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Home My WebLink AboutOrange Leaf Frozen Yogurt 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:. MARIO COSTA Whose place of business is: ORANGE LEAF FROZEN YOGURT 321 SCHOOL STREET, UNIT A-120 PERSON(S) IN CHARGE: DEBRA FITZSIMMONS Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-72 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream O o Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream l This is to certify that., MARIO COSTA having a place of business at: ORANGE LEAF FROZEN YOGURT 321 SCHOOL STREET, UNIT A-120 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-72 Board of Health 3V1ichae[NcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Manufacture Frozen Desserts and/or Ice Cream Mix i 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 ORANGE LEAF FROZEN YOGURT 321 SCHOOL STREET, UNIT A-120 a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This license expires December 31 st of each year. License Number: FS-72 Freezers: 8 TOTAL: $200.00 MANSFIELD BOARD OF HEALTH MichaeCMcCCean, Chairman l.i FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS72 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name ORANGE LEAF FROZEN YOGURT 2) Establishment Address 321 SCHOOL STREET, UNIT A-120 3) Establishment Mailing Address (if different) 66 FAIRFIELD CIRCLE 0 k!" NORWOOD, MA 02062 t 4) Establishment Telephone No (508) 339-9020 5) Applicant Name & Title: MARIO COSTA, OWNER 6) Applicant Address 66 FAIRFIELD CIRCLE, NORWOOD, MA 02062 7) Applicant Telephone No.: (781) 769-2426 8) Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. C A Corporation Name Title Address i I An Individual A Partnership 24 Hour Emergency No.: (781) 640-1056 MARIO COSTA 66 FAIRFIELD CIRCLE, NORWOOD, MA 02062 (781) 769-2425 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IDEBRA FITZSIMMONS Address: I53 HEMLOCK STREET, NORWOOD, MA 02062 Telephone No: I(617) 771-7662 FAX: E-mail. CNCYOGURT(a@GMAIL.COM -- Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: I Telephone No FAX: E-mail: 24 Hour Emergency No: (781) 640-1055 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 10-15 17) DAYS/HOURS: SUN-THURS 11:00 AM - 10:00 PM FRI-SAT 11:00 AM - 11:00 PM 18) Name of Person In Charge Certified in Food Protection Management: DEBRA A. FITZSIMMONS 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 119) Person Trained in Anti -Choking Procedures (If 25 Seats or more) i] 20) Location: [] Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: [] Annual Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type �._] Retail ( Sq. Ft) EV:! Food Service up to 100 or up to 10' PHF display $125.00 ❑ I Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service -Institution ( Meals/Day) ❑ Caterer $25.00 W Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 �] Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 [] Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF - Potentially hazardous food (tlmeRemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) ;Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) I. ] Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ------------— ----- --- [] Sale of Commercially Pre -Packaged PHFs —-------------- ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service [] PHF and RTE Foods Prepared For Highly ry o - Packaged P -- — - Delivery of Packaged PHFs - - ----- -- ----- - -- --- - ❑Sale of Raw Animal Foods Intended Susceptible Population Facility ❑ Reheating of Commercially to be Prepared by Consumer �� Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours — vice - - -- — ❑ Customer Self -Service of ice of Non PHF and Non- - - ---- -- (JI Customer Self -Service F❑ Use of Process Requiring A Variance i and/or HACCP Plan (including bare hand Perishable Foods Only -- -- ---- ----- F_] Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs - - Retail Sale _- - control) Other Food Operations I, the undersigned, attest to the accuracy establishment operation will comply with board of health on how to obtain g4lq4 24) Signature of Applicant: [ ] Juice Manufactured and Packaged for (❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Orioin 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: $125.00 Payment is due with application ❑ waived i provided in this application and affirm that the food I and all other applicable law. I have been instructed by the )0 and the federal Food Code. Pursuant to MOIL Ch.62CoVec. 49ei certify under the penalties of pe that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 0 25) Social Security Number or Federal ID: 46-4522605 26) Signature of Individual or Corporate Name: 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: ORANGE LEAF FROZEN YOGURT ADDRESS: 321 SCHOOL STREET, UNIT A-120 TELEPHONE AT LOCATION: (508) 339-9020 FAX NUMBER: OWNER OF BUSINESS: MARIO COSTA TELEPHONE OF OWNER: (781) 769-2425 FEDERAL ID/SS NUMBER: 46-4522605 FEE: $10.00 PERMIT NUMBER: FS-72 SIGNATURE: DATE: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for License to Manufacture Frozen Desserts and/or Ice Cream Mix To the Board ofHealth at the Town ofMansfteld: In accordance with the provisions ofsection 65H ofChapter 94 of the General Laws, as most recently amended, and the regulations made thereunder, the undersigned hereby appliesfor a license for it WHOLESALE�RETAIL manufacture of%rozen desserts and ice cream mix and submits the following information: 1. Full name of applicant: ORANGE LEAF FROZEN YOGURT 1. Business address 66 FAIRFIELD CIRCLE NORWOOD, MA 02062 3. it'appliemtt is an individual: FDII name: MARIO COSTA, OWNER Residence: 66 FAIRFIELD CIRCLE, NORWOOD, MA 02062 3a. !(applicant is a partnership, fidl name and residence of all partners: 31). ff applicant is a corporation: State of incorporation: MASSACHUSETTS Date of incorporation: 1-14-2014 Full natne and address o/ Principal office: 66 FAIRFIELD CIRCLE President MARIO COSTA Treasurer: KATHLEEN NEE Clerk: 4. Location of Plants: 321 SCHOOL STREET, MANSFIELD, MA 02048 S. Names of7rrands and trade or corporation name t/ any, under which the products are to be sold• 6. Nunher and capaeitrr offr'eezens arrdfees: 8 Fee: ($25.00 perfreezer) $ 200 1 Is the mix purchased? YES lfso, from whom purchased? 8. Is the min° pasienrized? YES 9. Number of ;gallons of frozen desserts andlor ice cream mix to be sold in Nfassachusetts during the licensing Period 5000 I(), Number ql gallons oflirozen desserts andlor ice cream nrix sold in Massachusetts during the previous licensing period 11. /s the plant corrsh,ucied and eyuippetl as provided in the regulations? YES /2. Is the water supply public or not? YES 13. Have you received a copy of the regulations? YES 1 hereby certify that the frozen desserts and/or ice cream mix I sell in Massachusetts will be manufactured in compliance with all law of the Commonwealth ofMassaschusetts pertaining thereunder and all rules and regulations promulgated by the Massachusetts Department of Public He 191made thereunder and will be manufactured under sanitary conditions. I attest that the information stated In this applic sin Yana accurate under the pains and penalties of perjury. la-s i'r ( Wnerofficer's signature) (DATE) M� y�,� ( &-j2-C — 1 I 1A' (Title) (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. or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "*Social Security No. (Voluntary) or Federal Identification Number *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:\HnIthUan&s Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc \ The Commonwealth ofAfassachuseits Department of lndushialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www rnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMTTING AUTHORITY. Dnlicant Information P) Business/OrganizationNaine:_ ckTCQNQt� City/State/Zip: �ri��s �'�\ m� Phone#: Are you an employer? Check th�propriate box: 1. Ia(J I am a employer with _ L employees (full and/ Y for part-time).* 2, E] 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. END workers' comp, insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. INo workers' comp, insurance req.] tAnv aoolicant that checks box #1 must also fill out the Business Type (required): S. ❑ Retail 6. gRntaurant/Bar/EatingEstablishment 7. Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9, ❑ Entertainment 10, ❑ Manufacturing 11. ❑ Health Care 12.❑ Other compensation Policy information. *4 If the corporate officers have cxcmplcd tbemselves, but the corporation has other employees, a workers' compensaton policy is required and such an ' organization should check box M. I am an employer that is providing workers' conipentration hisurance for my employees. Below is the policy information. Insurance Company Insurer's Policy # or Self -ins, Lic. #- �--)C _ 0c) 1 �' Expiration Date: I Ia I I'R Attach a copy of the workers' compensation policy declaration page (sboming the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 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 fo $250.00 a day against the violator. Be. advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert�y�jcryd'"r f�p�p4ius and penalties ofperjury lhatthe information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town ofjiciaL 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 ww Mass.gov/dia Phon Acc�ava CERTIFICATE OF LIABILITY INSURANCE nATEtM}an,a-TTI - 12vitZniT 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 CONSTITUT£ A CONTRACT BETWEEN THE ISSUING INSURERIS}. AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, IMPORTANT: It iha catTifkato hohlor to an ADDITIONAL INSURED, the Pol"Iee1 mast have ADDITIONAL INSURED provlslona or he onaorsad. It SUBROGATION IS WAIVED, subject to the forma and conditions of tho pollcy, cartatn policies may requmb an ondorearw nt- A staternenl on this eoriffinto does not Gooier rights to the cenffieafe holder In IYntt of such anaorsamonr{a}. F%PD MfR uva_. CT!a Xs+P.innrmit,; �PRa7[ QIII)762+S138 N�ahsy Zen"ninw;nnce �Aeeaexx: HNTyrsr•I�cgrtxn A000IM 4A5 VC."l Yalun 51r k ry,..._.4VSLNENy91 Arl ob w; COYEAAC.a NAI.i flc�Vt�atl NIA 1�130274211 IpXtIP.ER A- DIIINGY MU(VALL� ibfY6't INkLN[@'Lt -._...��....�,.a,,..�_.....,_...�. !NaUAt7i6 . C14C YOGNPI INC INSURER L�-- t6 FA IRFIELb CIRCI_< *asuAER o !N:rUAEP E' NORVYCDO9 IiAA 0t062 1 INSUREA.f: COVERAGES CERTIPiCATE NUMBER: C1.17127W108 REVISION NUMBER: TM515 TO CeFRTTY THAT TRIE Pr,X KIES OF INSURANCE L18.5EO BEL IN HAVE -ZAN IStWhD TO h151NS(MED r4AMED AbOVt FOR THE Pmo,,-Y REP18D :RVF: ATEsr REOIPFEMENs_ TERM OR CONN IICIN CF A.ITv OCC! MEN!"AID I RESPECT TO'Nrt=CH THIS ' CERT `,C,ATE MAYBE 15,5tJEU OR MAV M11'TA1W. Thi ,NS.:RWh F: "J FQRDE0 RY THE FCLICIEh G£SGRIBEIJ>+EREIW tp SC6ib_t;T TO ALL THE TERM9- EXCLUSIONS SITU CQPtDYtaO}ic OF 5kr-H r'''3. LICTES ')*T@ °,r{FWN MAY PAYE BEEN REDUCED a PAID;:LAIM$ LFFt YVFb pF 3NS+daRNGEoilro1 OeX.JCY 1AUN0E11 TWA UyiTa LViANtti:UL GaNEMLLIAaY.fTf _1M ' Ebz.Ji lF-X.:1nnENif d � �: dINI>NAiG (J� }.t'_'M1 ( VPEM151- t. d.-wnxA <Y•_.... f MCREF }ggx ierm - 1}y 4Nix.X+OJ IHa ?'! i A B0201PA3 D'7;ifll,nlJ a%dai?MI EN, V^.;A 1iE 44ui APR Qi'3x YJiM JA6 �:C✓- 1<YfJ fit nstaFG+ip qT(-Y"f'i �C 'WJP r: I� I � Rh,ER AUfC31!MdiLa LAPAAYY ��QM3!'}i.iL OT d ANv xU*9 11CO, rwatntrtWzn CM.Y'cll sCnEtk;::tl FUirh `n:" u �x `Y'F,!::r NM1NJFyPa, :v^.J;rr. f AWi� ]H:" Rll(W:fvll'r , uv�!p.R�!uAM?J"r F i d )! 1W8HELlP UF9 •efYl M' --•—•^.. t EACESa Lwn .-:_�� ;-;nflrC'giE S (iED 'ne `EgIY.?N9 3 N;a ( WCPii67l (e aha'*'"1 1J2116t20Td A ANDEEa8SCe1AEN3aTUY1 111D E.0 -R" a' IARIITT t in a'{,Er `gA'YJjTv nbn U.A"t YIN 15%?fR.RPAEilrE<Y E�f,C'1 � a $Lf .�+ ulCEnf S rGO one Et 05E NF tot t 1Nl dory Yn W11 I ye xsnW kv ! 1,7 a Tnll3 , i DESI:A:PiWN (� UPEAATiONa l L4CA'npNS! VFNt10 FS (Al:bAa 16i, AlgtiplNN P.Aa,{a 5ct«.yda, h,uy to ttteMbd a nme qvm b rentu' a5i SNOUL13 ANY OP THE ABOVE DESCRIBED P1 U06S BE CANCELLED BEFORE THE EXPIRATION DATE TWREDF, NOTICE WILL BE DELIVERED IN Taw! �I1Aansael.] ACCORDANCE WITH THE POLICY PROVISIONS. It 1998-20I5 ACORD CORPORATION. ACORO 26 (201Tif0)I The ACORD (iamb and logo an NPIMP rod IVAMO Of ACORD DECLARATION PAGE QUINCY MUTUAL GROUP ACCESS CODE: DBGQFW 57 Washington Street BILL TO: CUSTOMER Quincy, MA 02169 WORKERS COMPENSATION POLICY RENEWAL POLICY MA TAXPAYER ID NO: XXXXX5684 NCCI NO: 32247 PRIOR POLICY NO: WC 001621 NAMED INSURED IS: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IF APPLICABLE. FEDERAL 10 NO: XXXXX5684 RISK ID NO: 2. POLICY PERIOD: FROM 02/18/2017 TO 02/18/2018 12:01 AM STANDARD TIME AT THE INSURED'S MAILING ADDRESS. 3.A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS COMPENSATION LAW OF THE STATES LISTED HERE: MA 3.B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WORK IN EACH STATE LISTED IN ITEM 3•A• THE LIMITS OF OUR LIABILITY UNDER PART TWO ARE: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE 3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY, LISTED HERE: ALL STATES EXCEPT ND, OH, WA, WV, WY. 3.D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: wC 00 00 0o c WC 00 04 22 B WC 20 03 02 A WC 20;03 03 D WC 20 06 01 A WC 20 QM O1 WC 20 03 Ol WC 20 04 O1 WC 20 04 05 WC 20 06 04 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES, CLASSIFICATIONS, RATES AND RAPING PLAN. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT: PREMIUM BASIS RATE PER TOTAL ESTIMATED$100 OF ESTIMATED CLASSIFICATIONS CODE ANNUAL REMUNERATION ANNUAL NO REMUNERATION PREMIUM (SEE EXTENSION OF INFORMATION PAGE) TOTAL ESTIMATED PREMIUM $1,210.00 DIA ASSESSMENT ( 5.600%) $54.00 TERRORISM RISK INSURANCE CHARGE ( 3.000%) 9740 $27.00 MINIMUM PREMIUM $216.00 TOTAL ESTIMATED COST $1,291.00 DEPOSIT PREMIUM $1,291.00 COUNTERSIGNED BY AUTHORIZED REPRESENTA71VE O1/10/2017 WC 00 00 01 B CONTINUED ON NEXT PAGE INSURED COPY ..dam Aga, od 4Pri CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name Date of ComQle666 5151x016 Date of Expuatron ci oxi Wie above -named person is hereby issued this certocate for completing an allergen awareness trainingprogram recognized by the MassachusettsDepm-tment ofPubReHealtb in accordance witb 105 CMX 590.009(G)(3)(a). Ms reriffscate will he valid forfive (5) years from date ofcompletion. lcsued Sy: Massachusetts Restaurant Associaeoa 333 Turnpike Raed, Swte 102 Southborough, MA 01772 508-303-9905 xww.macesfaurmnasoeorg M13 NAT ANAL RESASSOCIATION® 800.7651122 mvw.resm.t.osg