HomeMy WebLinkAboutFlint Farm Ice Cream 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:.
DONALD FLINT
Whose place of business is:
FLINT FARM ICE CREAM
789 EAST STREET
PERSON(S) IN CHARGE
DONALD FLINT
Permit Expires: December 31, 2016
License Number: FS -22
Food Fee: $62.50
Milk & Cream OO
BOARD OF HEALTH
MichaeCvlcCtean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
DONALD FLINT
having a place of business at:
FLINT FARM ICE CREAM
789 EAST STREET
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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 1213112016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -22
Scott Leite, Heaah .Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS -22
FOOD ESTABLISHMENT PERMIT APPLICATION
-----CAPpTic—atio—n-most--U-e-sub-m—ittt?d—affeasf-30 days before the pTanned-opening date
1) Establishment Name FLINT FARM ICE CREAM
2) Establishment Address 789 EAST STREET
3) Establishment Mailing Address (if different) 789 EAST STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 337-6473
5) Applicant Name & Title: DONALD FLINT
;-Applicant -Address 789 EAST STREET, MANSFIELD, MA 02048----- -
7) Applicant Telephone No.: (508) 339-7115 24 Hour Emergency No.: (508) 339-7115
8) Owners Name & Title DONALD FLINT
9) Owner Address (If different from applicant) 789 EAST STREET, MANSFIELD, MA 02048
Owner's telephone number (508) 339-7115
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
El An Association or partner,
El A Corporation Name Title Address
V An Individual
L1 A Partnership
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: DONALD FLINT
Address: �789 EAST STREET, MANSFIELD, MA 02048
Telephone No: �(508) 339-7115 24 Hour Emergency No: tl'508.1'339-7115
FAX:
E-mail: j
LAItE-Mail:
13) District Or Regional Supervisor (if applicable)
[Name &Tiitle: T
1 Address:
!Telephone No: 24 Hour Emergency No:
FAX: -4-
E-mail:
Food Establishment Information
F14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) NO. Of Food Employees:
17) DAYS/HOURS: 7 DAYS 12-9 PM
18) Name of Person In Charge Certified in Food Protection Management:
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: 0 Permanent Location 22) Establishment Type
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: Food Food Service up to 100 or
Moblie Comments: up to 10' PHF display $62.50
21) Length of Permit:
W Annual
W Seasonal
Seasonal Dates: APRIL- OCTOBER
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain nate.
❑ Food Service up to 101 -200
or up to 25' PHF display $75.00
❑ Food Service up to 201 +
or 25'+ PHF display $137.50
❑ Food Service - Institution
( Meals/Day)
SEPTIC
26 PART TIME
❑ Caterer $12.50
Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts:
❑ Residential Kitchen $50.00
❑ Retail Food $50.00
❑ Retail Snack Food $12.50
❑ Tobacco Products $12.50
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs
❑ Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
❑ Reheating of Commercially
Processed Foods for Service Within 4 Hours
❑ Customer Self -Service of Non PHF and Non -
Perishable Foods Only
❑ Preparation of Non-PHFs
❑ PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
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)
Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
al
Retail Sale Aniigin
premareOSrFood/Sin le Meals for '
-- — - — ---
❑ Offers RTE PHF in Bulk Quantities p - -
� Catered Events or Institutional Food Service
El 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 obtain copies of 105 R 9 .000 nd the federal Food Code.
24) Signature of Applicant:
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: 20-2648155
26) Signature of Individual or Corporate Name:
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.
NAME OF BUSINESS: FLINT FARM ICE CREAM
ADDRESS: 789 EAST STREET
TELEPHONE AT LOCATION: (508) 337-6473
FAX NUMBER:
OWNER OF BUSINESS: DONALD FLINT
TELEPHONE OF OWNER: (508) 339-7115
FEDERAL ID/SS NUMBER: 20-2648155
FEE: $5.00
PERMIT NUMBER: FS -22
SIGNATURE:
DATE:
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:L C re" L L C
Address: 7-0 `%' Z1- 34 12, Kv 3 4e /J
City/State/Zip: AX -4 02-0
Are you an employer? Check the appropriate box:
1.2. 1 am a employer with 96 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.]
Phone #: SAO q,- 77-7 - 6 ic 7 3
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
10.0 Manufacturing
11, F1 Health Care
12.1K Others
*Any applicant that checks box # 1 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 my en loyees. Below is the policy information.
Insurance Company Name: Y t2.:�i �U"�� U
MN
Insurer's Address
City/State/Zip:
Policy # or Self -ins. Lic. #. I\ib-, �� � 0 ! Expiration Date:, A A " Q
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 DTA for insurance coverage verification.
I do hereby certif ,/under the pains and penalties of perjury that the information provided above i true and correct
Sirmafiire' W/ 7.� Date: -;/? l 4
Phone #• _5 02 ` 31.7 — 6 V 7 3
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
11 Contact Person: Phone #: 11
www,mass,gov/dia
IIVI-UKIVIAIIVI1 VAUL
�u
FARM FAMILY CASUALTY INSURANCE COMPANY
INSURED AND MAILING ADDRESS:
FLINT FARM ICE CREAM LLC
789 EAST ST
MANSFIELD, MA 02048-3458
THE INSURED IS LIMITED LIABILITY CO
Workplaces covered by this policy:
ST WP NO. ADDRESS OF WORKPLACE RTG.BUR NO.
MA 01 789 EAST ST 479544
MANSFIELD MA
AGENT NO 1710 OFFICE NO 1710
FRANCIS E BINGHAM
1408 PROVIDENCE HWY # 5-130
NORWOOD MA 02062-4652
781-255-2002
POLICY NO 2003W6255
RENEWAL OF NO. 2003W6255
EFFECTIVE 4/14116
INTRASTATE NO.
The policy period is from 4/14/16 to 4/14/47 12:01 A.M. Standard Time at the insured's mailing address.
-'.::::i::::....::::::::::i:-::::::::::i::::::::::::::::::::::i:::::i:i:::::�::i
ITEM;:3t;:;V�.:.:............................................................................................................. .........:.:.�::::::::::::::::::.:::.....:............................._...........................................................
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the state listed here: MA
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:
Bodily Injury By Accident Bodily InjurV By Disease Bodily Injury By Disease
$ 100,000 each accident $ 500,000 policy limit $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states
except the states designated in item 3.A. of the information page and ND, OH, WA, and WY
D. This policy includes these endorsements and schedules:
WC 00 00 00C WC 00 00 01B WC 00 03 15 WC 00 04 14 WC 00 04 22B WC 20 03 01
WC 20 03 02A WC 20 03 03D WC 20 04 05 WC 20 06 01A
-pyright 1987 National Council
Compensation Insurance
INSURED COPY
PROCESSED 02/26/16
00 00 01 B Issuing Office - PO Box 656 9 ALBANY, NEW YORK 12201-0656
Information and Instructions
Massachusetts General Lawn chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required,"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority,"
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. "1Vhere a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like, to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1 -877 -MASSA -FE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05