HomeMy WebLinkAboutJohn's 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
Type: PUSHCART
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:.
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Whose place of business is:
JOHN'S ICE CREAM
70 POTASH ROAD
PERSON(S) IN CHARGE:
EDWARD J. UNDERWOOD
Permit Expires: December 31, 2019
Food Fee: $50.00
License Number: P-1
BOARD OF HEALTH
MichaecWeatey, Chairman
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: a j. �'5 tat C P-eccc w
Establishment Address: 7v Po I o 5?-/ %Z�.� f�A�5•`'tc s7r M
Establishment Mailing Address (if different):
Establishment Telephone No: .) 08 339 JUN 11 2Q}q
Applicant Name & Title: LOVS0t
Applicant Address: 77? i'e5050 �'�• it1/t�S,'i�+J�
�__,. l
Applicant Telephone No. sl:>8 S'S 9 B 36 24 Hour Emergency No.: 5c0 � 9 Y a � � , `C
Applicant Email L (� %r1tL�7cx�D / 9 6 M A tGl'v'
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
❑ An Association
partner.
El A Corporation
Name Title Address
ffrAn Individual
❑ A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name&Title: LJ) (,a'D'_:a(40L�b
Address:
Telephone No: 24 Hour Emergency No:
n�M L
FAX: C d�
l
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
WATER SOURCE: fJ A
SEWAGE DISPOSAL: till)
DEP Public Water Supply No: (If applicable)
—
No. of Food Employees:
DAYS/HOURS: Vo(II -r-�
Name of Person In Charge Certified in Food Protection Management: r//R
If more than 3 individuals are certified, complete list is on file.
Person Trained in Anti -Choking Procedures (If 25 Seats or more):j� fl ❑
El Permanent Location
Establishment Type:
❑ Caterer $35.00
�Loccation:
U✓ Moblie Moblie Start Date:
❑ Retail -NO FOOD PREP ( Sq. Ft) $125
❑ Milk & Cream $10.00
Moblie End Date:
Food Service up to 100 seats
❑ Mobile Food Consession
Moblie Comments: Le i;jz-t q+ 2-R.
INCLUDING FOOD TRUCKS $175.00
❑ Food Service for 101 -200 seats $250.00
NO PHF PREPARED ON SITE $100.00
❑ Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
L epg th Of Perm lt:
Annuat
❑ Food Service for 201+ seats $300.00
,._,(
L+� Pushcart $50.00 # of Pushcarts:
-- -
Seasonal
❑Residential Kitchen $100.00
Seasonal Dates:
Supermarkets $400
❑ Tobacco Products $150.00
❑ Retail Snack Food $50.00
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Dale:
Food Operations:
Definitions.. PHF- Potentially hazardous food (timeltemperature controls required)
Non-PHFs -non-potenfally hazardous lood(no time/temperature controls required)
(Check all that apply):
RTE-
ready -to -eat foods (Ex. sandwiches, salads, mulins which need no further processing)
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
❑ Sale of Commercially Pre -Packaged PHFs
❑ Preparation of PHFs For Hot And
❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Cold Holding For Single Meal Service
❑ Delivery of Packaged PHFs
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
El Reheating of Commercially
❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
Customer Self -Service of Non PHF and Non-
❑ Customer Self -Service
Perishable Foods Only_
contact alternative, time as a public health
control)
❑ Ice Manufactured and Packaged for
Sale
_
❑ Preparation of Non-PHFs
Other Food Operations
_Retail
❑ Juice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
❑ Prepares Food/Single Meals for
❑ Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
_
❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food
pleted by the Board of Health
mit Fee:
FP,yment
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 obtaiff koaieAofA05 pNffY590,000 anuOhe federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, tec. 49A, 1 ce it
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
r under the penalties of perjury that 1, to my best knowledge and belief, have fled all stale tax returns
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 Indi ' ual or Corporate Name
10 Q 0 Ild- �;&`%
"Social Security No. (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.
0Users\s1eite\Desktop\ScotCs Documentffood Establishments-'remp\TAX CERTIFICATION FORM.doc
The Commonsvealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, ALL 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print LeeiblV
Business/Organization Name: "pl l'J5 C c Lej.1
(7 7� 1 a-SYI 6Z J
City/State/Zip:
M lkr15 r`ncLJ mill &-�-Z%Ci
Phone #: �®s .;�—
Are you an employer? Check the appropriate box:
Business Type (required):
) C t y
L ❑ I am a employer with employees (full and/
5. [✓(Retail LM fr
r part-time).*
e
6. ❑ Restaurant/Bar/Eating Establishment
2. �VI 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.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12.❑ Other
*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 are corporation has other employees, a workers' compensation policy is required and such an
organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lic.
Expiration
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 cZIA
onr the�i a p liies of perjury that the information provided bo a is trite and correct
Signature: Date: ) 1 t
Phone #: 5 � 351
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 Person: Phone
www.moss.gov/dia
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date / 9
We
L 9 rlrA��dz'oeaI JOHNS 1 i8�' ICc
organization )
request a waiver of the Food Service Permit Fee for the following reason:
❑ This is a request from a town department.
Please list the department:
❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
/organization. *
L We are donating ALL proceeds earned directly to a 501(c)(3) organization.
Please list the organization: y ieGj � 14&' i'JL>
❑ We are not charging a fee for food/drink being served.
❑ We are a religious organization.
❑ Other:
Thank you, j4f h
Signat/u're n
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date: