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Home My WebLink AboutWhite Wave Foods - 9/20/2008TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD, MA 02048 PERMIT TO OPERATE A MOBILE FOOD TEMP 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: WHITE WAVE FOODS Whose Place of Business is: DEAN FOODS/WHITE WAVE FOODS COMCAST CENTER Permit expires September 20, 2008 License Number. MF-325T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH Dr. Raymond Martin, Chai man III SEP 1 6 Z008 Date Received Date Inspected Approved By Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 6 2) Establishment Address: Qg� S . r Ad "A_ 5� /> .,rtSh',e�ol ✓u DZO'714 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: SZJ 9 _ 339 _ 7-33 5) Applicant Name & Title: S 1 Cep- o — � 6) Applicant Address: OCJ 2 r �o L' O 00Z—I 7) Applicant Telephone No.: 30 3 —&3S'— Q 2 Hour Emergency No.: 303 — gOZ — 7 100 8) Owner Name & Title (if different from applicant): 9P✓\ �DOa�s �, rFi)am, Dal S 9) Owner Address (if different from applicant): 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers or partner. 1-'oA /� -c ❑��Q Ai�rr Association IJ'ACorporation I7-00'Z AArrP4- ❑ An Individual ❑ A Partnership %rIDOr'1�lki'e�oC CA7 •�ZI ❑ Other legal entity 121 Person nirecflv RP.Snnngihle Fnr r)nily nneratinns Irlwnar narvnn in charne Runanrisnr Manancr afc 1 Name & Title: Address: Telephone No: Fax: Emergency Telephone No: 13) District Or Regional Supervisor If applicable) Name & Title: Address: Telephone No: Fax: BLANK rO DPERMIT &PPLICATICN Food Establishment Information 14.) Water Source 15) Sewage Disposal DEP Public Water Supply No: (if applicable): Aj/IBC A. 16) Days and Hours of Operation: ZO 08 : pO _ to .. Pie r7 17) No. of Food Employees 18) Name of Person In Charge Certified in Food Protection Management: i¢,, it 5 e-7or-� Required as of i0/i/2001 in accordance with 105 CMR 590.003(A) Please attach co of certificate J 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): 20) Location: 22) Establishment Type: ❑ Caterer ❑ Retail ( S% Ft) ❑ Food Delivery ❑ Food Service - ( ) Seats ❑ Residential Kitchen for Retail Sale ❑ Permanent ❑ Food Service - Institution ❑ Residential Kitchen for Bed & Breakfast Home B'Mobile (Dates) ZOO ( Meals/Day) ❑ Residential Kitchen for Bed & Breakfast Establishment ❑ Frozen Dessert Manufacturer Other (Describe) 21) Length Of Permit: rg oop- (check one) ❑ Annual I ❑Seasonal/Dates Temporary/Dates/Times 23) Food Operations: Definitions: PHF-Potentially hazardous food (time/temperature controls required) (Check ail that apply): Non-PHFs- non -potentially hazardous food (no Urne/temperature controls required) RTE- ready -to -eat foods Ex. Sandwiches, salads, muffins which need no further processing) ❑ Sale of commercially Pre- ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service ❑ Sale of Commercially Pre- ❑ Preparation Of PI -Fs For Hot And cold ❑ PHF and RTE Foods Prepared For Highly Packa ed PHFs HoldingFor Single Meal Service Susceptible Population Facility ElDelivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to ❑ Vacuum Packaging/Cook Chill be Prepared by Consumer ❑ Reheating of commercially ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service of Non ❑ Ice Manufactured and Packaged for ❑ Offers Raw Or undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin Only. ❑ Preparation of Non-PHFs ❑ Juice Manufactured and packaged for ❑ Prepares Food/Single Meals for Catered Retail Sale Events or institutional Food Service Other (Describe): LJ Otters R I E PHF in Bulk quantities 11 To be completed by the Board of Health r�; Zoe , ❑ Retail Sale of Salvage, Out-0f--Date or Total Permit Fee: ✓ a .Ik Reconditioned Food Payment is due with application ,,,.� Gltioe . rvf, I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. lave been by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, returns and paid state tax, I certify under the penalties of p ry thaCl, to my best knowledge and belief, have filed all state underlaw. 25) Social Security Number or Federal ID: 7S - Z-2 LZ $ .5- 26) Signature of Individual or Corporate N7::�� ,'. BLANK FOOD PR MITAPPLICAMN 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. Co. Signature of Individual or Corporate Name 75-- 77-1 gBJS "Social Security No. (Voluntary) or Federal Identification Number 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. RAHe IthVane's Documents\TAX CERTIRCATION EORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: I2-Oc77- kir j2e> -�-- 1,.�� F I City/State/Zip: Phone #: 303 -(a 35-- yoco 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. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity. workers' comp. insurance required] $• ❑ Non-profit ,_/JNo 3. M We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.[�Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We IL F1 Health Care area non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0Other *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 Address: City/State/Zip: Policy # or Self -ins. Lie. 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, antler the pains a !ties ofperjury that the information provided above is true and correct Official use only. Do not write in this area, to be coutpleted by city or town official 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 www.mass.gov/dia Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05 IF v n 0 3 z o =� F- p z 4 y g � m 4 a ctJ x X > w Q w p O � p N p 3 4 4 O � z 0 Tin a, N;a ¢,O :W @iz ai° o m i Q i Z'W �- T'd 0T B T-bSb-b TE iazJe0 aajjuo