HomeMy WebLinkAboutDylan & Pete's Ice Cream 09/30/2016Commonwealth 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: TEMPORARY
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:.
DYLAN ARCHAMBAULT
Whose place of business is:
DYLAN & PETE'S ICE CREAM DBA INCREDIBLY PERFECT TRUCK - XFINITY
885 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
DYLAN ARCHAMBAULT, OWNER
Permit Expires: September 30, 2016
License Number: T-126
Food Fee: $100.00
BOARD OF HEALTH
MichaeCMcClean, Chairman
Date Received Date Inspected Approved By Permit # Issued
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name.
2) Establishment Address:
2 g/
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
D
5) Applicant Name & Title:
6) Applicant Address:
liC) '-es
7) Applicant Telephone No: ! _ - ®
24 Hour Emergency No:
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of
m An association
officers
Name
or partner.
Title Home Address
A corporation
m An individual
mA partnership
m Other legal entity
11 iG
12 Person Directly Responsible For Daily Operations
Owner, Person in Charge, Supervisor, Manager etc.
Name & Title:
R
Address:
Ae
Tele hone No:
9_ rILr/ /
Fax: 3'��
Emergency Telephone No:
o
13 District Or Regional Supervisor if applicable
Name & Title:
Address:
Telephone No:
Fax:
590application6-2. do c
Food '15stablishment Information
14) Water Source:
`)j(11f
15) Sewage disposal:
DEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation:
17) No. of Food Employees:
18) Name of Person In Charge Certified in Food Protection Management:
7—Required as of 101112001in accordance with 105 CMR 590.003(A)please attach ofoe fificate.
—
19) Person Trained In Anti -Choking Procedures (if 25 seats or more): ® Yes ®No
20) Location:
22) Establishment Type(check all that apply)
❑ Caterer
(check one)
❑ Retail ( Sq. Ft)
❑ Food Delivery
❑ Permanent Structure
❑ Food Service — ( Seats)
❑ Residential Kitchen for Retail Sale
❑ Mobile
❑ Food Service — Takeout
❑ Residential Kitchen for Bed and Breakfast
❑ Food Service — Institution
Home
( Meals/Day)
❑ Residential Kitchen for Bed and Breakfast
Establishments
Other (Describe)
❑ Frozen Dessert Manufacturer
21) Length Of Permit:
(check one)
❑ Annual
❑
/Seasonal/Dates:
GY Temporary/Dates/Time:
vYt wwr
Definitions: PHF— potentially hazardous food(time/temperature controls required)
23) Food Operations:
Non-PHFs — non- potentially hazardous food (no time/temperature controls required)
RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
check al/ that apply):
❑ Sale of Commercially Pre-
❑ PHF Cooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held for
Packaged Non-PHFs
More Than a Single Meal Service.
❑ Sale of Commercially Pre-
❑ Preparation Of PHFs For Hot And
❑ PHF and RTE Foods Prepared For Highly
Packaged PHFs
Cold Holding For Single Meal
Susceptible Population Facility
Service.
❑ Delivery of Packaged PHFs
❑ Sale Of Raw Animal Foods Intended
❑ Vacuum Packaging/Cook Chill
to be Prepared by Consumer.
❑ Reheating of Commercially
❑ Customer Self -Service
❑ Use Of Process Requiring A Variance And/Or
Processed Foods For Service
HACCP Plan (including bare hand contact
Within 4 Hours.
alternative, time as a public health control
❑ Customer Self -Service Of Non-
❑ Ice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of Animal
PHF and Non -Perishable Foods
Retail Sale
Origin.
Only.
❑ Preparation Of Non-PHFs
❑ Juice Manufactured and Packaged
❑ Prepares Food/Single Meals for Catered
I
for Retail Sale
Events or Institutional Food Service
❑ Offers RTE PHF in Bulk Quantities
Other (Describe): To be completed by the Board of Health
❑ Retail Sale of Salvage, Out -of Date or Total Permit Fee:
Reconditioned Food Payment is due with application
I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. 1 have been instructed by the board of
health on how to obtain copies of 105 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: L Ja d !612 &f?a�J AdALL
Pursuant to MGL Ch. 62C, sec. 49A, 1 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.
25) Social Security Number or Federal ID: 7
26) Signature of Individual or Corporate Name:, V am,
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, 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 By: Corporate Officer (Mandatory, if Applicable)
c� /� l- d
**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.
C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
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 Legibly
Business/Organization Name:
Address:
City/State/Zip:
e)j Phone #:
Are you an employer? Check the appropriate box:
1. [f I am a employer with (iz 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.]
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. F-1 Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11.❑ Health Care
12.2 Other AaAe,'
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy mtormatron.
**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 my employees. Below is the policy information.
Insurance Company N
Insurer's Address:
City/State/Zip:
_
Policy # or Self -ins. Lic. # 7- W. al'
s 3,�/��i & 9� 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 certify, under the pains andpenalties ofperjury that the information provided above is true and correct.
�ienahire:
l�nJ 1 1i i sal Date:
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 Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person:
www.mass.gov/dia
Phone
Technology Insurance
20 Trafalgar Square, Suite 459
Nashua, NH 03063
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY INSURANCE POLICY
In Witness Whereof, we have caused this policy to be executed and attested, and, if required by
state law, this policy shall not be valid taxless countersigned by our authorized representative.
)4k� * 7Z
Stephen Ungar, Secretary Jeff Leo, President
To obtain information, please contact your agent or Technology Insurance Company
877-528-7878. You may also write Technology Insurance Company Consumer Relations at:
5800 Lombardo Center
Cleveland OR 44131-2550
WC990000A
A Stock Insurance Company
WORKERS COMPENSATION
WC 99 00 01 B
AND EMPLOYERS LIABILITY
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
INSURANCE POLICY
INFORMATION PAGE
Ncei Code: 39071
$500,000 each accident $500,000 policy limit $500,000 each employee
1. Insured:
Policy Number:
TWC3527468
Dylan & Pete's Ice Cream, Inc
D. This policy includes these endorsements and schedules: See Extension of Information Page
558 Chelmsford Street
Plans. All information required below is subject to verification and change by audit.
Lowell, MA 01851
_Individual
_Partnership
Other workplaces not shown above:
X Corporation
STATE ASSESSMENT
See Extension of Information Page
TOTAL ESTIMATED COST
5,954
Producer:
Federal Tax ID:
262541485
AmTrust North America, Inc.
Risk Id:
c/o The Keating Group, Inc.
Renewal of
T WC3456978
144 Turnpike Road, Suite 150
Southborough, MA 01772
2. The policy period is from 2/11/2016 to 2/11/20-1712:01 a.m. at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the states listed here: Massachusetts
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:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$500,000 each accident $500,000 policy limit $500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except ND, OH, WA, WY and State(s) Designated in Item 3A.
D. This policy includes these endorsements and schedules: See Extension of Information Page
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
5,640
STATE ASSESSMENT
314
TOTAL ESTIMATED COST
5,954
Minimum Premium
500
Issue Date: 12/31/2015 Countersigned by:
Authorized Representative
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