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HomeMy WebLinkAboutCold Stone Creamery -12/31/202111 FOR BOARD OF HEALTH USE ONLY if Permit# issued," II FOOD ESTABLISHMENT PERMIT APPLICATION 4,i. (Application must be submitted at least 30 days before the planned opening date Establishment Name a L T _C WL qg , 5 -ni 0, Establishment Address Z, d4 Establishment Mailing Address (if different) A Establishment Telephone No Li_ Applicant Name & Title: 1'` W� itst T /V q A Applicant Address LA' VO�, , f -3 S-), Applicant Telephone No.: �(X 24 Hour Emergency No.: A Applicant Email r_ C. 0_0 Yt � V60 Y, C VYr Owner Name & Tide (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, tide, and home address of officers or 1-1 An Association partner. Ef A Corporation Name Title Address 0 An Individual I o4 0 EJ A Partnership 0 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �_: 0 cam. (<a sv% Address: Telephone No: 1 24 Hour Emergency No: FAX: E-mail: (U q 'wtv, cez Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 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 Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number t 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\ScotPs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.dac Food Establishment Information WATER SOURCE: "� !i-'� L%C u` SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) �No. of Food Employees: DAYS/HOURS: � "k `, I 1 . ty c` Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) in Charge Certified in Allergen Awareness Training �. f . ti.©^,! Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a person trained in manual choke saving procedures will be 6n' site at all times food is being prepared. ❑ Yes Does this establishment require a FOG permit? % If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [`Annual E] Retail Food $125.00 Mobile Food Consesslon Temporary LI Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 . Manufacture Frozen Desserts/Ice Cream Temporary Start Date: Food Service up to 101 -200 $250.00 :p $25.00/freezer Temporary End Date: Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: Milk $ Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(dmenempemture cortrmismquin:d) (Check all that apply): Non-PHFs -non-ratenflally hazardous food(no aMe/temperalum conhols required) RTE - ready-to-eaf foods (Ex. sandwiches, salads, muffins which need no furtherpmcessfng) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ 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 Reheating of Commercially 9 y to be Prepared by Consumer ❑ Use of Process Requiring di 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) Preparation of Non-PHFs Retail Sale ❑ Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 odtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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:`- Town of Mansfield Health Department ' APPLICATION FOR FATS, OILS, and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS / .0 Address:L MailingAdd Phone/Fax Number: Enoni| Contact Person/Title for Grease Traps: ' Name mfCompany scheduled to pump internal grease t,ap(s)monthly: Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: w Most recent waste hauler receipt n,waste hauler manifest * Appropriate permit fee based onnew fee schedule (Checks can bcmade out tothe Town uf Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection, container $50 Each grease interceptor/trap over 3 $50 ($200 max) | THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE kA � F|EUDROARD0FHEALTHFATSU|CS, AND GREASE (F()5) REGULATIONS APPROVED AmDAD0PTEDVNOCTOBEK4,2o18.In . � considerationof the grantingof the the undersigned,eej the conditions of and a owledges that the information^ ni�tc these documents ^ agrees true, �accurate 'nd/cqrn�|ete, Signed Date Print Name v, Town of Mansfield - Board o 'Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or 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 UWOLESALE/RETAIL manufacture offrozen desserts and ice cream mix and submits the following infonnation: 1. Food Establishment Name t 2. Establishment Address: 3. Location of Plants/ dessert machines: 4. Names of brands and trade or corporation name, if any, under which the products are to b 5. Number and capacity of freezers: p y Fee: ($25.O0perfieezer) $ ? 6. Is the mix purchase 1 If so, from whom purchase 7. Is the mix pasteurized? 8• 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 manufacturedunder sanitary conditions.) attest that the information stated in this'application is true and accurateSnder the pains and penalties of perjury. (Comp34 owner/officer's signature) (DATE) (Title) ` (City or Town) Facility Operational Information Please answer all questions in this section. If an Item is not applicable, indicate "N/A". Unless otherwise Seating Capacity (per Fire Department Regulation){{: 10 Normal Hours of Food Preparation/Service: Mondav if". fib, n �'1t Tuesdav — Wednesday �t Thursdays` Friday Saturday <+— auUudy Please indicate the NUMBER of kitchen fixtures used in your establishment and if it attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU' M �- Handwashing sink Bar sink.. ,.. ,:.. r. i i IVIUh Jlllh Garbage Disposal .. icelvldam�-'Iv�aauiea _.._.. .. €eyatators .: - trlt or Uvens. Exhaust Hoods Fioor drains' Other: Now are,hocia vents Geane15 i h.e., 1n three (3) bay smky oh, site by private company):' ID U11111tl1 WON III C-1 io]eu UEIUI C Ocmr VVtldl lcu, if yes, at what statiosr%sink? r 2NyftlS"1F'¢,n',.'AMC'ALAY,IAWS 'The following bylaws apply to all food establishments permitted by the Mansfield Wealth'Pepartment: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic'Straw/StirrerReduction. A,copy of each bylaw is included. It is the responsibility of the applicant to read and understand sill 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 cfwckaslrt, 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 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. k"'"' I 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. I 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. Applicant Signature Applicant Name (please print clearly) i,i);,/ - Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU%Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? How often is this grease storage unit emptied? Please list the vendor who removes the waste: 3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: ., � �- i .r Address: City/State/Zip ;n%,;,, (r { �,� - ;� �' l ., Phone #: s li ! Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (fulYand/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment I ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 1 L❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box 91 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 providing workers' compensation insurance for iny employees. Below is thepolicy itiforntation. Insurance Company Insurer's Address: , . t' P,; Y Y I �,7 i c" f; i r , , d'i„ _ ;a-£ � N.:� ` [ .... City/State/Zip: `1 Policy # or Self -ins. Lic. # L" 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 DIA for insurance coverage verification. I do hereby cerdify, under the pains andpenalties ofperjury that the information provided above is true and correct. / Official rise 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 Phone #: www.mass.gov/dia z 0 � � _ LUAM � | � Z � r U) Q C3 C3 �­7 ){ \ . CO G! «/ @ �2 % Q; n = =j W Z 2 0 Z .. Z CY) NN T o Q. CO Ne- O O 4-4 1-4 • Q v � � � Q Q