HomeMy WebLinkAboutFlannel Cow Creamery 12/31/2016Commonwealth 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: FOOD ESTABLISHMENT
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:.
RYAN HEEDEN, PRESIDENT
Whose place of business is:
FLANNEL COW CREAMERY, LLC
88 CHILSON AVENUE
PERSON(S) IN CHARGE:
RYAN HEEDEN
Permit Expires: December 31, 2016
License Number: FS -74
Food Fee: $87,50
Milk & Cream W
BOARD OF HEALTH
MichaecMCCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Sell Milk and Cream
This is to certify that:
RYAN J. HEEDEN, PRESIDENT
having a place of business at:
FLANNEL COW CREAMERY, LLC
88 CHILSON AVENUE
in the Town of Mansfield has been granted a license to sell MILK and CREAM and
is subject to the Provisions of the Laws of the Commonwealth of Massachusetts,
relating to the terms and conditions, and to the rules and regulations established by
the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream
and shall remain in force until 12/31/2016 unless previous to that time is
suspended or revoked.
Expires 12131/2016
License No.: FS -74
Scott Leite, Health .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Manufacture Frozen Desserts and/or Ice Cream Mix
The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the
General Laws, as most recently amended, and the regulations made hereunder, hereby issues
FLANNEL COW CREAMERY, LLC
88 CHILSON AVENUE
a license for the wholesale/retail manufacture of frozen desserts and ice cream mix.
This license expires December 31st of each year.
License Number: FS -74
Freezers: 2
TOTAL: $25.00
MANSFIELD BOARD OF HEALTH
Scott Leite, Heaah .Agent
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS -74
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at leastay7 e ore e planned opening date)
1) Establishment Name FLANNEL COW CREAMERY, LLC
2) Establishment Address 88 CHILSON AVENUE
3) Establishment Mailing Address (if different) 88 CHILSON AVENUE
MANSFIELD, MA 02048
-
-
4) Establishment Telephone No (781) 475-4829
5) Applicant Name & Title: RYAN HEEDEN
6) Applicant Address 3 LEE ANN DRIVE, BARRINGTON, R102806
7) Applicant Telephone No.: (781) 4754829 24 Hour Emergency No.: (617) 877-0181
8) Owners Name & Title RYAN HEEDEN Ge 41
9) Owner Address (if different from applicant)
Owner's telephone number 7814754829
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
'K A Corporation
ElAn Individual
ame f Tit' Address
'Gt �i , 3 i
El Partnership
_
SSe� f ®!/I l ► %I9�'�t` G l _A�,1 ® zy��rt
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
RYAN HEEDEN
Address:
3 LEE ANN DRIVE, BARRINGTON, RI 02806
Telephone No:
FAX:
(78111475-4829 24 Hour Emergency No: (617) 877-0181
E -mail:
Alt E -Mail:
-
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
F
-
E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees:
17) DAYS/HOURS: SEASONAL 12:00'PM - 9:00 PM
18) Name of Person In Charge Certified in Food Protection Management: RYAN HEEDEN
If more than 3 individuals are certified, complete list is on file.
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
20) Location: Permanent Location
22) Establishment Type
❑ Caterer $12.50
❑ Mobiie Moblie Start Date:
❑ Retail ( Sq. Ft)
0 Milk & Cream $5.00
Mobile End Date:
Food Service up to 100 or
❑ Mobile Food & Consession $37.50
Mobile Comments:
up to 10' PHF display $62.50
❑ Food Service up to 101 -200
0 Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
21) Length of Permit:
W Annual
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
❑ Pushcart $12.50 # of Pushcarts: 0
❑ Residential Kitchen $50.00
❑ Seasonal
Other Food Operations
or 25'+ PHF display $137.50
E]Retail Food $50.00
Seasonal Dates:
❑ Food Service - Institution
❑ Retail Snack Food $12.50
❑ Temporary
Temporary Start Date:
( Meals/Day)
❑ Tobacco Products $12.50
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions: PHF - Potentially hazardous food (time/temperature controls required)
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)
❑ Sale of Commercially Pre -Packaged Non-PHFs
PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
❑ 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
Susceptible Population Facility
Delivery of Packaged PHFs
❑ rY 9
❑ Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
—_—
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
❑ Customer Self -Service of Non PHF and Non-
Perishable Foods Only
❑ Preparation of Non-PHFs
❑ Customer Self -Service
❑ Ice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of
Animal Origin
Other Food Operations
F1Juice Manufactured and Packaged for
Retail Sale
E] Offers RTE PHF in Bulk Quantities E] Prepares Food/Single Meals for
Catered Events or Institutional Food Service
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee: $62.50
Payment is due with application ❑ waived
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 obtairyloopies of 105 CVIl 590.00 and the federal Food Code.
24) Signature of Applicant:
v
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.
25) Social Security Number or Federal ID: 47-4941373
26) Signature of Individual or Corporate Name: A'7_ 4i4:n:
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for Milk and Cream Permit
I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year.
f �
NAME OF BUSINESS:
ADDRESS: � 5
TELEPHONE AT LOCATION: % � 1
FAX NUMBER:
OWNER OF BUSINESS: & J
TELEPHONE OF OWNER: 7 0 j
FEDERAL ID/SS NUMBER:
FEE: $5.00
PERMIT NUMBER: ,�-
SIGNATURE: _ 3
DATE: (g/�
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix
To the Board of'I-Iealth at the Town of Mansfield:
1.
In accordance with the provisions of section 65H of Chapter 94 of the General Latins, as most recently amended, and
the regulations made thereunder, the undersigned hereby applies fbr• a license for a WHOLESALEIRET,4IL
manufacture of frozen desserts and ice cream mix and submits the,folloiving information:
Full name of applicant: FLANNEL COW CREAMERY, LLC
2. Business address 88 CHILSON AVENUE
MANSFIELD, MA 02048
3. If applicant is an individual: FUII name: RYAN HEEDEN
Residence: 3 LEE ANN DRIVE, BARRINGTON, RI 02806
3a. If applicant is a partnership, fid/ name and residence of all partners:
3b. ff applicant is a corporation: State of incorporation: MA
Date of incorporation: 8/24/2016
Frdl name and address gf : Principal office: A 88 CHILSON AVENUE
President RYAN HEEDEN
Treasurer: MELISSA HEEDEN
Clerk: NONE
4. Location gfPlants: 88 CHILSON AVENUE, MANSFIELD, MA 02048
S. Names of brands and trade or corporation name, if'any, under which the products are to be sold:
FLANNEL COW CREAMERY LLC
6. Number and capacity, gf freezers and, fees: 2 Fee: ($12,50 per. freezer) $ 25
7. Is the mix purchased? YES If so, f •orn whom purchased?
8. Is the mix pastew*ed of not? YES
I. Number ofgallons offrozen desserts and/or ice cream mix to be sold in Massachusetts during the licensing
Period TO BE DETER
10, Nuniber oj'gallons o/:fi•ozerr desserts and/or ice cream rnix sold in Adassachusetts during the previous licensing period 0
11. Is the plant constructed and equipped as provided in the regulations? YES
12. Is the water supply public or not? PUBLIC
13. Hm�e you received a copy of the regulations? YES
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 thls a lication is true anV,,accurar nder the pains and penalties ofperjury.
/3 /P
Z(Cpowner/officer's signature) (DA E)
(Title) (City or Town)
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.
* Si ature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
`/'7-qqy/ ,5 7
** Social Security Number (Voluntary) or
Federal Identification Number
* This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A.
The Commonwealth of Massachusetts
DI 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: C C LZC..
Address: 6AAbb n AIL
City/State/Zip: ,�' Y IUPC M 0 201Y Phone #: 75 ' `J'a Z�
L,
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/
or part-time).*
2. 1 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. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
U. . ❑ Health Care
12.❑ Other
*Any applicant that checks box # I 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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informatiom
Insurance Company
Insurer's Address:
City/State/Zip:
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 DIA for insurance coverage verification.
I do hereby cert, under the pains and penaltiesofperjury that the information provided above is true and correct.
-tM--
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):
I. 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
RYAN HEEDEN
for successfully completing the standards set forth for the ServSafe" Food
which is accredited by the American National Standards Institute (ANS
DATE OF I
Local laws apply.
ACCPEUItED PHUfiPAA1
f inn m� 64s4ard. E�ttlM�
andib Gaal vbPond P.A.ib
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• 2015 Nati, .I
MBER
— h.4,—k, J the rRAff.
51
EXA
DATE OF EXPIRA
for recertification requirements.
tification Examination,
Protection (CFP).
Cwdw u, wdh q�—, a 175 W )-t— BW Ste 1501), Ch -9, It 004 . .9
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: RYAN HEEDEN
Certificate Number: 2316397
Date of Completion: 55/1016
Date of Expiration: 55!1021
77v abo r nrnnrdp rson is herb), issrnd this rertrfrrate
.1br completing an a11.1gen (IMP"nrss /Yell HI
recognized by the Massaebusetts 1)rpar tnnew of Pubhr Health
in accordance with 105 G`IIIR 590.009(G)(3)(a).
77)i.s eerti,6eate will he valid for, five (5) yens from date of rrinrjrletion
LTJ
Issued By:
F
4
NATIONAL
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RESTAURANT
ak
ASSOCIATION,
Massachusetts Restaurant Association
900.765.2122
333 Turnpike Road, Suite 102
roww.restaurant.org
Southborough, AIA 01772
503-303-9905
www.marestaur:tntassoc.org