HomeMy WebLinkAboutRuby's Ice Cream 12/31/2018�y
Commonwealth 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: MOBILE ICE CREAM TRUCK
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 NIXON & DEBORAH HORNER
Whose place of business is:
RUBY'S ICE CREAM & FROZEN LEMONADE
152 ORNE STREET
PERSON(S) IN CHARGE:
Permit Expires: December 31, 2018
Food Fee: $75.00
License Number: MF-1
BOARD OF HEALTH
.Michae(.McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
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Permit Fee Approved By Permit #Issued
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: K') �
2) Establishment Address: L5 a Din e-
ST
3) Establishment Mailing Address (if different): 3
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Let Abel
4) Establishment Telephone No:
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5) Applicant/Owner Name & Title:
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6) Applicant/Owner Address: � �!E p1 %f1
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7) Applicant/Owner Telephone No: Jbs-,
8) Applicant/Owner Email address:
g) Person Directly Responsible For Onsite Operations:
Name & Title:
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Address:
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Telephone No:
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Fax: _
Emergency Telephone No:
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10) Event Attending
Date(s):
Event Name:
Event Location:
Event time:
11) Check one
i_ Food Truck
L Caterer ,�
5l Other:
12) Solid waste disposal plan::
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13) Water Source:
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14) Sewage disposal
plan:
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151 Please give a brief description of the food to be served:13
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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.
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Signature of Individual or orporate Name
a Z, P ` `�1L78�:
"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\sleile\Desktop\acotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc
The Commonwealth gfMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
GG
Phone #: 5D&.—S-S 9-a ) tO) S
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ElRestaurant/Bar/Eating Establishment
2. I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] A• ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have I0.❑ Manufacturing
no employees. [No workers' comp. insurance required]* l 1. ❑Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req,] 12.q Others
*Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, bat the corporation has other employees, a workers' compensation policy is required and such an
organization should check box M.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company N
Insurer's Address:
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 tine
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 and penalties of pet jury that the information providedabove is true and correct.
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 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone #:
wwwanass.gov/dia
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ATTLEBORO
BOARD OF HEALTH
NO: MF 434-18
This is to certify that:
Ruby's Ice Cream
Deborah Horner
32 Pratt Ln
North Attleboro, MA 02760
FEE: $ 250.00
IS HEREBY GRANTED A PERMIT FOR
Mobile Food & Frozen Desserts
This permit is granted in accordance with regulations promulgated under authority of Chapter
94, Section 305A and Chapter 111, Section 5 of the General Laws and remains in effect until the
expiration date unless sooner suspended or revoked.
LOCATION: North Attleboro, MA
REGISTRATION # T73-137
PERMIT ISSUED: May 3, 2018
PERMIT EXPIRES: April 30, 2019
Board of Health
SPECIAL STATE LICENSE
Hawker or Pedler
Licensee: Deborah A. Horner
32 Pratt Lane
lug No. Attleboro, MA 02760
4-24-19
Expires:................................................................ ..
10-9-1956
Date of Birth :................................
Above portion must be worn in a visible
and conspicuous manner on outer clothing.
Take care of your license.
Lost license will not be replaced.
Fee: $60.00
Display $2.00
mot (Qnmmanwrelth of filunm4unrtis
DIVISION OF STANDARDS
ONE ASHBURTON PLACE, BOSTON
Date .............4-25-1 8
........................
lit It known unto all to whom these presents come, that the above -named person is hereby
licensed to go about as a HAWKER or PEDLER in all the Cities and Towns in this Common-
wealth, and to sell or expose for sale or barter any meats, butter, cheese, fish, fruits, vegetables,
or other goods, wares or merchandise; except jewelry, furs, wines, spirituous liquors, small arti-
ficial flowers or miniature flags.
This license is not valid until after the licensee has endorsed his usual signature in the space
provided in the margin hereof, and the license is dated and stamped with the official stamp or
signature of the Director. The portion of the license indicating the license number, licensee's name
and the date of expiration must be worn in a visible and conspicuous manner on outer clothing,
otherwise he will be liable to the same penalty as if he had gp license:
......................... ...................... ......................................... i ..................
Direetor of Standards
THIS LICENSE IS NOT TRANSFERABLE
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