HomeMy WebLinkAboutKelloway-Colwell 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 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:.
CRAIG COLWELL, OWNER
Whose place of business is:
KELLOWAY-COLWELL LLC
1 CROCKER STREET
PERSON(S) IN CHARGE:
CRAIG COLWELL
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-92
BOARD OF HEALTH
MichaeCMcCCean, 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:
CRAIG COLWELL, OWNER
having a place of business at:
KELLOWAY-COLWELL LLC
1 CROCKER 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-92
Board of Health
Michae(McCCean, 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 FSFS92
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name KELLOWAY-COLWELL LLC
2) Establishment Address 1 CROCKER STREET
3) Establishment Mailing Address (if different) P.O. BOX 702
FOXBORO, MA 02035
4) Establishment Telephone No (880) 212-7089
5) Applicant Name & Title: CRAIG COLWELL, OWNER
6) Applicant Address P.O. BOX 702, FOXBORO, MA 02035
7) Applicant Telephone No.: (880) 212a089 24 Hour Emergency No.: (808) 369-8241
8) Owners Name & Title CRAIG COLWELL, OWNER
9) Owner Address (If different from applicant) P.O. BOX 702, FOXBORO, MA 02035
Owner's telephone number (880) 212-7089
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
An Association or partner.
A Corporation Name Title Address
An Individual
A Partnership
Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: ICRAIG COLWELL
Address: P.O. BOX 702, FOXBORO, MA 02035
Telephone No: !(880) 212-7089 24 Hour Emergency No: (508) 369-5241
FAX:
E-mail: CRAIGMCOLWELL(a)YAHOO.COM
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
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: MON-FRI 5 AM - 10 AM
18) Name of Person In Charge Certified in Food Protection Management: CRAIG COLWELL
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): 1-,
20) Location: '.V Permanent Location 22) Establishment Type
Moblie Mobile Start Date: i I Retail ( Sq. Ft)
Mobile End Date: 1 ;�/� Food Service up to 100 or
Mobile Comments: up to 10' PHF display $125.00
21) Length of Permit:
IV/'I; Annual
SSeasonal
easonal Dates:
- Temporary -
Temporary Start Date:
Temporary End Date:
Temporary Time:
Food Service up to 101 -200
or up to 25' PHF display $150.00
[__ 1 Food Service up to 201 +
or 25'+ PHF display $275.00
Food Service - Institution
( Meals/Day)
i
Caterer $25.00
Milk & Cream $10.00
' Mobile Food & Consession $75.00
Manufacture Frozen Desserts/Ice Cream
-' $25.00/freezer
I Pushcart $25.00 # of Pushcarts: 0
[J Residential Kitchen $100.00
J Retail Food $100.00
I ] Retail Snack Food $25.00
[� Tobacco Products $25.00
I Rain Date:
23) Food Operations Definitions: PHF- Potentially hazardous food (tlme/temperelure controls required)
Non -PMI's - non -potentially hazardous foodino tlme4emperature controls required)
',(Check all that apply): RTE - ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs IV] PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held
- -- - -,- ----- ----- -- - a for More Than a Single Meal Service
Sale of
I Deheetin Commercially
of ckagedrall Pre -Packaged PHFs ICJ PreparationCold p9 fFor PHA s9 or Hot And Service :I PHF and RTE Susceptible Population Facility
Delivery of Packaged PHFs tole of RawAn b al Foods Intended Vacuum Packaging Chill or Highly
9 Y
Processed Foods for Service Within 4 Hours
y, - -- --- -! -- - - - j Use of Process Requiring A Variance
Customer Self -Service of Non PHF and Non- IVI Customer Self -Service iand/or HACCP Plan (including bare hand
Perishable Foods Only I e ___ _- -- - - - I contact alternative, time as a public health '
V; Preparation of Non-PHFs IRe al Sale Lured and Packaged for control)
Other Food Operations Juice Manufactured and Packaged for '! Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
Catered Events or ail Institutional ice
Retail Out -Of -Date
or Food be
dby the Board of
Tocompleted
Fe$50 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 Cyjk 590.000 and all other applicable law. I have been instructed by the
€€tt board of health on how to obtain copies of MR 5 0 and the federal Food Code.
`t--24) Signature of Applicant:
iii� Pursuant to MGL Ch.62C, sec. 49A rtify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required unde aw.
25) Social Security Number or Federal ID: 034-48-8228
'�,-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: KELLOWAY-COLWELL LLC
ADDRESS: 1 CROCKER STREET
TELEPHONE AT LOCATION: (880) 212-7089
FAX NUMBER:
OWNER OF BUSINESS: CRAIG COLWELL, OWNER
TELEPHONE OF OWNER: (880) 212-7089
FEDERAL ID/SS NUMBER: 034-48-8228
FEE $10.00
PERMIT NUMBER: FS-92
SIGNATURE:
DATE:
The Commonwealth of Massachusetts
a 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 PERMITTING AUTHORITY.
Applicant Information �i Please Print Leeibly
Business/Organization Name: - 60e e'V6&_- Z,&-�--
Address:
City/State/Zip: M6'9U/2 Rai Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑ I am a employer with employees (full and/
5. ❑ Retail
6. ] iestaurant/Bar/Eating Establishment
part-time).*
U 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.
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
10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.❑ Other
with no employees. rNo workers' comp, insurance req.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If 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 #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
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 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, un r the pains and penalties of perjury that the information provided ab ve is true and correct.
��ail 11
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.
C�
Signatu�ual or Corporate Name
z
L",,116.W ((e / N
"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:\HealthVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
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