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Home My WebLink AboutBig Team Ice Cream 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 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 Whose place of business is: BIG TEAM ICE CREAM - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE RICHARD MCLAUGHLIN Permit Expires: April 17, 2016 License Number: T-1 Food Fee: $75.00 BOARD OF HEALTH wlichaeCMcCCean, Chairman r 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: BI 7,6--19 ' C A /"L 2) Establishment Address: Z 10 4; �-� ' ;cr / t3 s A-%-(Ltrhe) ev-C) _ 3) Establishment Mailing Address (if different) / P �� Am-L� t14/-1 .- ��Z- j to 4) Establishment Telephone No: 5) Applicant Name &Title: -C L)(:,jIV\i \j e 6) Applicant Address: / 0 G 94 C0 A UE L 76 , j 7) Applicant Telephone No.. 3 24 Hour Emergency No.: 6 i — 3 � J 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: ❑ An Association ❑ A Corporation JWAn Individual ❑ A Partnership ❑ Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. 47\ 0-- ni-o..fl.. D—nnneihlo P— Il�ily r)--finne fr)%Aincr ncrenn in rhnrna Simaniienr Mananar Mr- 1 Name & Title: W, e- /"CL /Ij Address: 2/�i /IG !y""'I 2 �S�r� i� �% �� CLQ i !/Vl li 2 7,6 Telephone No:� - Fax: Emergency Telephone No:� 13 District Or Regional Supervisor if applicable Name & Title: Address: Telephone No: Fax: BLANK FOOD PERMIT APPLICATION Food Establishment Information 14.) Water Source >�2.7i9�� G'°��i!�'�-- 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: 'TiCif iA r>P G`4l`l AD6, kZ4 °i Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach co of certificate 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): 20) Location: 22) Establishment Type: ❑ Caterer ❑ Retail ( Sq. Ft) ❑ Food Delivery ❑ Food Service — ( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Permanent) ElFood Service - Institution El Residential Kitchen for Bed & Breakfast Home Mobile (Dates) 41f r Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment 'Frozen Dessert Manufacturer Other (Describe) 1�� 21) Length Of Permit:iLL��-•Its (check one) r_1 Annual ❑Seasonal/Dates ❑ Temporary/Dates/Times 23) Food Operations: Definitions: PHF — Potentially hazardous food (time/temperature controls required) (check all that apply): 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- ❑ PHFCooked 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 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 ❑ Vacuum Packaging/Cook Chill 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 for ❑ Prepares Food/Single Meals for Catered Retail Sale Events or institutional Food Service Other (Describe): ❑ Offers RTE PHF in Bulk Quantities 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 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: -9-7 _ J5 t 9 z4 3 q'3 26) Signature of Individual or Corporate Name: 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. Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number Z/7 * 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. 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) By: Corporate Officer (Mandatory, if applicable) `17- /z? ** 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. 0011rs } MASSACHUSETTS DEPARTNIENT 6F REVENUE Letter ID: L0503058432 PO BOX 7044 Notice Date: February 11, 2016 s BOSTON, MA 02204 Case ID: 0-000-092-243 CONTACT CENTER ffc,°Ff (617) 887-6367 CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE RICHARD R MCLAUGHLIN 210 RICHARDSON AVE ATTLEBORO MA 02703-1222 Why did you receive this notice? The Commissioner of Revenue certifies that, as of the date of this certificate, RICHARD MCLAUGHLIN is in compliance with its tax obligations under Chapter 62C of the Massachusetts General Laws. This certificate doesn't certify that the taxpayer is compliant in taxes such as unemployment insurance administered by agencies other than the Department of Revenue, or taxes under any other provisions of law. This is not a waiver of lien issued under Chapter 62C, section 52 of the Massachusetts General Where can you find additional information? Visit our website at mass.gov/dor for one-stop access to taxpayer information. You can learn more about state tax laws and DOR policies and procedures, including your Taxpayer Bill of Rights and the appeals process. You can file your returns, make payments and manage your account at mass.gov/masstaxconnect. You may also contact us by phone at (617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 9:00 a.m. to 5:00 p.m. Charlene Hannaford Acting Deputy Colmnissioner 1 ne L omrnonweaun of Ivlassaenuseus Department of Industrial Accidents Office oflnvestigtetions 600 Washington Street Boston, MA 02111 Uf www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: B g; J l" _,T -C- ,:� C CCA6t Address: j /c lli au),, io ri 4 t/ _ City/State/Zip: d 0 %yL L a � 1,% 1 �° Phone #: �� ®'S 4� S Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2.0 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. ❑ 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 run an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Addre 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 certify, under the painsanr Ities ofperjury that the information provided above is true and correct. 6-e)ke, > `_3-,SS� 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 #: J r= V J U 75 `� o W N o Z C3 .t 0 0 Rq Q� z z c/1 W W P4 3 z w w R ok Z 0 b J v N x c� D �o MI -M J -C U XAU P4 a 0°° ti a NV tUC M N Q 2 N N O N H �i � a a a� o a� CIS 1.4 Cd U Q ``G' \17��c7� �G��, �ch��c��`G�\, ��,�� G��. ��'c�� G�"�.�►��C� ;�f.�,��c�� 0 b v N O Low i. �o MI -M -C XAU P4 a 0°° ti � tUC M H N M H �i ``G' \17��c7� �G��, �ch��c��`G�\, ��,�� G��. ��'c�� G�"�.�►��C� ;�f.�,��c�� 0 12, O ti � H �i ``G' \17��c7� �G��, �ch��c��`G�\, ��,�� G��. ��'c�� G�"�.�►��C� ;�f.�,��c�� Commonwealth 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:. NANCY GOODALL, OWNER Whose place of business is: DBA THE COD SQUAD/CAPTAIN MARDEN'S SEAFOODS - NEFFA MANSFIELD SCHOOL COMPLEX - EAST STREET PERSON(S) IN CHARGE KEITH MARDEN, PRESIDENT Permit Expires: April 17, 2016 License Number: T-77 Food Fee: $75.00 BOARD OF HEALTH NichaeCNcCCean, Chairman