HomeMy WebLinkAboutMansfield Elks - 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:.
MANSFIELD LODGE OF ELKS
Whose place of business is:
MANSFIELD ELKS #2633
140 NORTH MAIN STREET
PERSON(S) IN CHARGE:
MARK WALSH, SECRETARY
Permit Expires: December 31, 2019
Food Fee:
License Number: FS-48
WAIVED
BOARD OF HEALTH Milk & Cream
MichaeCHeatey, Chairman
�r
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: M/iruSrl6�9 [ t-)c 5 (o CEIVIED
Establishment Address: /c/D N, MA)N S1 02-04
Establishment Mailing Address(if different):
TNOV 0 2 2018
Establishment Telephone No.: S'Gf- 7 b f - i S !F'°—
Applicant Name & Title: MA ZlC W47-50 Sfe,(WTii>Z)'
Applicant Address: JNb A), IAA+') St MA O'LOq9
Applicant Telephone No.: 6 17. ?3 7 - O S 6 q 24 Hour Emergency No.: (,)7
Applicant E-mail: E41cS 7-633 @, oo r' CAST'- NCT
Owner Name & Title (If different from applicant):
Owner Address:
Owner Telephone No.:
Owner E-mail:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
An Association partner.
O A Corporation Name Title Address
O An Individual --
El A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: hlj k)( b,JALSP S((AC r4l
Address: />♦p ,) nAl,sr Mn�st 1E D q ozoNb
Telephone No: 5-0& r Z 61 iS95 24 Hour Emergency No: 6 i7-8'39-0S6q
I
I FAX:
E-mail: ELKSZ��3cetnHc9ST. �i�
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: our Emergency No:
FAX: g
E-mail:
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS:
..__..........
Name of Person In Charge Certified in Food Protection Management
If more than 3 individuals are certified, complete list is on file.
Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑
Location: Q Permanent Location Establishment Type
❑Caterer $35.00
❑Moblie Moblie Start Date. �❑. Retail ( Sq. Ft)
Milk & Cream $10.00
Moblie End Date: Food Service up to 100 INCLUDING
❑ Mobile Food Consession
Moblie Comments: FOOD TRUCKS $175,00
NO PHF PREPARED ON SITE $100.00
Length of Permit:
❑ Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00
$25.00/freezer
Annual
------ ❑Food Service up to 201 + $300.00
❑Pushcart $50.00 # of Pushcarts:
Seasonal
❑ Residential Kitchen $100.00
Seasonal Dates: ❑ Supermarkets $400
❑Retail Food $125.00
El Temporary
❑ Retail Snack Food $50.00
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations Definitions:PHF-Potentially hazardous food(timeltemperature controls required)
Non-PHFs - non potentially hazardous foodpw limMemperatum controls required)
(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre Packaged Non-PHFs Qq. PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
- — ----- - ----- for More Than a Single Meal Service
Sale of Commercially Pre Packaged PHFs ❑ Preparation of PHFs For Hot And -___..___
-- - --- 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
�y ll Reheating of Commercially - .._
J j to be Prepared by Consumer Vacuum Packaging /Cook Chill
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
of Non-PHFs
Other Food Operations
Customer Self -Service
Ice Manufactured and Packaged for
Retail Sale
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities El Prepares Food/Single Meals for
Catered Events or Institutional Food Service
L] Retail Sale of Salvage Out -Of -Date — ____
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
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 1 Q5 �MR,590.000 and the federal Food Code.
Signature of Applicant:
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.
Signature of Individual or Corporate Name: MN A)Jrl6L]>
Social Security Number or Federal ID: Qy— 2_77e— G
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.
Signature of Individual or Corporate Name
t7 y - Z75 l 17 1
"Social Security No. (Voluntary) or Federal
Identification Number
S{(C ac7fJ,El
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:\Usm\sleite\Desktop\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
lne uommonweatta ofmassacnusetts
Department of Industrial Accidents
Offtee of Investigations
600 Washington Street
Boston, MA 02111
wwopanass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: C-'L(LS # 2.633
Address:
hi ET
Phone#:
Are you
an employer? Check the appropriate box:
Business Type (required):
1.9
I am a employer with 2— 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 (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]*
I1.❑ Health Care
4. ❑
We are anon -profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
12. ❑ Other
*Any applicant that checks box 41 must also fill out the section below slowing 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 Ail,
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy ittfortaation.
Insurance Company Name: 7'iu11j E tgR C 1 NSU It F}v✓ Q6
Insurer's
City/State/Zip: 14A1Z- F'ORj,C,% Obi0Z
Policy # or Self -ins. Lic. # 6 fi1J ry (<i �'�3 --1 ^' Expiration Date: 1 ] Az/a
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 ofpeijury that the information provided above is true and correct.
Phone #: Es / 7 -- ?-3 9 ` ns b y
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 Person: Phone #:
www.mass.gov/dia
TRAVELERS/ J WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (CHUB-1 K05813-1 -18 )
RENEWAL OF (GHUB-1K05813-1-17)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
1.
NCCI CO CODE: 13439
INSURED: PRODUCER:
MANSFIELD LODGE OF ELKS 2633 ROBERT W EAMES INS
140 NORTH MAIN STREET 126 NORTH MAIN ST
MANSFIELD MA 02048 P 0 BOX 289
MANSFIELD MA 02048
Insured is ASSOCIATION, LABOR UNION, RELIGIOUS ORG.
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 11-22-18 to it '-22-19 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
oe
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
ti= C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB
o
m=
D. This policy includes these endorsements and schedules:
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required Information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 10-26-18 WC ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: ROBERT W EAMES INS 73M9B
000787
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Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date / 11 6i 4
We, {:t� 2(�3.3 (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:
❑ 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.
F1 Other: rfp T6 K.o eiL G'2GAn lZf} f7'o n1
Thank you,
/W
Signature
sc&g 6---r/4 2/
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date: