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Home My WebLink AboutFlint Farm Ice Cream - 6/1/2010Commonwealth 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: FOOD SERVICE 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:. BETH FLINT Whose place of business is: FLINT FARM ICE CREAM 789 EAST STREET PERSON(S) IN CHARGE: 11 f Permit Expires: ,June 01, 2010 License Number: FS-22 Food Fee: $75.00 Milk & Cream ❑� Dr. Raymond Martin, Chairman 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: BETH 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 June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 License No.: FS-22 Scott Leite, Health Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-22 FOOD ESTABLISHMENT PERMIT APPLICATION (Annlication must be submitted at least 30 days before the planned openino date) 1) Establishment Name: FLINT FARM ICE CREAM fB (t� f� I, 'I}� LS v 2) Establishment Address 789 EAST STREET Ann ,rn 3) Establishment Mailing Address (if different) 789 EAST STREET MANSFIELD, MA 02048 By 4) Establishment Telephone No: (508) 337.6473 5) Applicant Name & Title: BETH FLINT, OWNER 6) Applicant Address 789 EAST STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339.7115 24 Hour Emergency No.: (508) 339-7115 8) Owners Name & Title BETH FLINT 9) Owner Address (If different from applicant): 789 EAST STREET, MANSFIELD, MA 02048 10) Establishment Owned By: ❑ An Association ❑ A Corporation V An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: SEPTIC DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 7 DAYS 12=9-em ja • PM 18) Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. 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: ❑d Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: Annual ❑� Seasonal Seasonal Dates: APRIL-OCTOBER ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) Food Service up to 100 or up to 10' PHF display $75 ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ( Meals/Day) ❑ Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 lV1 Milk & Cream $2 ❑ Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 # of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 ❑ Tobacco Products No Fee 23) Food Operations Definitions:PHF - Potentially hazardous food ftime/temperature controls required) Non-PHF's - non -potentially hazardous twalino time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑ 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 ❑ Delivery of Packaged PHFs - Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ 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- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health _ control) ❑ Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service. ❑ Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: $75.00 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 copies of 105 CMR 590.000 anfl the federal Food Code. 24) Signature of Applicant: A.Z x� rv.-.iY`..L.i Pursuant to MGL Ch.62C, sec. 49A, 1 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 June 1st of each year. NAME OF BUSINESS: FLINT FARM ICE CREAM ADDRESS: 789 EAST STREET TELEPHONE AT LOCATION: (508) 337-6473 FAX NUMBER: (508)-337-6473 OWNER OF BUSINESS: BETH FLINT TELEPHONE OF OWNER: (508) 339-7115 FEDERAL ID/SS NUMBER: 20-2648155 FEE: $2.00 PERMIT NUMBER: FS-22 SIGNATURE: DATE: 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. G1� 4-EJ * Signature of Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses pplicant Information Please : Business/Organization Nat Address: �) � 7 n City/State/Zip: Phone 0 61—C i�)-61/7. Are You an employer? Check the appfopriate box: Business Type (required): 1. X I am a employer with =/ employees (full and/ 5. [-]Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 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. $• ❑ 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, §l (4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]* 4. ❑ We by 11.❑ Health are a non-profit organization, staffed volunteers, with no employees. [No workers', comp. insurance req.] n/� � 12.4.Other Tip � �Aavi TLvAo *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 01. I am an employer that is providing workers' compensmiyn Insurancefor my employgrs. Below Is the policy information. Insurance Company Insurer's City/State/Zip: 1;l- 0 Policy # or Self -ins. Lic. # a o o J ( � t �� Expiration Date: q I / k / o Attach a copy of the workers' compensation policy declaration page (showing the policy number a d expirati n 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 certif%�y�under the pains an�dpenuddes o�f'perjury that the information provided above is true a d correct. Cinnan,rr• /i._l�l�� -i-' nara• oq l 1 I 0 33 2 -- Official use only. Do not write In this area, to be completed 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 NOTICE Irej EMPLOYEES NOTICE m EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above -mentioned chapter by insuring with: FARM FAMILY CASUALTY INSURANCE COMPANY NAME OF INSURANCE COMPANY P. O. BOX 656, ALBANY, NY 12201-0656 ADDRESS OF INSURANCE COMPANY 2003W6255 FROM DATE 4/14/09 TO DATE 4/14/10 POLICY NUMBER EFFECTIVE DATES FRANCIS E BINGHAM 875 PROVIDENCE HWY STE L10 DEDHAM MA 02026-6826 781-326-2002 NAME OF INSURANCE AGENT ADDRESS PHONE # FLINT FARM ICE CREAM LLC 789 EAST ST MANSFIELD, MA 02048-3458 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the I 1 ,, NAME OF hOSPITAL ADDRESS O _7Q TO BE POSTED BY EMPLOYER WC 7606g (2-02) UNIFORM