, Inc: RI PNCNND (401)431-9200 ac (401)431-9201 Ea: No): 376 Newport Avenue EMAIL kclemente@crossagency.00m ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC9 P. O. BOX 4830 East Providence RI 02916 INSURERA: Employers Mutual Casualty Cc 21415 INSURED INSURERS: Hartford Accident and Indemnity CO 22357 PASTURE PROPERTIES LLC INSURERC: 308 MAPLE ST INSURER D: INSURERE: MANSFIELD MA 02048-1509 INSURERF: COVERAGES CERTIFICATE NUMBER: CLIB11968947 REVISION NUMBER: 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 rypE OF NSD POLICYNUMBER POLICY EFF MMARNYyyy) POUCYEXP (MMVD= LIMITS X1 COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE © OCCUR PREMISES Ea o=mnce $ 500,000 MEDEXP(Anyonspersen) $ 10,000 PERSONAL BADV INJURY $ 1,000,000 A 5D52258 08/12/2018 08/12/2019 GERL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY JECTIRI LOG PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident)$ PROPERTY DAMAGE Perecddenl $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLAUAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMSAMDE DED I I RETENTION $ $ WORKERS COMPENSATION IPER OTH- B AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE MN/A OFFICER/MEMBER EXCLUDED? (Mandate, in NH) 02WECEK7727 08/13/2018 08/13/Z019+ STATUTE ER EL EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 Ryes, DESCRIPTIONOF O DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT E 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD let, Additional Remarks Schedule, mey be Muscle" lima space is required) RE: FLANNEL COW CREAMERY' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 All ri.hf. rewwruud ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD MI.d, rLfPNI!(DYXe4PY1 Pm Y+neibW6uWv�Yv4N, W NLWnmpfudfl W!v 4. rvSafe RYAN HEEDEN for successfully completing the standards set fadl, for the SmSafd° Food Protection Manager Certification Exuminalion, which is accredited by the American National Standards Institute (ANSI( -Conference for Food Protection (CFP). 5133 MBER EXAM FORM NUMBER 4/6/2021 DATE OF EY�ArTj''i"I IJfT"'[I�,-r.., DATE OF EXPIRATION Local laws apply. CI sc-sy1tXsyou'.�amf' regu�abiy envy for recent firwion regeire..W, T!"r o C,., rs wrh qwl .175 Wkul-,aF Ste I SW.Chicago. R 0o a SrvhkB,e,t .uq CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: RYAN HEEOEN Certificate Number: 2316397 Date of Completion: 562016 Date of Expiration: 55"4 l Dn shave nourrd per,mr is berehI, issued this nv tr/imv for rompluigq are a/1 •r Sex ewaraneo mnixirg program rcwgxr"ed h!, the dlasrnrhxseua Depm mnent o% Pvhlic Health ix arronhw,v rrith 105 CHR 590.009(6)(3)(a,). 71ds rcrt lirrrre will be valid )or.%r've (S) yews from date o/ e nrpletiriu. ls,"ttd BY: MR Z NAT ONAL RESTAURANT N �•�� ( �n ION ASSOCIATION„ Mnssachusns RcsraumnruAssocu¢im. 800.765.2122 333 Turnpike Rmrd, Sake 102 ovlv.nsrauraneerg $oarhbamagh,\IA 01772 503-303-9905 av�nnr:mstanr:mrussocorg