HomeMy WebLinkAboutAnnie B's Honey Farm 4/17/2016Commonwealth 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 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:.
ANNETTE BIRMAN, OWNER
Whose place of business is:
ANNIE B'S HONEY FARM LLC - NEFFA
MANSFIELD SCHOOL COMPLEX - EAST STREET
PERSON(S) IN CHARGE
ANNETTE BIRMAN, OWNER
Permit Expires: April 17, 2016
License Number: T-2
Food Fee: WAIVED
BOARD OF HEALTH
AichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Al --
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must he submitted at least 7 days prior to planned event)
1) Establishment Name: `
2) Establishment Address , Ci c -� %i , �V �� C-� 1 ) -(- 1�� (Oy-
—
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
5) Applicant Name & Title: ,
6) Applicant Addresscu
7) Applicant Telephone No.: 24 Hour Emergency No.:
8) Owners Name & Title
g) Owner Address (if different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
Cl A Corporation
Name Title Address
An Individual
11 A Partnership
O Other legal Entity
--� - -
12) Person Directly Responsible For Daily Operations (owner, person in cnarge, supervisor, manager eic.)
Name & Title:
Address: n� 1
Telephone No: (fi t _ (k 1 24 Hour Emergency No:
FAX:
- ---- E-mail: n n rl
_T Alt E -Mail: u � -(
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
24 Hour Emergency No:
Food Establishment Information
5} SEWAGE DISPOSAL:/jr"
-
14) WATER SOURCE: 1DEP Public Water Supply No: (If applicable) I" 1 7 16} No. of Food Employees:
- - -- - -- ---- --.—._.. - - ---._.._.--
17) DAYS/HOURS:
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 Seals or more):
20) location: ❑ Permanent Location 22) Establishment Type
Mobile Mobile Start Date: ❑ Retail ( Sq. Ft)
Mobile End Date: ❑ Food Service up to 100 or
Mobile Comments: up to 10' PHF display $75
21) Length of Permit:
❑ Annual
❑ Seasonal
Seasonal Dates:
1 Temporary /�
Temporary Start Date: AV6 �
Temporary End Date: A'rr
Temporary Time:
Rain Date:
❑ Food Service up to 101 -200
or up to 25' PHF display $100
❑ Food Service up to 201 +
or 25'+ PHF display $125
❑ Food Service - Institution
Meals/Day)
❑ Caterer $25
❑ Milk & Cream $2
❑ Mobile Food & Consession $50
❑ Mobile Food Temporary $25
Manufacture Frozen Desserts/ice Cream
$5/freezer
❑ Pushcart $25
❑ Residential Kitchen $25
❑Retail Food $5D of Pushcarts:
❑ Retail Snack Food $10
(] Tobacco Products No Fee
23} Food Operations t?efinillons: PHF- Potentially hazardous rood (limeAemperalure controls required)
Non•PHF's - non•potentiolly hazardous tood(no time/temparature controls required)
;Check all that apply): RTE- ready -to -oat foods (Ex. sandvdches, salads, muffinswhich need no further processing)
❑ Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order U Hot PHF Cooked and Cooled or Hot Heid
El Sale of Commercially Pre Packaged PHFs E] Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
ry g -• Susceptible Population Facility
------•-- -- ❑ Sale of Raw Animal Foods Into
❑ Reheating of Commercially to be Prepared by Consumer Ej Vacuum Packaging) Cook Chill
Processed Foods for Service Within A Hours
❑ Use of Process Requiring A Variance
Ej Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service and/or HACCP Plan (including bare hand
Perishable Foods Only - contact alternative, time as a public health
_ _ ❑ Ice Manufactured and Packaged for
Q Preparation of Non-PHFsm Retail Sale- - control)
Other Food Operations I ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities ❑ 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:
Payment is due with application ❑waived
1, 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 CMR 540.000 andAie federal Food Code.
24) Signature of Applicant: >> y//
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, 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: ? )
26) Signature of Individual or Corporate Name:�i7� Jot 0 A
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 (Mandatory)
By: Corpora e Officer ez
(Mandatory, if applicable)
q& 3624? X00
** 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.
Mansfield Board of Health Date
w
Food ,Service Permit Fee for the following reason
Thank you,
request a waiver of the
Title
FOR BOARD OF HEALTH USE ONLY
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: ` i5 � �/YJ
�� C
2) Establishment Address: /'S C
v f j1
3) Establishment Mailing Address (if different)Q
Fax:
4) Establishment Telephone No: A
5) Applicant Name & Title: zj
6) Applicant Address:
7) Applicant Telephone No.: V6(1,/,W4 Hour Emergency No.: 5 —
S�Ov`�S(o /�'' `7C, 4
8) Owner Name & Title (if different from applicant):
-e rPres j 4 „eli
9) Owner Address (if different from. applicant): U d 0)'�
10) Establishment Owned By: 1111) If; corporation or p rtnership, given mei, title, and home address of
&A --officers or partner. I'M 04Q 4 e �'-
An Association
A Corporation
An Individual
A Partnership
Other legal entity L L G
12 Person Directly Responsible For Daily OperationsOwner, person in charge, Supervisor, Manager, etc.)
Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No:
g44 -e#-( 1jsrMctn- Own -el'
S lq---! cer lccf Sk_ e (u m b -el- 1 ,? ,? d,
Iry l- YC(3
13 District Or Re Tonal Supervisor (if applicable)
Name & Title.-
Address:
itle:Address:
Telephone No: Fax:
Food Establishment Information
-
14.) Water Source n /
15) Sewage Disposal „
��
DEP Public Water Supply No: (if applicable):
16) Days and Hours of Operation:
17) No. of Food Employees 021-
i/18)
18)Name of Person In Charge Certified in Food Protection Management:
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:
22) Establishment Type:
Caterer 141119—
Retail ( Sq. Ft)
Food Delivery
Food Service – ( ) Seats
Residential Kitchen for Retail Sale
Permanent
KV-VW-3XG9
Food Service - Institution
( Meals/Day) „ /
Residential Kitchen for Bed & Breakfast Home
Residential Kitchen for Bed & Breakfast
Mobile (Dat
/(//�/
Establishment
/
Frozen Dessert Manufacturer
Other (Describe)
21) Length Of Permit:
(check one)
Annual
Gl
Seasonal/Dates
�7 &h V v I
Temporary/Dates/Times
23) Food Operations:
Definitions: PHF — Potentially hazardous food (time/temperature controls required)
(check all that apply):
Non-PHF's — 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
PHFCooked To Order
Hot PHF Cooked and Cooled or Hot Held for
Non -PRFs
More Than a Single Meal Service
Sale of Commercially Pre-
Preparation Of PRFs For Hot And cold
PHF and RTE Foods Prepared For Highly
Packaged PHFs
Holding For Single Meal Service
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended to be
Vacuum Packaging/Cook Chill
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 PHF
Ice Manufactured and Packaged for Retail
Offers Raw Or undercooked Food Of Animal
and Non -Perishable Foods
Sale
Origin
Only.
Preparation of Non-PHFs
Juice Manufactured and packaged for
Prepares Food/Single Meals for Catered Events
Retail Sale
or institutional Food Service
Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date or
Reconditioned Food
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 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
returns and paid state taxes required under law.
25) Social Security Number or Federal ID: j'�/" Y�, f � V L4- U =)—o o
26) Signature of Individual or Corporate Name: &4,"( 1315 A/v 4-e K /�/,� �—L C—
BLANK FOOD PERMIT APPLICATION
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.
ignature of Individual or
Corporate Name (Mandatory)
aze� 1L-- D -
Corporate Officer
(Mandatory, if applicable)
** 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.
MassTaxConnect Page 1 of 1
Mass.;,
0 2016 Commonwealth of Massachusetts ( Site Policies I Web Browsers
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CONNECT
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SALES TAX
NAMES AND ADDRESSES
I WANTTO... Profile Accounts
MENU Lr� 0P
Federal Employer ID
01-0861177 Legal Name ANNETTE K BIRMAN
Make an EFT Debit Payment
Quarterly SLS -10988685.003 DBA Name ANNIE B'S FARM
Make a Credit Card Payment
Home
Balance
$0.00 Location Address 15 ALASKA ST CUMBERLAND RI 02864 File a Dispute
Print ACH Credit Layout
Pending Transactions
$0.00 Legal Address 15 ALASKA ST CUMBERLAND RI 02864
Back
Payment Source
Citizens Bank Mailing Address
NAViGATION
Ft as ACTIVITY E -MESSAGES
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PERIODS FROM 09 -FEB -2014
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0 2016 Commonwealth of Massachusetts ( Site Policies I Web Browsers
https://mtc.dor.state.ma.us/mtc/,/ 2/9/2016
www.annieusfarin.com
F
. k
Maswchusefts Department Of Revenue ST-It
R Customer Service Bureau
PO BOX 7010
Boston, MA 02204-
-
The vendor henfn named is �edtesell tangible persona} P dYst n ori n ate; pursuant is the General
Laws, Chapters 62C, 64H and 641. This mosiraiion is diect only for -the registrant at-the location speafied herein.
Any change of name or address must be reported to the Department of Revenue so that a correct ST 1 can be issued.
- - - " ir�mRenztorr
— - 018-861-177 "UBM
ANPiIi I r K - BIRMAN
ANNIE $' S ;ARi�i - Hoare
IB ALASKA STREET
rd !' in ... .
CUMOMMAM _ = RI 42964
BAL --
-m� it g hart idttlst �4d"dd foirstorners-to see arid- not assign ileor transferable_
---- _ _ - - -- - - - -- - cOMMISSIONER OF REVENUE
i'
f
t
is
F
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w;
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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: V1 t 6(%�) L` L C-
Address: I S rtg s ) u, e -e �-
ej
City/State/Zip: , �t �J �' /-A Cr' Phone #: U -Yy I —�)jA t 3
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with U employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity.
3. d[No workers' comp. insurance required]
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.]
Bus
me 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
11.❑ 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 am an employer that is providing workers' compensation in uranc or my employees. Below is re policy information.
Insurance Company Name: A .Q � 1_5 �L l'% Gj y' A eq .-/ f
Insurer's Address: �/ %%%i/ {' 5 LA_A,(� ral"M _P0 %,6p i— / ✓ /T��C J �L ��
City/State/Zip:
Policy # or Self -ins. Lic. # Expiration Date:u�
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.
Simature: /Za t I ,
- YPJ) --
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
Contact Person:
Permit/License #
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
www.mass.gov/dia
Phone #:
OP ID: CG
C' CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
09/17/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Pro Insur,inc. dba
Campbell Risk Management
9595 Whitley Drive, Suite 204
Indianapolis, IN 46240
Larry Spiiker ext 203
CONTACT Lar S liker ext. 203
NAME:
FAX
PHONE 317-848-9075 c No): 317-848-9093.
A/C No Ext
E-MAIL SS: Ispilker@campbelirisk.com
PRODUCER
CUSTOME IDa:ANNET-1
INSURERS) AFFORDING COVERAGE NAIC #
INSURED ANNETTE K BIRMAN
P O BOX 7821
CUMBERLAND, RI 02862
INSURER A:The Hartford 29424
INSURER B
INSURER C
INSURER D:
INSURER E:
INSURER F
rnvconr_cc CFRTIFIRATF NIIMRFR• REVISION NUMHEH:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
SUBRI
POLICY NUMBER
POLICY EFF
MM/DD
POLICY EXP
MMIDQIYYYY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
AAI DAMIEREN� 1 000 000
PREMISES Ea occurrence $ > >
A
X COMMERCIAL GENERAL LIABILITY
X
36SBM 808041
08/31/2015
08/31/2016
MED EXP (Any one person) $ 10,000
CLAIMS -MADE ® OCCUR
PERSONAL &ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
$
X POLICY FRO LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
HIRED AUTOS
I
PROPERTY DAMAGE
(PER ACCIDENT) $
$
NON -OWNED AUTOS
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIAB
CLAIMS MADE
DEDUCTIBLE
$
$
RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY y/N
ANY PROPRIETORIPARTNER/EXECUTIVE❑
OTR
WC STATU- JH
TORY LIMITS ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
N/A
E.L. DISEASE -POLICY LIMIT $
If yes, describe under
DESCRIPTION OF OPERATIONS below
DESCRIPTION / LOCATIONS /VEHICLES (Attach ACORD 1101 Additional Remarks Schedule if more space is required)
�O' F OPERATIONS
D ZONAL INSURED PER B ANKET ADDITIONAL INSIURED
COVERAGE FORMS 0ADDITIONAL
I
r'c CTIRICATR Erol nFR CANCELLATION
FESTGAR
—
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
Food And Drugs
C TER 21-27
Sanitation in Food Establishments
SECTION 21-27-6
§ 21-27-6 Businesses exempt. — The provisions of this chapter shall not apply to those activities of food business
which are licensed and regulated in accordance with the provisions of this title; provided, that retail food businesses
and food vending machines limited solely to selling or dispensing ice and/or non-perishable foods, including, but not
limited to, gumballs, unopened bottled or canned beverages, and prepackaged candy, nuts, gum, popcorn, chips, .
pretzels, cookies, and crackers. Honey producers who are registered with the state are exempt from the provisions of
this chapter.
History of Section.
(G.L. 1938, ch. 260, § 6; P.L. 1948, ch. 2026, § 1; G.L. 1956, § 21-27-6; impl. am. P.L._ 1962, ch. 80, § 5; P.L. 1984,
ch. 51, § 1; P.L. 1986, ch. 237, § 1; P.L. 1986, ch. 276, § 1; P.L. 1995, ch. 55, § 1.)
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2/10/2016
To: Scott Leite-Health Department
6 Park Row
Mansfield, MA 02018
From: Annie B's Honey Farm, LLC
Annette Birman
PO Box 7821
Cumberland, RI 02864
Subject: NEFFA Event April 15-16-17
Dear Scott,
Enclosed is all documentation I received from you and fiom another e-mail.
Honey is considered a natural herb in the state of MA.,RI and numerous other states as
well in New England
Please find the following:
*Insurance
*State tax ID
*EIN Number
*Forms filled out
*Chapter 21 guidelines
If there is anything else that you would need please let me know before March 29th.
As I will be out of state until April 14th.
I look forward to working with you for this event as we did last year.
Warmest Regards, Annette Birman,PO Box 78/21
Cumberland RI 02864,cell-401-481-8293
e-mail-anniebshoney@gmail.com