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HomeMy WebLinkAboutFlannel Cow Creamery - 12/31/2021FOR BOARD OF HEALTH USE ONLY , Permit* Issued FOOD ESTABLISHMENT PERMIT APPLICATION; (Application must be submitted at least 30 days before the planned openingate) ( (ow 0,&k�� ment Name }��L�K �' ru �1-�^ ment Address �� C �S �r Avt rEstablishrrientMailing Address (if different) Establishment Telephone No 5-0� -33� Applicant Name & Title: Applicant Address30$ m4ye� s� MC�ar%ie/d ,/ 9 o�YY Applicant Telephone No.: 7 $' l -175-` r2 c 24 Hour Emergency No.: Applicant Email ?'Gtn�G(Co�C/ZkIhE/? e'Po"" 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 171 An Association partner. 0 A Corporation /(J,,ame (�n ro n .' Title Address O An Individual J _knS -�" _ ` El A Partnership Kj'3v �xc�wti `l��sa✓`N" It'II,M�litel� /�� 0 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: SAA%, t-_. G-S Aq,'o j al r { � Address: Telephone No: 24 Hour Emergency No: 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 SEWAGE DISPOSAL: WATER SOURCE: �bl r r9 Public Water Supply No: (If applicable) No, of Food Employees: vwl� - !k zj r DEP P Ti(^DGfO�'i' //!-f4• IL ur 1, id $y"+�� �k'}-rSwr-M "tl-i �2� DAYS/HOURS: 5 W—v'A u Nam of Person(s) In Charge Certified In Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training kkIp- Name of pest control company routinely inspecting the premises for evidence of pests Yin�Ef� anro/ 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. H Yes Does this establishment require a FOG permit?_ If yes, please attach the FOG permit application. Length of Permit: Establishment Type: JV(Annual stall Food $125.00 Q Mobile Food Consession r Temporary , U Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 p�fManufaciure Frozen Desserts/Ice Cream Temporary Start Date: C7 Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service up to 201 + $300,00 (] Pushcart $50.00 # of Pushcarts: Temporary Time: Q Supermarkets $400 0 Residential Kitchen $100.00 Rain Date: Milk & Cream $10.00 (a Caterer $35,00 Food Operations: Definitions: PHF- Potentially hazardous food himeRemperature controls required) Non-PHFs- non -potentially hazardous(ood(no timeRemperetum controls required) (Check all that apply): RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no furfherprocessing) Q Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order n Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ,,� W Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly MJ Delivery of Packaged PHFs Susceptible Population Facility ❑Sale of Raw Animal Foods Intended Reheatingof Commercials Y to be Prepared by Consumer i❑'.S Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand fr.J',' Customer Self -Service contact alternative, time as a public health Customer Self-service of Non PHF and Non- I, Perishable Foods Only i,' Ice Manufactured and Packaged for control) ❑ Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of Q Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale `r Vacuum Packaging / Cook Chill Offers RTE PHF in Bulk Quantities 0 Prepares Food/Single Meals for IN 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 obtain copies of 10; CMR 590,000 and the federal Food Code. Signature of Applicant: ^ / t_� 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. _e4 Social Security Number or Federal ID: lq*. q pi Signature of Individual or Corporate Name: Y/F/�G✓ ` Town of Mansfield - Board of 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 of section 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 WHOLESALEIRETAIL manufacture of frozen desserts and ice cream int-c 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, if any, under which the products are to b Z t 5. Number and capacity of freezers: R ��_--_ Fee: (825.00 er p f•eezei) $ 6. Is the mix purchase IGS If so, from whom purchase 7. Is the mix pasteurized? 8. Number of gallon of frozen desserts and/or ice cream mix sold in Massachusetts during the previous licensing period /AP^• - siWt P atbeg Jg1A#'r" 9. Is the plant/dessert machine constructed and equipped as pro ided in the regulations`% 10. Certified laboratory used for monthly testing 11. Regulations can be found at https://www.mass.gov/regulations/i05-CMR-50000-good-manufacturing-practices- for-food. Please indicate if you would like a copy of the regulations emalled 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 'ppains and penalties of perjury. (Company owner/officer's signature) (DATE)N� / (Title) (City or Town) RYAN HEEDEN for successfully mmPlaling the standards set faith for the S.,Safee food Fmi ciion.Manager Certification Examination, which is accredited by the American National Standards Institute (ANSII=CogferenoD Far Food Protedlan (CFP). 5133 EXAM FORM N�UMAE.R 4/6/2021 )ATE OF EXPIRATION ecerti6calton requirements. Cbnixiwu)hq�eiernm 1]5WMAvn 6`.d 61 ISee.ckv .tt (9604aSmW+Q�rwaianiag Name of Recipient: FYAII HEED' CerCificate Number: �31ml Date of Completion: 6111 Date of Expiration: 5r4011 qJr, nhoer-nrsnnvl prrsmr is hrrclq' issurd this a r'Owte J0r romple iag an alJngelr awvrr(ness nrrining pr0gmnr rrragmsirrd Lp the Nlassarbusem Dip irmlenr 01Trdrlir Nmlth in anmrdance wire 105 Cb1R 590.009("G)('3 ta). 9his eall s'nrte n.'ill A' awful %o, iiVe I i 1 roans fi'our dale q% ronmplelion. TssocdBy: REST J RANI' ASS CIATION,,. blassnchuscm Re6tanrnntdssncindon 333 Twnrikc Rond, Suitc 102 Sonrhborough.AlA 01772 800.755.2132 a¢v+v.mtuurantoeg 508-303-9905 .......... M.huY:lnuil wc'.Org 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. a_ 44V Signature of Individual or Corporate Name 'il- `tg913.73 *"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. C:\Users\sleite\Desktop\ScotPs Documents\Food Establislunents- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts IV Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses .._.i$nnri rnfltHM Ailflfl Please Business/Organization Name: rkrwyG ' Address: I � OlV lJn 6P& .- Y Are y u an employer? Check the appropriate box: 1.I am a employer with !�SIL 1 'employees (full and/ or par��inie).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 30 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.n We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Phone #: 7?1'`/7S_``Id29 ( Pl Business Type (required): 5. ❑ Retail 6. 2estaurantBar/Eating Establishment 7. Q Office and/or Sales (incl, real estate, auto, etc.) 8. Non-profit 9. ❑ Entertainment 10.0 Manufacturing 1171 Health Care 12.0 Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation bas other employees, aworkers' compensation policy is requieed and such an organization should check box,1 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Natne:G,t^��'e-c " 2p��`�� — ¢4�-� Insurer's Address: i--� City/State/Zip: /?2>t_ Policy # or Self -ins. L� 61 4 0 774- Expiration Date: D6 74 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 imprisomnent, 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 pains and penalties ofperjury that the information provided above is true and correct. phnne#• -7ki- /7S -qY0 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1, Board of Health 2. Building Department 6. Other Permit/License 3, City/Town Clerk 4. Licensing Board 5. Selectmen's Office Contact www.mass.gowom Phone (Policy Provisions: WCOOOOOOC) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Hartford Accident d Indemnity Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: 10448 Company Code: 5 POLICY NUMBER: 02 WEC EK7727 Previous Policy Number: 102 WEC EK7727 1. Named insured and Mailing Address: PASTURE PROPERTIES, LLC (No., Street, Town, State, Zip Code) 308 MAPLE ST MANSFIELD MA 02048 FEIN Number: 47-4952115 state Identification Number(s): The Named Insured is: LLC Business of Named Insured: Full -Service Restaurants Other workplaces not shown above: 88 CHILSON AVE MANSFIELD MA 02048 2. Policy Period: From 08/13/20 To 06/13/21 ANNUAL 12:01 a.m., Standard time at the insured's mailing address, Producer's Name: CROSS INSURANCE INC RHODE ISLAND PO BOX 4830 EAST PROVIDENCE RI 02916 Producer's Code: 02090786 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 853-2582 Total Estimated Annual Premium; $932 Deposit Premium: Policy Minimum Premium: $267 MA (Includes Increased Limit Min. Prem.) suffix LARS RFNPWAL L 4 4 Audit Period: ANNUAL Installment Term: Ten Pay (25%Down+9@8.33%) The policy is not binding unless countersigned by our authorized representative. Countersigned by 07 Form WC 00 00 01 A (1) Printed in U.S.A. Process Date: 07/04/20 Page 1 (Continued on next page) Policy Expiration Date: 08/13/21 EXTENSION OF THE INFORMATION PAGE - ITEM 1 - NAMED INSURED Policy Number: 02 WEC EK7727 Endorsement Number: Effective Date: 08/13/20 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PASTURE PROPERTIES, LLC 308 MAPLE ST MANSFIELD MA 02048 Item 1 of the Information Page Is completed to include as named insured: Named Insured : PASTURE PROPERTIES, LLC State ID : Not Applicable FEIN : 47-4952115 DBA Name FLANNEL 001+UCREAM, RY, LLC:OEIN 47.4941373_ Form WC 99 03 66 Printed in U,S.A. Process Date: 07/04/20 Policy Expiration Date: 08/13/21 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Address: Mailing Address: �UA�'c Phone/Fax Number: S*/emu , ca,., Contact Person/Title for Grease Traps Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date L 1 ! Print U Y i� Qi m Q E f0 E 3 z a Z Ol O Q S CL S,. mm FI 'tlI '♦ o- Your Grease Trap Pro & Drain Specialist P.O. Box 294 Bridgewater, MA 02324 LIKE US ON (508) 697.9565 1 (800) 449-4480 (508) 759-0979 www.PatriotServicesMa.com ` i f 11, Date of Sery" , ice t. i Customer Name Invoice # City, _ ::_ : ..s:,;' .. c. Zip Job Address (if different than customer) Apt. # you to perform the above described services and I agree to pay the amounts indicated to that I am duly authorized to order and approve the work requested. Signature Terms: Cash-,, � PO # Bill Out'f` ? •,( }t This is to acknowledge completion of the above described work which has been done to complete satisfaction. (ey r PARTS LABOR OTHER TOTAL DISCOUNT TOTAL DUE F=, j % Date / ) 'i / b Customer Name Customer E Mail Address Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. 1 D Seating Capacity (per Fire Department Regulation): N0 /- Seating Capacity (Actual Count): epo ,e iz. Normal Hours of Food Preparation/Service: 51WV7 Monday zga � Tuesday Z�fl'���5 Wednesday Z'tId 0% Thursday 20" p��7 Friday !z.•pSaturday /Z - LYJf11 Sunday IL-1''s" Please Indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU J 3 compartment sink 2 A)-o Handwashing sink li AJ4 Commercial Dishwasher Al✓ Bar sink /Lb Mop Sink Garbage Disposal (� NA Ice Making Machines /U Fryolators Grills or Ovens AA Exhaust Hoods W Floor drains Other: How are hood vents cleaned? (Le., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? j/ Yes No If yes, at what station/sink? Grease Trans 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 6 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 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. 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 4 Date: Applicant Name (please print clearly) ol 0 II L N O N LO M 0 ,o 0 y � � W-4 u (4� z *-4 z � � W4 z P4 � � z � � � � �4 49� / © � } ar) / \ (a\ {\®6 \ w \+\) ) ) lok <\0 ( \ � 2 .. \ % \ / \Ji \ ?\\\ 2 / ƒ)\\ g ry\ / r