HomeMy WebLinkAboutFlannel Cow Creamery 12/31/2018Commonwealth 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:
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:.
RYAN J. HEEDEN
Whose place of business is:
FLANNEL COW CREAMERY, LLC
88 CHILSON AVENUE
PERSON(S) IN CHARGE:
RYAN HEEDEN
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-28
BOARD OF HEALTH
MichaeCMcCCean, Chairman
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
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
FLANNEL COW CREAMERY, LLC
88 CHILSON AVENUE
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-28
Freezers: 1
TOTAL: $25.00
MANSFIELD BOARD OF HEALTH
Michae(McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-28
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name FLANNEL COW CREAMERY, LLC r
2) Establishment Address 88 CHILSON AVENUE
NOS r i
3) Establishment Mailing Address (if different) 88 CHILSON AVENUE
MANSFIELD, MA 02048 " ---
4) Establishment Telephone No (781) 475-4829
5) Applicant Name & Title: RYAN HEEDEN
6) Applicant Address 308 MAPLE STREET, MANSFIELD, MA 02048
7) Applicant Telephone No.: (781) 4754829 24 Hour Emergency No.: (617) 877M81
8) Owners Name & Title RYAN J, HEEDEN, PRESIDENT
9) Owner Address (If different from applicant)
Owner's telephone number (781) 475-4829
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
l An Association or partner.
l A Corporation Name Title Address
]An Individual
Li' A Partnership
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: IRYAN HEEDEN
Address: 1308 MAPLE STREET, MANSFIELD, MA 02048
----- - - -
Telephone No._[(781) 475-4829
FAX: - 1
E-mail: IRYANH EED@YAHOO.COM
Alt E-Mail.
13) District Or Regional Supervisor (if applicable)
I Name & Title:
Address
Telephone No.
FAX: E-mail:
- -- L —
24 Hour Emergency No: (617) 877-0181
24 Hour Emergency No:
i 7N10 S21AMia:j
Food Establishment Information
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS; SEASONAL 12 00 PM • 9:00 PM
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees: 10
18) Name of Person In Charge Certified in Food Protection Management: RYAN HEEDEN
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
20) Location: [I Permanent Location
25 Seats or more) I -.J
22) Establishment Type
] Moblie Moblie Start Date:
1--1 Retail ( Sq. Ft)
Moblie End Date:
IV] Food Service up to 100 or
Moblie Comments:
up to 10' PHF display $125.00
21) Length of Permit:
❑ Food Service up to 101 -200
[) Annual
or up to 25' PHF display $150.00
----------------------------- -
(d; Seasonal
[l Food Service up to 201 +
or 25'+ PHF display $275.00
Seasonal Dates
- Temporary -_.- __— - _-- - --_- -
1 _,I
I Food Service - Institution
Temporary Start Date:
( Meals/Day)
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Check all that apply):
❑ Caterer $25.00
EV]-MHk*en arrr$1b'.b0—•
❑ 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
Definitions PHF - Potentially hazardous food (time/temperah a controls required)
Non-PHFs - non -potentially hazardous food(no timeltemperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
[I 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
T 1 Preparation of Non-PHFs
Other Food Operations
Jv] 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
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities-1 Prepares Food/Single Meals for
Catered Events or Institutional Food Service
or Reconditioned Food I To be completed by the Board of Health
c u
Total Permit Fee:0-
/Sn
Payment is due with application I 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 obtaingopies of 105 Cty1R 590.000 and the federal Food Code.
24) Signature of Applicant: / ,� a 5_/�
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: 47-49413
26) Signature of Individual or Corporate Name: -,/-T
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 of Health at the Town of Mansfield:
In accordance with the provisions of section 65H ofChapter 94 of the General Laces, as most recently amended, and
the regulations made thereunder, the undersigned hereby applies for a license for a WHOLESALFIRETAIL
manufacture of frozen desserts and ice cream mix and submits the following information:
I. FUII name of applicant: FLANNEL COW CREAMERY, LLC
2. Business address 88 CHILSON AVENUE
MANSFIELD, MA 02048
3. If applicant it an individual: Full name: RYAN HEEDEN
Residence: 308 MAPLE STREET, MANSFIELD, MA 02048
3a. Ifopplicant is a partnership, full name and residence of all partners:
3b. Ifapplicant is a corporation. State of
Date of incorporation: 8/24/2016
Full name and address of: Principal office: 88 CHILSON AVENUE
President RYAN HEEDEN 308 MAPLE STREET, MANSFIELD, MA 02048
Treasurer: MELISSA HEEDEN
Clerk: NONE
4. Location q('Plants: 88 CHILSON AVENUE, MANSFIELD, MA 02048
5. Nantes of brands and trade or corporation name, if any, under which the products are to be sold. -
FLANNEL COW CREAMERY LLC
6. Number and capacity gffreezers cad fees: I i Fee: ($25.00 per freezer) $ 50
Z is the inix pu chased? YES Ifso, from whom purchased?
8. is the mix pasteurized? YES
9. Number of gallons of frozen desserts and/or ice cream rnis to be sold in Massachusetts during the licensing
Period TO BE DETER
10. Nwnber ofgallons glfi-ozen desserts and/or ice cremn mix sold in Massachusetts during theprevious ticensiugperiod
11. Is the plant oonshzicted and equipped as provided in the regulations? YES
12. Is the water supply ptiblic or not? PUBLIC
13. Have you received a copy of Ilse regul(itions? YES
I hereby certify that the frozen desserts and/or ice cream mix 1 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 Massachusotts
Department of Public Health made thereunder and will be manufactured tinder sanitary conditions. I attest that the information stated
m this ap ation is true nd accurate under the pains and penalties ofperjury.
(Com any ownertoffI er's signature) (D�A,TtE) j+ �/
-�� W _ -Ll A�r�C.
(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.
- /" a o �,— /, 4
Si re of Individual or Corporate Name
**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:\Hn1thuane's DocumentAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
0
RYAN HEEDEN
for ,,ssIelly cmplmmg the standards set foilh for the Se,SaV Food Prolecfion Manager Cedificalion Examinmion,
Ad, is eccreditecl by the American National Standards Inslifule (ANSIJ-Conference for Food Proleclion fCFPI.
5133
EXAM FORM NUMBER
4/6/2021
DATE OF EXPIRATION
for recerti{i<alion regoiremenls.
c���rv.-rn v�u�,a »s vr�u,kvneNd. sty Ism. cn.w>.n enaw ..5r..seLaw,��um.
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: RYM NEEDEN
Certificate Number: 2315397
Date of Completion: 55ao16
Date of Expiration: 5r"21
7T.re abo ue nanvdPerson is here6l, issued this mr Neale
for rourpleting an all rgan auvnruesn bniningploguun
rnngniz,d hp the dlassmLusetts Odra, onew olPublit Health
in ononlnuee with 105 CIIR i90.009(C)(JJ(aJ.
77& r ertilimte -will be valid 1br/rae (_S) pears- l iom date a1 rontlrlfion.
Issued By:
Rai
NATIOML
RESTAURANT
ASSOCIATION,
M...... 6-,- s R,,uo ua As,,,6. ion
800.75.5.2122
333 Turnpike Road, Saito 102
.... mturg
Southborough,\IA 01772
508-303-9905
.mascstaanumrsso..org
W[77,,)� I I 1.7L tt1INI O TL 101
TTl^FPT.n,T RFpF)Ri- CrM'T^'
C IIdC-IN MATT uH 4S999-00.
hi!'1T,I5Ss HEFDEN CEfJ PPF:
88 CH7:LSON AVE
MATISFIELD, MA 02043
Date of this notice-.: 09-01-201s
,employer Identification Lumber:
47-4941373
Form: SS-4
A"111Uer0L tnis nOLlce: CP s7S ii
For assistance you may call us at:
1-800-829-9933
IF YOU V?RITE, A'I7'ACH T13E
STUB AT THE END OF THIS NOT1.CT.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NOIJB3R.
Thank you for applying for an Employer Idontification Number: (EIN). We assigned you
EII9 47-4941313, This EIN will identify vou, your business accounts, tax returns, and
-�ocurnents, even Ir you have no employees. Please keep this notice in your permancnL
records ,
..her; f=1.,,g tax dommeni p _ cents, and _elated correspondence, i; is very impo-tant-
that you use your EIN end complleL'e name and ads_ess exactly as shown abuse. Any variation:
may cause a c1claw it , _ _Cs_-tg, result in incounct information in your account or evcn
cnwe jou to be assig,.__, more than one Cie.. if the information is not c-rrect as shown
abo oleaa_ rilskc. the rorrec'ion usiag the ati2_he.d tear off stub and reuurn it to us.
Based on the information received from you or your r-epresentative, you must file
the Yolloviinq form(s) by the date(s) shown.
0��l1 /201.
if you have questions about the fonn(s) or the Cue date(s) shown, you can call us at
the phone number or write to us at the address shown at the top of this notice. l£ you
used helm iu determining YOU anneal. accounting Period (Lax year) ,..a Publication 53b,
AcccluntiLg Periods and iiethod: .
We assigned you a tax classification based on information obtained from you or your
representative. It is not a .Legal deterrniration of your tax classification, and is not
bindinq or, the IRS. if you want a legal determination of your tax classification, you may
request a private letter ruling from the IRS under the guidelines in Revenue Procedure
004-1, 2004-1 1.R_B. 1 (or superseding Revenue Procedure for the year at issue). Note:
Certain tax classification elections can be requested by filing Form 8832, Entity
Classification Islection, See Form 8832 and its inst:ucti.ons ror additional information.
A limited liability company (LLC) may file Form 8832, Entity Class!f ication
H',)a,-flora, =nrl elect i_n he rl. gsifierl _ as. ac-,nciatinn raxable as a corporation. If
Me LLC is rlhoble to be treated as a Corporation that meets certain tests and it
will be electing S corporation status, It must t.i.me).V file Form 2553, Election by a
Small Business Ccrporation. The LLC will be treated as a corporation as of the
effective date of the S corporation election and does not: need to file Form 8832.
To obtain ,aa forms and publications, includinq those refer_n_ell in this notice,
visit our Web site at rnala.irs.gov. if you do not have access to the lnternet, call
1-800-829-3676 ('PTYlTDD 1-800-829-4059) or visit your local TRS office.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, 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 LedblY
Business/Organization Name: aG ni to en.) nCliuC x L- L�—
Address: C IC41 fw !! Ve
Phone#: 7r1--175 =-VS'Z4'
Are you an employer? Check the appropriate box:
Business Type (required):
I. I am a employer with 0 k employees (full and/
)
5. ❑ Retail
6.�RestaurantBar/EatingEstablishment
or rt-ti ).* Tv"
a 2.0 1 am sole proprietor or partnership and have no
y. Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ Non-profit
[No workers' comp, insurance required]
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]*
1 L❑Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
12, ❑ Other
*Any applicant that checks box #1 most also fill out the section below showing their workers' compensation policy information.
**If the eorpoate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such son '
organization should check box N.
[am an employer that is providing wprkees' compensation huwran�e for m4 employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:Cl_ (�AJ34V` L,0`1fI` u/ILV7 VW/J J
/ (% ri" / l Policy # or Self -ins, Lic. #- U L Lt) C y /-7Z 1 7 Expiration Date: l � �
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 pains and penalties of perjury thatthe information provided above is true and correct.
Phone #: 7iz-/-/ /O L
Official use only. Do not write in this area, to be completed by city or town offaciak
City or Town:
Permit/License
1117-111-7
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
11121/2017 16:31
(FAR)4014319201 P.0011001
4 Ril' CERTIFICATE OF LIABILITY INSURANCE
YM
11/27./ 03.7
11/21/2017
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 CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must he endorsed. It SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require all endorsement. A statement on this certificate does not confer rights to the
certificate holder In Ifou of ouch andonsement(a).
PRODUCER
G
NMTF.ACBath Deachene
Cross Inouranoe, Ina,- RI
NE (401)431-9200ima, ;(4D1)43T-9201
376 Newport Avenue
L `Ldaschoneecrossagnncy. cam
P. 0. Box 4930
INSURERIS) AFFORDINI COVERAQk
NAIC9
_
INIURERAOmployerm Mutual Casualty Co
21415
East Providencs RI 02916
INSURED
INSURER a 4AttEDYd AOOidant and Indemnity Cc
22357
PASTUn PROPERTIES LLC
INSURER C:
80 CHILSON AVE
INSURER D:
INSURER_E:_
NANSSIELD MIL 0204E-1935
INSURER F:
COVERAGES CERTIFICATE NUMBER:CL17112131229 REVISIONNUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMES ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENY. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SU13JEOT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSH TR
TYPE OF INSURANCE
MM1V60/YY1
MnVn
LIMITSR
A
COMMERCIAL GENERAL LIABILITY
CLAIM& -MADE ®OCCUR
_
51552299
6/12/2017
0/12/2010
EACH OCCURRENCE
g 1,000,000
_
W""
MEO EZP (my ane pm2N
g 506,000
s 10,000
PERSONAL& AOV INJURY
g 11000,000
GEHL AGGREGATE LIMIT APPLIES PER:
X POLICY 'Pro, El Loc
OTHER;
QMERALAGGREGATE
S 2,000,000
PRODUCTS. COMP/ AGO
g 2,000,000
EmpinymanlPrI MMILIANlMy
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AND EMPLOYERB'UAMUTY YIN
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E.L. DISEASE -EA EMPLOYE
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E.L. DISEASE -POLICY LIMIT 16
$00,000
DESCRIPTIONOFOPERATONSILOC ONSIVEHICLU(ACORD 101, AddRlead 14MItko 50hsdats, may 99 aNa9lud It mom Wags Is nqulnd)
RTC: FLANNEL COW CRRA=RY
Town of mansfield
6 Park Row
Mansfialld, t4A 02048
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED RFFCRE
THE EXPIRATION DATE THEREOP, Nance WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Deachelte/BOX
All
ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD
INSOMM14nll
THIS ENDORSEMENT CHANGES THE POLICY. PI EASE READ IT CAREFULLY.
INSURER: HARTFORD ACCIDENT AND INDEMNITY COMPANY
NCCI Company Number: 10448 AUDIT PERIOD: ANNUAL
POLICY EFFECTIVE DATE: 08/13/17 POLICY EXPIRATION DATE: 08/13/18
Policy Number: 02 WEC EK7727 Endorsement Number: 01 HOUSING CODE: SB
Effective Date: 11/21/17 Effective hour is the same as stated in the Information Page of the policy.
Named Insured and Address: PASTURE PROPERTIES, LLC
308 MAPLE ST
MANSFIELD, MA 02048
FEIN Number: 474.952115 _ ...PRO RATA FACTOR: - .726 - - - - -
PRODUCER NAME: CROSS INSURANCE INC RHODE ISLAND PRODUCER CODE: 090786
It is agreed that the policy is amended as follows:
ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING
STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR
BANK ACCOUNT, CHANGES IN PREMIUM SWILL CHANGE FUTURE DRAW AMOUNTS.
THIS IS NOT A BILL.
IN CONSIDERATION OF NO CHANGE IN PREMIUM IT IS AGREED THAT:
MAILING ADDRESS IS AMENDED TO READ:
308 MAPLE ST
MANSFIELD,: MA 02048
Countersigned by
Form WC 99 00 06 A (1) Printed in U.S.A.
Process Date: 11/21/17
Authorized Representative
Page 1
Policy Expiration Date: 08/13/18