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HomeMy WebLinkAboutSt. Mary's Catholic School - 12/31/2019Commonwealth 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 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:. ST. MARY'S CATHOLIC SCHOOL Whose place of business is: ST. MARY'S CATHOLIC SCHOOL 330 PRATT STREET PERSON(S) IN CHARGE: MATTHEW A. BOURQUE, PRINCIPAL Permit Expires: December 31, 2019 Food Fee: License Number: FS-69 WAIVED BOARD OF HEALTH Milk & Cream MichaecYleatey, Chairman Vx i V� FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: 5t J-5 Establishment Address: 330 �q�ki gt5� elOt oLo �8 Establishment Mailing Address (if different): Establishment Telephone No: 5 o g • 3�a • A Applicant Name & Title: 4v . Applicant Address: e(-C.• + 'C� S t Applicant Telephone No.: 24 Hour Emergency No.: Applicant Email: Owner Name & Title (If different from applicant): 9c . M aM `5 0 U o lst �U(n o0 Owner Address: J Owner telephone number: Owner email: Establishment Owned By: if a corporation or partnership, give name, title, and home address of officers or El An Association partner. 13 A Corporation Name Title Address 11 An Individual O A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: P�tnJ (� • (�e�/ ( Pr1 r LiwQ � (�FY 0 vQ f Address: f;y2e, Mw✓ S a Er� Telephone No: 24 Hour Emergency No: FAX: 5 Q . 'b3i E-mail: MQbuvrGVk'UFiSkivLa wuw�ss oo(.Q Alt E-Mail: ®"Js 1 Cd riMWJWULVt 124dA106 1. 9T� � t v� D 3h� ?;iv A / A-A&,,A ✓, , District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 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. L . 6-2 = Signature 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. C:\Users\steite\Desktop\Scoter Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc IINL N i.w vou.... v.. rv, . J ua wwwe..suuw Department of Industrial Accidents 'Office of Investigations 600 Washington Street Boston, MA 02111 Wi— www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �k ' ^ " s ° i" ° C& ° ° t Address: b-q o MS't M(k City/State/Zip: Phone M Are yo 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. 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, 12.0 Other with no employees. [No 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 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 that the information provided above is true and correct. �fia 0t�0bi �. �Vuo Official use only. Do not write in this area, to be completed by city or town official City or Town: PermittLicense # 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: Phone #: www.mass.gowma A� LIP CERTIFICATE OF LIABILITY INSURANCE DATEIMMMDNYYY) 01/03/2019 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 policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder In lieu of such endorsement a . PRODUCER Massachusetts Catholic Self Insurance Group C T AME: T PHONE X- 617-746-5742 ac Not: 617-7794572 +"AIL , losscontrol@masseatholic.org 66 Brooks Drive INSUREI 8 AFFORDING COVERAGE LAIC If INSURERA: Massachusetts Catholic Self Insurance Group Braintree MA 02184 INSURED INSURERC: Diocese of Fall River, MA IN RERERD: Office of The Chancery INSURER E: 460 Highland Avenue / POB 2577 INSURERF: Fall River MA 02722 Cr1VFRAr.FN CERTIFICATE NUMBER' REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRTYPE OF INSURANCE ADDLB BR POLICYNUMBER POLICY EFF DDIMWDDNYYYl POLICYEKP LIMITS COMMERCIALGENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE S DAMAGE TO RENTED PREMISES Ea occunence $ MED EXP (Any one arson) $ PERSONAL SADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ jEqCf LOC OTHER: GENERALAGGREGATE $ PRODUCTS -COMPIOPAGG $ $ AUTOMOBILELIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT E r1en0 $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE Per ecoldent $ S UMBRELLALIAB EKCESS LAB OCCUR CLAIMS -MADE EACHOCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFIC ANYPROPRIETORIPARTNEWEXECUTIVEatIn NH) ❑ (Mandatory InNH) RE%CLUDED? If yyea describe under 0ESdft PTION OF OPERATIONS balm NIA Certificate of Approval Commonwealth of Massachusetts 3000001012018 07/01/18:: 03/31/19 E xis TATUTE ERH E.L. EACH ACCIDENT S 1,D00,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT a 1.000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace is required) Re:046.0 1046-3 St Mary's Parish & School 330 Pratt Street Mansfield, MA 02048 Evidence of Workers Compensation Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield, MA 6 Park Rowe Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE ©1988.2o15 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD l • 1 ~r • ti r :.Y ✓ s? oAo NON CMC V 3JV oWp 9p9 EOE m'c fof �zt ;oo �aq c'a u� Ri � \ � � w u � � � \ k ) - _ \ \ \ z / / 1 A «■}_ / »F&\ \ ƒ\§\ } |p\> \ 4{®u ! � / 0 Mansfield Board of Health Request for Fee Waiver for Food Permit Date We �� y Cwo l `;C�A ° 0 (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department, Please list the department: W We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. * Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, Signature Pr AC. �d' Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: