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HomeMy WebLinkAboutFlint Farm Ice Cream - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening 7144252bfyt!� Establishment Name � \ , rV '�-\ rw� Establishment Address _�c-e\� S� 2.vr� \ `"A Establishment Mailing Address (if different) Establishment Telephone No Av -� 3 Applicant Name & Title - � )A ' Applicant Address a Applicant Telephone No � _,�> bye U` �C }� 24 Hour Emergency No.: Applicant Email Owner Name & Title (If different from applicant)w- 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. A Corporation Name Title Address An Individual El A Partnership 13 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: , c-v A\, Telephone No: �_� _ Gv 24 Hour Emergency No: u� �lv"�j' u 1�5 (,� 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 WATER SOURCE: °�=y� SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: �} Name of In Charge ' ertified� iinp Food Protection` Management: (fP`*erson(ys`) Name of Person(s) In Charge Certified in Allergen Awareness Training 1� Name of pest control company routinely inspecting the premises for evidence of pests S 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? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual Retail Food $125.00 Mobile Food Consession 0 Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 OOD TRUCKS $175.00 o Manufacture Frozen Desserts/Ice Cream Temporary Start Dale: Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Q Food Service up to 201 + $300.00 EA Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Q Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF- Potentially hazardous food(time4empereture controls required) (Check all that apply): Nan-PHFs- non -potentially hazardous lood(no time/lemperature controls required) RTE-ready-to-eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) E] Sale of Commercially Pre -Packaged Non-PHFs [] PHFCooked To Order E] Hot PHF Cooked and Cooled or Hot Held 0 Sale of Commercially Pre -Packaged PHFs ❑I Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service EJ PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer 0 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 control) 0 Preparation of Non-PHFs Retail Sale 0 Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging I Cook Chill Offers RTE PHF In Bulk Quantities 0 Prepares Food/Single Meals for ❑1 Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 1, the undersigned, attest to the accuracy of 11% information provided in this ap lication and affirm that the food establishment operation will comply with 105 C��ryl 00 aall of �app' le law. I have been Instructed by the board of health on how to obtain copies of 105 CC R 9 .0O a d O1 rip ood Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify and paid stale taxes required under law. ' of perjury that I, to my best knowledge and belief, have Fled all state tax returns Social Security Number or Federal ID: k,, Signature of Individual or Corporate Name: r V', `� [� t' `bl�'T Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts andlor Ice Cream Mix In Conjunction with Food Establiahment Permit To the Board of Health at the Town of Mansfield: In accordance with the provisions ofsection 65H of Chapter 94 of the General Laws, as most recently amended, and the regulations made thereunder, the undersigned hereby applies for a license for a WHOLESALEIRETf1IL manufacture offrozen desserts and ice cream mix and submits the following information: 1. Food Establishment Name 2. Establishment Address: 3. Location of Plants/ dessert machines: 4. Names of brands and trade or corporation name,lf any, under which the products are to b 5. Number and capacity of freezers: 6. Is the mix purchase Fee: ($25.00 per freezer) $_ if so, from whom purchase 7. Is the mix pasteurized? g Number of gallons of frozen desserts and/or ice cream mix sold in Massachusetts during the previous licensing period 9. Is the plant/dessert machine constructed and equipped as provided in the regulations 10. Certified laboratory used for monthly testing 11. Regulations can be found at https://www.mass.gov/regulations/105-CMR-50000-good-manufacturing-practices- for-food. Please indicate if you would like a copy of the regulations emailed to you I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth of Massaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public Health made thereunder and will be manufactured under sanitary conditions. I attest that the information stated in this application is true and accurate under the pains and penalties of perjury. (Company owner/officer's signature) (Title) (DATE) (City or Town) �j z c f3 t,5 C: LL LAW LL. rd Ln x W C O d v N Z v cC� � c H « d 0 ® Ul m t� O N i E ,-mow LL Z + a+ b N k LOL � n to �\ x a� x 7 � - w u V VI w W � w qz oo �= o Zoa �r ua.y Z v$ M Z ° A O� c O w �o> a O u= aCv �V 0.. © U*) J W > L LO v (4� z � z � � W-4 z pp"4 I : % § z ong LON /\mk {r»I§ :j \|g �§ .: }° ) ,r) / \(±X y )\/\\ & / ƒ\ƒ \ƒ\§ ^ � ,-0 \ � / 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. 0 C\ P"A Signature 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. (` \r lerrc\elnifrUlr�4tnn\Srnfl'e nnromnntc\Fnnd P&Afi�hmrnta_ Trmn\TAX f FRTW ATaIN FARM dnr The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations W-j 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Address: "i c� �, ' �. Are you an employer? Check the appropriate box: 1.[3,,II am a employer witli� 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 #: ' =, Business Type (required): 5. ❑ Retail 6. ❑Restaurant/Bar/EatingEstablishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I Ln Health Care 12.❑ Other *My 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. Into an employer that is prpyiding worr#ers' contpensadon insurance for my employees. Below is the policy information. Insurance Company Name: Nw. Insurer's Address: City/State/Zr4 t k; l i_ r ':> ` 10 m\ Policy # or Self -ins. Lic. 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 MA for insurance coverage verification. I do hereby certify, undN the pahAand penaldey perjury that the information provided above is true and correct. Official use only. Do not write it) 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 #: AiVlr—r1hW.d A1W I An American National Company NAB 344 ROUTE 9W I GLENMONT, NY 12077-2910 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI COMPANY NO. 16721 POLICY NO. 2003W6255 EFFECTIVE 04/14/2021 TRANSACTION TYPE Renew FEIN # 20-2648155 ITEM 1: INSURED INSURED 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 MA 1 789 EAST ST MANSFIELD MA 02048-3458 ITEM 2. POLICY PERIOp SHEILA MCCARTHY 89 MAIN STSTE 209 MEDWAY MA, 02053-1815 508-321-3288 RTG.BUR NO. INTRASTATE NO, 479544 The policy period is from 04-14-2021 to 04-14-202212:01 A.M. Standard Time at the insured's mailing address. ITEM 3. COVERAGE 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 under Part Two are: Bodily Injury By Accident Bodily Injury By Disease Bodily Injury By Disease $ 100,000 each accident $500,000 policy limit $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except the states designated in item 3.A. of the information page and ND, OH, WA, and WY D. This policy includes these endorsements and schedules: WCODOOOIA0319 WC00000000115 WC0003150985 WC0004140790 WC200302AO908 WC200303DO810 WC2004050601 WC2006OIA0708 Copyright 1987 National Council on Compensation Insurance W0000422CO121 WC2003010484 WC2006041102 WC 000001A Edition 03-19 PROCESSED 2021-03-10 2003M255 14/LUL1 IT FARM ICE CREAM LLC The premium for this policy is determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Audit of premium shall be made upon policy expiration. State and Workplace Number Code Annual Rate Per $100 Annual Classification Description No. Estimated Remuneration/Per Estimated Total Capita Premiums Remuneration MA 1 FARM --NURSERY EMPLOYEES AND 0005 0 2.05 0 DRIVERS MA 1 STORE: DAIRY PRODUCTS --RETAIL 8006 110,900 1.08 1,198 MA 1 CLERICAL OFFICE EMPLOYEES NOC 8810 9,800 0.06 6 TOTAL PREMIUM SUBJECT TO EXPERIENCE 1,204 MODIFICATION MERIT RATING SURCHARGE 0.95 9885 -60 TOTAL ESTIMATED STANDARD PREMIUM 1,144 EXPENSE CONSTANT CHARGE 0900 338 TERRORISM 0.03 9740 36 MA ASSESSMENT CHARGE 40 Copyright 1987 National Council on Compensation Insurance PROCESSED 2021.03-10 WC 000001A Edition 03-19 2003N/0255 TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out \bags to customers. ` I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. 1 have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. 1 have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. 10/?"w Applicant Signature Applicant Name (please print clearly) f" 4 I-\'y