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Home My WebLink AboutFlint Farm Ice Cream 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:. DONALD FLINT Whose place of business is: FLINT FARM ICE CREAM 789 EAST STREET PERSON(S) IN CHARGE: DONALD FLINT Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-29 BOARD OF HEALTH MichaelMcClean, Chairman Milk & Cream ❑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 This is to certify that: DONALD FLINT having a place of business at: FLINT FARM ICE CREAM 789 EAST STREET 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-29 Board of Health MichaeCMcCCean, Chairman - POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS29 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name FLINT FARM ICE CREAM 2) Establishment Address 789 EAST STREET 3) Establishment Mailing Address (if different) 789 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-6473 5) Applicant Name & Title: DONALD FLINT 6) Applicant Address 789 EAST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (608) 339-7115 24 Hour Emergency No.: (508) 339-7115 8) Owners Name & Title DONALD FLINT 9) Owner Address (If different from applicant) 789 EAST STREET, MANSFIELD, MA 02048 Owner's telephone number (608) 339-7115 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers LJ An Association or partner. 7 A Corporation Name Title Address Vj An Individual J A Partnership 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title IDONALD FLINT Address: 1789 EAST STREET, MANSFIELD, MA 02048 ------- ----------- Telephone No 1(508) 339-7115 24 Hour Emergency No (508) 339-7115 FAX: E-mail Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: I FAX: E-mail: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL SEPTIC DEP Public Water Supply No (If applicable) 16) No. of Food Employees. 26 PART TIME 17) DAYS/HOURS: 7 DAYS 12-9 PM 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 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: [] Permanent Location 22) Establishment Type Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: [yj Food Service up to 100 or Mobile Comments: up to W PHF display $125.00 21) Length of Permit: L] Annual j; Seasonal Seasonal Dates: APRIL-OCTOBER Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: [ ] 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 n 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 I I Tobacco Products $25.00 23) Food Operations Definitions PHF- Potentially hazardous food (fimeRemperature controls required) Non-PHFs 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 I i J PHFCooked To Order i Hot PHF Cooked and Cooled or Hot Held -- - - Sale of Commercially Pre Packaged PHFs -{- I J Preparation of PHFs For Hot And for More Than a Single Meal Service _ - Ell Delivery of Packaged PHFs --- Cold Holding For Single Meal Service [_] PHF and RTE Foods Prepared For Highly -- ---- ------ - ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility j Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours - - --- ---- ❑ Customer Self Service of Non PHF and Non ❑_ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand [ ]Customer Self Service Perishable Foods Only — ❑Ice Manufactured and Packaged for contact alternative time as a public health Preparation of Non PHFs Retail Sale control) Other Food Operations j Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin TAKE OUT ICE CREAM _ ------ ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for -.. -._-. _-_-_ I Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Dale or Reconditioned Food I To be completed by the Board of Health - _- - ---- _"- Total Permit Fee: $125.00 Payment is due with application ]] 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 cooies%f 105 DMR 590-000 and the federal Food Code. 24) Signature of Applicant: ._/t-''y ( G ) IV-== 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: 20-2648155 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: FLINT FARM ICE CREAM ADDRESS: 789 EAST STREET TELEPHONE AT LOCATION: (508) 337-6473 FAX NUMBER: OWNER OF BUSINESS: DONALD FLINT TELEPHONE OF OWNER: (508) 339-7115 FEDERAL ID/SS NUMBER: 20-2648155 FEE: $10.00 PERMIT NUMBER: FS-29 SIGNATURE: r d DATE: ` 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 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:\HealthVane's DocumentsWERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ' www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMUTING AUTHORITY. Business/Organization Name: City/State/Zip: Are you an employer? Check the appropriate box: 1. X1 am a employer With orpa -time).* SQUaYemployees (full and/ o✓ 2: ❑ 1 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.] Phone #: Business Type (required): 5. ❑Retail 6. [ARestaurant/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 most also fill out the section below, showing their workers' compensation policy information, A4If 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 91. I am an employer that is proleding workers' compensatiou insurance for my employees. Below is the policy informadori. Insurance Company Name:'cficrl\�r"t\r,e insurer's Address: V\vliz) \\ y)C-1iQ\ City/State/Zip: N� Oi W rC n `N O'�- \�\-4 - "6 \ 91'1 1, `\ Policy #or Self-ins,Lic.ab 5 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/orpne-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 forjpsurance. coverage verification. that the information provided Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License is true and correct A\% 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.mms.gov/dia Phone IrypVtiMHllVty rraaac Fd�� , 0 -ARM FAMILY CASUALTY INSURANCE COMPANY NCCI COMPANY NO. 16721 ITI;IVI'',1 Ii�ISITItE INSURED AND MAILING ADDRESS: FLINT FARM ICE CREAM LLC 789 EAST ST MANSFIELD, MA 02048-3458 THE INSURED IS LIMITED LIABILITY CO Workplaces covered by this policy: ST WP NO. ADDRESS OF WORKPLACE MA 01 789 EAST ST MANSFIELD MA RTG.BUR NO. 479544 AGENT NO 1710 OFFICE NO 1710 FRANCIS E BINGHAM 1408 PROVIDENCE HWY # S-130 NORWOOD MA 02062-4652 781-255-2002 POLICY NO 2003W6255 ADJUST RENEWAL EFFECTIVE 4/14/17 INTRASTATE NO. The policy period is from 4/ 14/ 17 to a/ 14/ 18 '12:01 A.M. Standard Time at the insured's mailing address. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state listed here: MA 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: u B Disease Bodily Injury By Disease Bodily Injury j y Bodily Injury By Accident $ 100,000 each accident $ 500,000 policy limit $ 100,000 each employee ies to he states, if ted C. excher States Insurance: Part Three of the ept the states designated in item 3.A. of the inforlmationtpage and ND, OH,ISWA, hand Wy states D. This policy includes these endorsements and schedules: WC 00 00 00C WC 00 00 01B WC 00 03 15 WC 00 04 14 WC 00 04 228 WC 20 03 01 WC 20 03 02A WC 20 03 03D WC 20 04 05 WC 20 06 01A :opyright 1987 National Council INSURED COPY PROCESSED 05/30/17 n compensation Insurance vc 00 00 01 B Issuing Office - PO Box 656 • ALBANY, NEW YORK 12201-0656