HomeMy WebLinkAboutBig Team Ice Cream 05/14/2016Commonwealth 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 FOOD PERMIT
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:.
RICHARD MCLAUGHLIN, OWNER
Whose place of business is:
BIG TEAM ICE CREAM
888 SOUTH MAIN STREET
PERSON(S) IN CHARGE:
RICHARD MCLAUGHLIN, OWNER
Permit Expires: May 14, 2016
License Number: T-136
Food Fee: $50.00
BOARD OF HEALTH
MichaeCvicCCean, Chairman
Minity TemporaryFood Establishment Permit_Application
(Applieafidn musf`be submitted at least 7 working idays before the planned event.)
1}. Establishment Riame: /(,- 72--/�,Pl
2} Establishment Address: �� S� <� �f/ �ii�q /,-J -S`% 1f9/vl�iLZ 0 .. Vii"% 2 4) 9 .
3) Establishment Mailing Address (if.different)-, �`j � � 6'x 2 3 'C -C 6 o ac) o! LZ70Y-1
4) Establishment Telephone. No:� G �'" . �C'. % - 7 S _r
5}- .Applicant .{carne: & Title: � L v. s' /-/Z-
-/Z, C
6) . AppitcantAd.dress::
6)
7) Applicant Telephone. Nix -7 S"_�' -Z4 Hour Emergency No.
8) ®urner.Name Title: (if different front applicant):
9) Owner Address (if different from applicant):
1 ) Establishment Owned By:1:4) if a: corporaf ,n be partnership, give hame; title,,and horns address of
6 An association officers or partner.
a A corporation Name Title H6hie Address
SA—n-iiA-ivig"du .'
• A partnots p
• Qtheriega{ entity.
12 Person irectl Res onsibie For Daily O erations. owner;, person in Charge, $u ery sor, Miina er etc.
Name&Title::.. ...
iCAq,rf� %�Ls l/E�%Zi C�GL�rVG7L- .
Address:
Tele hone No:.
--!5 ok des / - �� . Fax:
Eerier oil Tele Bane No:.
13 District or Regional qupewisor (ifappficabte)
Name :&Title:.
Address:
Tele hone No ..
Fax:
_,7 VD4PI21 w4l tui cv-F:uvc
MMITMort
14) Water Source:
2cy � /
15) Sewage disposal:
DEP Public Water Supply No: (if applicable)
,�C,y¢ %.� L� —Z 2-�.
16) Days and Hours of Operation:
W fU,v
17) No. of Food Employees:
18) Name of Person In Charge Certified in Food Protection Management:
e— //,q 0
Required as of 101112001in accordance
with 105 CMR 590.003(A) Please attach copy of cert ficate.
"P—
19) Person Trained In Anti -Choking Procedures (if 25 seats or more): 0 Yes
0 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)
c4�:lSjo„�
❑ Annual
❑ Seasonlal/D tes*
�"VX'SZ 20/(a
Tem porary/Datesrrime:
Definitions: PHF— potentially hazardous food(timeltemperature controls required)
23) Food Operations:
Rion-PHFs — non- potentially hazardous food (no timeltemperature controls required)
RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
(check all that apply):
Sale of Commercially Pre-
❑ PHF Cooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
Packaged Non-PHFs
for 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
t`iUr F'05 r„Lt-t S
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
for Retail Sale
Events or Institutional Food Service
Ll Otters K I t 1`1-11-m rsuiK �tuannnes
Other (Describe): 7o be completed by the Board of Health
❑ Retail Sale of Salvage, Out -of Date Total Permit Fee ($25 per day):
or 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. I have been instructed by the board
of health on how to obtain copies of 105 CMR 590.000 and federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 4 , 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: 'Y i —3-16 -ZleV_3
26) Signature of Individual or Corporate Name: -
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.
.g'lature of Individual or Corpora 'e Name
7 % — —m —/ e -i
"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\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
Business/Organization Name
Address:
City/State/Zip:
Z%o 'ie�•j 14 tie �11CH=AS,940
, m,d. 62-76-3 Phone #:
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, § l (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.]
52v- 0/ -_3 -7.cr
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
I1.❑ Health Care
12.❑ Other
'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 cam an employer that is providing workers' compensation insurance for nip employees. Below is the policy inforination.
Insurance Company Name:
Insurer's Address:
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 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 tine -pain enalties o r that the information provided above is trate and correct.
�• � �. �_--- Gate•
Phone #: J 6D 0— k�-V l
Official use only. Do not write in this area, to he 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: Phone #:
www.mass.gouwma
Gmail - Permission
Permission
2 messages
tsouza11@aol.com <tsouza 11 @aol.com>
To: BIGTEAMICECREAM@gmail.com
Page 1 of 1
Richard McLaughlin <bigteamicecream@gmail.com>
Wed, Apr 6, 2016 at 11:53 AM
To whom it may concern
This is to confirm that I am allowing Dick McLaughin of BIG TEAM ICE CREAM to park his concession
trailer on my property at 888 South Main Street, Mansfield, MA 02048 for May 14 and 15, 2016. Mr
McLaughlin understands that he will park at his own risk, will observe all local laws, and that I and my
companies assume no responsibility and will be held harmless for any and all activities and liabilities that
might occur during this timeframe. Please feel free to contact me if there are any questions.
Tom Souza
USA World Media
888 South Main Street
Mansfield, MA 02048
617®331®4463
Richard McLaughlin <bigteamicecream@gmail. com>
To: "tsouza11@aol.com" <tsouzal 1 @aol.com>
Thank you very much Tom
Sent from my iPhone
[Quoted text hidden]
Wed, Apr 6, 2016 at 11:57 AM
https://mail.google.com/maillu/2/?ui=2&ik=bd8l 6faa59&viev--pt&search=inbox&th=153 e... 4/6/2016
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The Commonwealth of Massachusettsl
City of • '• •
HEALTH DEPARTMENT
FOOD ESTABLISHMENT PERMIT
Establishment No. Permit No.
307-2016 307-2016
Establishment Big Team ice Cream
Name:
Location 210 Richardson Ave.
Seating Reg.#D26-869
Date Issued:
412512016
Sq Ft MOBILE FOOD
This permit is issued in conformity with the authority granted to the Health
Department, by Chapter III, Section 31, of the General Laws, and is subject to
the provisions of the Laws of the Commonwealth of Massachusetts relating
thereto, and upon such terms and conditions, and to the rules and regulations
in regard to the carrying on of the occupation so permitted as adopted by the
Attleboro Health Department
expires: f unless sooner revoked.
Alan D. PerryPrepackaomed Ice Cream
Health Agent
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SYNOPSIS OF LAW RELATIVE TO STATE LICENSES
Each pedler shall wear his license in a visible and conspicuous manner on his outer
clothing with the license number, licensee's name and date of expiration exposed to view.
Every person licensed to peddle shall endorse his usual signature upon his license.
The licensee shall produce his license for inspection when the same is demanded of him
by a mayor, alderman, selectman, director or inspector of standards or sealer of weights
and measures, city or town treasurer or clerk, constable, police officer or justice of the
peace, and if he fails or refuses so to do he shall be subject to the same penalty as if he had
no license.
Whoever counterfeits or forges a license, or has a counterfeited or forged license
in his possession with intent to utter or use the same as true, knowing it to be false or
counterfeit, and whoever attempts to sell under a license which has expired or has been
revoked or cancelled, or which has not been issued to hum, or has in his possession
another's license with intent to use the same, shall be punished by a fine not exceeding
one thousand dollars.
Whoever employs a minor in peddling without a permit or license if one is required,
or who, having the care or custody of such minor,permits him to engage in such em-
ployment, shall be punished by a fine of not more than two hundred- dollars or by im-
prisonment, for not more than six months.
No hawker or pedler, holding inn auctioneer's license, shall sell or ,expose for sale
by public auction any goods, wares or merchandise in any city or town other than that
from whose authorities such license was obtained; nor in any place in such city or
town not expressly described in said license. This license is subject to such local rules
and regulations as may be made in a city by the mayor and city council and in it town
by the selectmen.
The director and inspectors of standards of the Commonwealth and, within their
respective cities and towns,. sealers or deputy sealers of weights and measures, con-
stables and police officers shall arrest and prosecute every hawker and pedler whom
they may have -reason to believe guilty of violating the provisions of this chapter.
Any license granted by the director to a hawker or pedler may be revoked by him
upon conviction of • the licensee of any crime which, in the judgment of the director,
warrants such revocation; or upon the submission to the director of evidence satisfac-
tory to him that, during the term of the license, the licensee has accepted or solicited
money otherwise- than through the bona fide sale or barter of goods, wares or merchan-
dise, or has violated any provision of section 10A of chapter 264, as amended, or has
in any manner begged or solicited alms from the public, or for, any other sufficient
cause. Whenever any person is convicted of a violation of any provision of this chap-
ter, relative to hawkers and pedlers, or a person holding such a license is convicted
of any crime, the clerk of the court in which, or the trial justice by whom, such person
was convicted shall notify the director.
NUMBER FEE
HP1609 THE COMMONWEALTH OF MASSACHUSETTS $15.00
City.._._. of . Attleboro
Richard McLaughlin dba Big Team Ice Cream
Thisis to Certify that----------------------------------------------------------- ----------------------------------------------------------------------------------------------
NAME
210 Richardson Ave. Attleboro, MA 02703
---------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------
ADDRESS
For
IS HEREBY GRANTED A LICENSE
Permission to sell Ice Cream on the streets of Attleboro
'-'iNO LICENSE SHALL OPERATE IN ATTLEBORO BEFORE 9AM OR AFTER 7P1Lt,-*
This license is granted in conformity with the Statutes and ordinances relating thereto, and
April 7, 2017
expires..............:............__-__-__.---____-______---__-______-_____--__-__________-.___-___ unless sooner suspended or revolted.
Granted: 4/5/2016'
Approved: 4/7/2016 ---------- -------------- � � . --- ---- --------------------------------
--------- -------------------------------------------- ._._.....
---April--- 1--------------------------------- 20._16 ------- .-Stephen --- K- ---WI-t;.hers- G-ty.--C-1-er�C--------------------
----------- ------
FORM 433 A.M. SULKIN GO. -CHARLESTOWN, MA
NUMBER FEE
RB1610 THE COMMONWEALTH OF MASSACHUSETTS n C
City Attleboro
------------------------- of --------------------- --------- ....---------------------------------
Richard McI.,aughli.n dba Big Team Ice Cream
Thisis to Certify that--------------------------------------------------------------------------- -------------------------------------------------
NANfE
210 Richardson Ave. Attleboro, MA 02703
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ADDRESS
IS HEREBY GRANTED A. LICENSE
For permission to ring a bell to sell ice cream on Attleboro streets
-- - - --------------------------------------------------------------.............
This license is granted in conformity with the Statutes and ordinances relating thereto, and
April 7, 2017 ----------------- unless sooner suspended or revoked.
expires ..................l - - --1 - p
Granted: 4/5/2016
Approved: 4/7/2016 - --'� n :, i'
April 11 16 ------------------------------ ` -- -------- . _ --
------------------------ ---
.............................•---------------------•-------- 20--------- ----------------------------------------- -------------------------------------------------- ---------------------------
---- Stepbjn...K......Ili.theta-.---Cil--y.---�zerk-----------------------
FORM 433 A.M. SULKIN CO. - CHARLESTOWN, MA