HomeMy WebLinkAboutCold Stone Creamery 12/31/2018Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishment
Type: FOOD SERVICE 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:.
ASHWANI RATHOR
Whose place of business is:
COLD STONE CREAMERY
280 SCHOOL STREET
PERSON(S) IN CHARGE:
ASHWANI RATHOR
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-12
BOARD OF HEALTH
MichaeCMcCCean, Chairman
Milk & Cream W
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
ASHWANI RATHOR
having a place of business at:
COLD STONE CREAMERY
280 SCHOOL 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 1213112018 , unless previous to that time is suspended or revoked.
Expires 1213112018
License No.: FS-12
Board of Health
MichaeCMcCCean, Chairman
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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
COLD STONE CREAMERY
280 SCHOOL STREET
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-12
Freezers: 1
TOTAL: $25.00
MANSFIELD BOARD OF HEALTH
MichaeC,%icCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS12
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name COLD STONE CREAMERY
2) Establishment Address 280 SCHOOL STREET
3) Establishment Mailing Address (if different) 280 SCHOOL STREET
MANSFIELD, MA 02048
4) Establishment Telephone No
5) Applicant Name & Title: SweeT TOOTH LLC
6) Applicant Address -11 WHITE OAK WAY, NORTH ATTLEBORO, MA 02760
7) Applicant Telephone No.: (508) 598-8841 24 Hour Emergency No.: (508) 598-8841 (508) 826-3893
8) Owners Name & Title ASHWANI RATHOR
9) Owner Address (If different from applicant) 11 WHITE OAK WAY, NORTH ATTLEBORO, 02760
Owner's telephone number 5085988841
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
I An Association or partner.
A Corporation Name Title Address
An Individual
V A Partnership
Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: IASHWANI RATHOR
Address: 11 WHITE OAK WAY, NORTH ATTLEBORO, 02760
Telephone No: I(508) 598-8841 24 Hour Emergency No: (508) 598-8841 (508) 826.3893
E-mail: ICOUDSTONEMA#SFIE DOGMAI"
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
24 Hour Emergency No:
-
E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 16) NO. of Food Employees:
17) DAYS/HOURS:
18) Name of Person In Charge Certified in Food Protection Management: ASHWANI RATHOR
If more than 3 individuals are certified, complete list is on file.
Required as of 101112001 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: i, Permanent Location 22) Establishment Type
j-..I Mobile Mobile Start Date: E ] Retail ( Sq. Ft)
Mobile End Date: iV Food Service u to 100 or
Moblie Comments:
21) Length of Permit:
V/ Annual
_ 1 Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
P
up to 10' PHF display $125.00
MEENAKSHIRATHORE
Caterer $25.00
Milk & Cream $10.00
-.. ] Mobile Food & Consession $75.00
Manufacture Frozen Desserts/Ice Cream
❑ Food Service up to 101 -200 -- $25.00/freezer
or up to 25' PHF display $150.00
Food Service up to 201 +
or 25'+ PHF display $275+00
❑ Food Service - Institution
( Meals/Day)
Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
!. Retail Food $100.00
❑ Retail Snack Food $25.00
[i Tobacco Products $25.00
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required)
Non-PHF' 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
!I_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
'I 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
Other Food Operations [ Juice Manufactured and Packaged for''! i. _'; Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
f ] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
_ Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date i
! or Reconditioned Food To be completed by the Board of Health
--- ---- - -- ! Total Permit Fee: $125.00
Payment is due with application L ! 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 1,t{05 CMR 590.000 and the federal Food Code.
V4) Signature of Applicant: �-i� `
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: 81-4511843
lr 26) Signature of Individual or Corporate Name: •�l.A--e-%��-'';�----i
Jane Doucette
From: Coldstone Mansfield <coldstonemansfieldma@gmail.com>
Sent: Tuesday, December 19, 2017 12:14 PM
To: Jane Doucette
Subject: Fwd: 2018 License Renewal -Town of Mansfield Coldstone Creamary
Attachments: BOP_2018.pdf, ATT00001.htm
Jane,
Please let me know if this the info needed for renewal.
Thanks
Ash
Sent from my iPhone
Begin forwarded message:
From: Coldstone Mansfield <coldstonemansfieldma a gmail.com>
Date: December 17, 2017 at 8:19:36 AM EST
To: adpalmer@mansfieldnia.com
mansfieldma.com
Subject: Fwd: 2018 License Renewal -Town of Mansfield Coldstone Creamary
Amy,
My wife had dropped paper work and check for renewing milk license for our store "280 School
Street, D 160, Mansfield" for coldstone creamery (ice cream store). Please find the attached
worker comp policy.
Please let me know when can we pickup our license.
Thanks,
Ash
---------- Forwarded message ----------
From: Coldstone Mansfield <coldstonemansfieldmaL&gmail.com>
Date: Mon, Dec 11, 2017 at 1:20 PM
Subject: Re: 2018 License Renewal -Town of Mansfield
To: Carrie Champagne <cchampa ne r mansfieldma.com>
Carrie,
Please find the copy of updated policy.
Thanks
Ash
Sent from my iPhone
On Dec 11, 2017, at 6:44 PM, Carrie Champagne <cchampapne(2mansfieldma.com> wrote:
Thank you very much for this paperwork ... I also will need a copy of the insurance
certificate verifying the Workers Comp coverage.
From: Coldstone Mansfield [mailto:coldstonemansfieldmaC,aamail.com]
Sent: Sunday, December 10, 2017 7:41 AM
To: Carrie Champagne; Coldstone Mansfield
Subject: Re: 2018 License Renewal -Town of Mansfield
Carrie,
Attached is the application form for renewal of our renewal. I will have my wife
drop the check for $50 by tomorrow.
Please let me know if additional documents are required.
Thanks,
NXIII
On Mon, Dec 4, 2017 at 12:39 PM, Carrie Champagne
<cchamPaagne@mansfieldma.com> wrote:
Good Afternoon,
Please find attached the renewal information that needs to be completed as soon
as possible. The last possible day to submit is December Ut".
Thank you
Carrie
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 December 31st of each year.
NAME OF BUSINESS: COLD STONE CREAMERY
ADDRESS: 280 SCHOOL STREET
TELEPHONE AT LOCATION
FAX NUMBER:
139 � 11 2-'31w
OWNER OF BUSINESS: ASHWANI RATHOR
TELEPHONE OF OWNER: 5085988841
FEDERAL ID/SS NUMBER: 81-4511843
FEE: $10.00
PERMIT NUMBER: FS-12
SIGNATURE:
DATE: I� I I I I� 01 1
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
Application for License to Manufacture Frozen Desserts and/or lee Cream Mix
To the Board gl wealth at the Town of Xfaus/ elcl:
In accordance with the provisions of.section 65H ofChapter 94 r f the General Laws, as most recently amended, and
the regulations made thereunder, the undersigned hereby appilesfor a licensefor a 111HOLESALEIRET411,
nrungfiwture gff-o�en desserts and ice cream mix and .submits thefotou-ing inlornuation:
1. Full name of applicant: COLD STONE CREAMERY
2. Business address 280 SCHOOL STREET
MANSFIELD, MA 02048
3. Ifapp(icant is an indiviclual: Fuli name: SWEETTOOTH LLC
Residence: 11 WHITE OAK WAY, NORTH ATTLEBORO, MA 02760
3a. if applicant is a partnership, fill name mrd residence of cdl partners:
3h. If(tl)plicnnt is a corprn ation: State of incorporation: MA
Date of incorporation: 11/23/2016
Principal office: Heel sTt3 ( r O1"I L, c
PSd(nmute and address gf : P
President
Treasurer:
Clerk:
, 4. Location of Plants: -
5. Nornes of brunds and trade or corporation name, ifmrv, under which the products are to be sold:
6. Number and capacity gfli'eesers andfees: 1 Fee: ($25.00 per freezer) $ 25
>�'7. Is the mix purchased?y � 5 / m ek llso, from of horn purchased?
>,(8. Is the mix pasteurized.' yes
,V-9. Number of gallons gffosen desserts and/or ice crearn rnir to be sold in Afassachu.sens dw�ing the licensing
period Y)6,i � j '
�1 //. �� unrher of gallons nI Jir_en de sserrs <md'i�r ire cream mir soft in :4las.rruha.mtl.+' during (he previous licensing period
1. rs the plant conso ucted and equipped as provided in the regulations? -� J
rf 12, is the water supply public or not.'-....--
03. Have you received a copy of the regulations? ��-
I hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all raw 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 santtary condiPtons. I attest that the information stated
in this application is true and accurate under the pains and penalties ofpeijury.
(Company owner/officer's signature) (DATE)
(� ctNY�gg i t n �f e
(Title) l (City or Town)
TAX CERTIFICATION FORM
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
z -
**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.
R:IFIealthVands Doo=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents
- 1 Congress Streef, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: t.z7Ce 00 (A 1, L
Address: - t�J�11{2 uGsf-�' No Ott Iehti(o fl)86 140
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
L ❑ I am a employer with �_ employees (fell and/
or part-time).*
2.0 I am a sole proprietor or parbiership 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.]
applicant that checks box #1 must also fill out the sccdon below
Business Type (required):
5. ❑ Retail
6. URtstaurant/Bar/EatingEstablishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
S. ❑ Non-profit
9. ❑ Entertainment
10. ❑ Manufacturing
11. ❑ Health Care
12°❑ Other
Policy infonnadon.
k4If the eurpom[e officers bave cxempted thcrosclves, but the mrporabon has DNMr employces, a worxerscompensauou pomy a requveo sca soon au
organization should check box C.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informaadon.
Insurance Company Name: "'
Insurer's
City/State/Zip: ;y rry
Policy# or Self -ins. Lic. # U 6o C4 Q } 3 C, ,> 7-7 q Expiration Date: / 6 / t
Attach acopy of the workers' compensation policy declaration page (sbowing 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 firm
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.
[do hereby certify, under the pains annd�penaldes ofperjury that the information provided above is true and correct
Signature: \ � "Y "t Date: I a ) ) f ) 1-7
a
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 Z. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
TRAVELERS WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTPORD CT 06163 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: UB-OJ368779-18-.42-G
RENEWAL OF (UB-OJ368779-17-42-G)
INSURER: TRAVELERS CASUALTY AND SURETY COMPANY
1 NCCI CO CODE: 11223
INSURED: PRODUCER:
SWEET TOOTH, LLC HYLANT GROUP INC
DBACOLD-=STONE"CREAMERY 811 MADISON AVE
11 WHITE OAR WAY TOLEDO, OH 43604-5684
NORTH ATTLEBORO, MA 02760
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policyperiod is from 01-01-18 to 01-01-19 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
Rem 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1,000,000 Each Accident
Bodily Injury by Disease: $ 1,000,000 Policy Limit
Bodily Injury by Disease: $ 1, 000, 000 Each Employee
C. OTHER STATES INSURANCE: PartThree of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC WE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF
- EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY
DATE OFISSUE: 11-21-17 SD
OFFICE: CLEVELAND ON 042
PRODUCER: HYLANT GROUP INC DHL20
009016
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