HomeMy WebLinkAboutJohn's Dream Ice Cream - 12/31/2021ve d
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FOR BOARD OF HtALTH USE ONLY Permit#'Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted atleast 30 days before the planned opening date)
Establishment Name John's Dream Ice Cream
Establishment Address 70 Potash Road, Mansfield, MA 02048
Establishment Mailing Address (if different)
Establishment Telephone No 508-942-3425
!Applicant Name & Title: Ed Underwood
!Applicant Address 70 Potash Road, Mansfield, MA 02048
Applicant Telephone No,: 508-942-3425 24 Hour Emergency No,: 508-942-3425
jAppilcantEmall EdUnderwood99@gmail.com or JohnsDreamIceCream@gmail.com
Owner Name & Title (if different from applicant)
1 Owner Address
Owner telephone number
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
Ed An Association � partner:
UA A Corporation Name Title Address
N An Individual
B A Partnership
O Other legal Entity
PersonDirectlyResponsible For Daily Operations (owner, person In charge, supervisor, manager etc;)
Name.&Title: Ed Underwood:
Address: 70 Potash Road, Mansfield, MA 02048
Telephone No: 508-942-3.425 24 Hour Emergency No: 508-942-3425
FAX:
E-mail:EdUnderwood99@gmail.com or JohnsDreamlceCream@gmail.cbm
Alt E-Mail:.
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone Not
FAX:
E-mail
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE: N/A SEWAGE DISPOSAL N/A
DEP Public Water Supply No: (If applicable) No. of Food Employees: 0
DAYWHOURS; Vx I e S
Name of Person(s) In Charge �Certified in Food Protection Management:
Name of'Person(s) In Charge Certified In Allergen Awareness Training
-k 11rZ
fVPX& JPCA
Name of pest control company routinely inspecting the premises for evidence of pests e l/9
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. Eyes FJ) (t
Does this establishment require a FOG permit? No If yes, please attach the FOG; permit application:.
Length of Permit:
Annual
[] Temporary
-
Temporary Start Dote;:
Temporary End Dater
TemporaryTime;.
Rain Date:
Food Operations:
(Oheck all that apply);
Establishment Type:
r1 Retail Food $125.)0
a rood Service up to 100 INCLUDING
FOOD TRUCKS $175.00
I] Food Service up to:1.01 -200 $250.00
tI�`-' FoodServlce up to 201 + $300.00
[] Supermarkets $400
9 Milk &,Cream $10,00
D Sale of Commardally Pre -Packaged Non-PHFs
X .Sale of Commercially Pre -Packaged PHFs
(; !] Deliveryof Packaged PHFs
[9 Reheating of Commercially
Processed Foods for Service Within Hours
Q Customer Self -Service of Non PHF and Non -
Perishable Foods Only
[]-Preparation of Non-PHFs
Other FoodOperations
haw
H PHFCodkad To Order
i , Preparation of PHFs For Hot And
Cold Holding; For: Single Most Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
0�1 Customer Self-service
[ ] Ice' Manufactured and Packaged for
Retail: Sale
EC�j Juice Manufactured and Packaged for
Retail Sale
ffu Offers RTE PHF In Bulk quantities
i] Retail Sale of Salve a Out -Of --Date
2 Mobile Food: Consession NO PHF: PREPARED ON:SITE '$100;00
1 Ti Menufaoture Frozen Dessertslice Cream
$25.001freezer
IX Pushcart $50.00 # of Pushcarts: /
El Residential Kitchen$100,00
IJ Caterer$35.00
El Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meot$ervice.
?q PHF and RTE`Foods Prepared For Highly
'Susceptible Population Facility
Use ofProcess Requiring A Variance:
and/or HACCP' Plan (including bare hand
contact alternative, time as a public health
control)
Ei] Offers Raw Or Undercooked Food Of
Animal Origin
[�- Vacuum Packaging [Cook Chili
I J Prepares FoodlSingie Meals for
`t Catered Events or Institutional Food Service
or Recondltforied Food
In this application and affirm that the food
heragplicabie law. I have been Instructed by the
Pursuant to MGL.Ch,62C, sec. 49A. I certify unAr the penalties of perjury that 1, to my beat knowledge and belief,. have filed all state taxreturnsand
d state taxes required under law.
Social Rio 2 t?fl'7 Lys
Security Number or Federal ID:
Signature of Individual or Corporate Name:
TAX CERTIFICATION FORM
l 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 lndivi l 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.
CAUsm\stejte\Desktop\$cows DocmmntsTwd Establishment$- TempWAX. CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass govtdia
Workers' Compensation: Insurance Affidavit; General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: j 0 W tJ �S Dirzi,v?
7
Address: t 0 Fc� '7 4.sht (2-b
mA 0X 0 Phone #i
Are you an employer? Check the appropriate box:
Business Type (required):
LEI I sin a employer with employees (full and/
5. Q Retail
or part-time),*
2.❑ I
6. >restaurant/Bpr/EatingEstablishment
am a sole proprietor or partnership and have no
7, I] Or e and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity,
[No workers' comp, insurance required]
g• Non-profit
3.❑ We are a corporation and: its officers have exercised
9, ❑ Entertainment
the'r right of exemption per e. 152, §1(4), and we have
10.n Manufacturing
o employees: [No workers' comp. insurance required]*
1 l.p Health Care
4,6j
We are a non-profit organization, staffed by volunteers
j
with no employees. [No workers' comp. insurance req,
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 haee exemptedthemselves, but the Corporation has other employees, a workers' compensation policy is required and such an
organization should check box M.
1 ail+ an employer that isprovidit g svorkers' compensation insurance for my employees. Below is thepolicy in/arntadom.
Insurance Company Name:
Insurer's
City/State/zip
Policy # or Self -ins. Lie.
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 MGLc. 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
,I do hereby
eta.. u 3 (jay"
that the
Official use only. Do not write in this area, to be co npleled by city or town of
ftciaC
City or Town.
hermit/License #
above is true and correct
Issuing Authority (circle one);
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
www:mass.bovidia
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.
ti'a0 I have received a copy of the Plastic Waste Reduction bylaw, l 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 expandedpolystyrene. 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.
yW 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.
1 t/ 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 Date:. 1' .5' — a`Q'Z )
Applicant Name (please print clearly)
�pw192'D 3_ u01'0cR„Jooa
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date 4/5/2021
We, John's Dream Ice Cream / Ed Underwood (restaurant/ 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(e)(3) organization and ALL proceeds earned will go directly to the
organization.
u We are donating ALL proceeds earned directly to a 501(c)(3) organization.
Please list.the organization: Epilepsy Foundation New England
❑ We are not charging a fee for food/drink being served. �i�t - 2
❑ We are a religious organization.
❑ Other:
Thank you; —�%✓�/ j (/ �j�--
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOM Use Only
Approved
Denied Reason. -
Signature:
Date:.