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HomeMy WebLinkAboutGlobal Food Truck Strategies, Inc. - 12/31/2019-4t (�6 / 1 (, 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: 16 GZGS Zl,_- Establishment Address: / o2G isG RSi/ �(� i 0 ( -5� • ce w 00 '� i 6 t ° 2 Establishment Mailing Address (if different): J�GGcaR JJ f�©x i30ZCa, All A C7��16 3 Establishment Telephone No: i'7 -q'7 7 - '7'7 1' 7 Applicant Name &Title: Applicant Address: La ti70 K I{'ALL is c,A✓i f 0)( r3 N O 4) 33, ',Applicant Telephone No.: G. j 1 • t/'7 2 —7 7y .' 24 Hour Emergency No.: Applicant Email: (� ( Owner Name & Title (If different from applicant): 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 An Association partner. Uf A Corporation Name Title Address El An Individualt?(u•), J�2C Ii�Ec�7 El A Partnership O Other legal Entity T ----..---_..__._----- --. _. - ---..- - - Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: � of I'loec;.00t� SEWAGE DISPOSAL: �cva It /lc�C %021� No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: S 4/h -1 v !I xi^7 Name of Person In Charge Certified in Food Protection Management: If morethan3 individuals are card 'ad, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): F1 Location: ❑ Permanent Location Establishment Type: ❑ Caterer $35.00 Mobile Mobile Start Date: ❑ Retail -NO FOOD PREP ( Sq. Ft) $125 0 Milk & Cream $10.00 Mobile End Date: Mobile Comments: Food Service to 100 seats )(INCLUDING FOOD TRUCKS $175.00 Food Service for 101 -200 seats $250.00 ❑ Food Service for 201+ seats $300.00 ❑ Supermarkets $400 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 El Manufacture Frozen Desserts/ice Cream $25.00/freezer 0 Pushcart $50.00 # of Pushcarts: E] Residential Kitchen $100.00 Tobacco Products $150.00 Retail Snack Food $50.00 Length of Permit: Annual -------- Q Seasonal Seasonal Dates: Ej Temporary Temporary Start Date: Temporary End Date: ---- ------------- Temporary Time: Raln Date: Food Operations: Definitions.,PHF - Non-PHF's (Check all that apply): RTE-ready-to-eat Potentially hazardous food(time/temperatum controls - non -potentially hazardous food(no a rre/temperafure foods (Ex. sandwiches, salads, muffins which required) controls required) need no fudherprocessing) 14 Sale of Commercially Pre -Packaged Non-PHFs PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs Lax Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly Susceptible Population Facility ckag E] Delivery of Paed PHFs 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially for S Service Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) -. Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service _. ❑Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs EJ Offers Raw Or Undercooked Food Of Animal Origin Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale 0 Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers ATE 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: 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 obtainpopies of 105 C 000 and the federal Food Code. Signature of Applicant: J 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. Social Security Number or Federal ID: 7 ;7" .S 8 s l c I Signature of Individual or Corporate Name: LC-,�4 L F062) 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. % 2 isclZ Signature of Individual or Corporate Name B Corporate Officer (Mandatory, i Applicable) i 8n rP Y� P y f PP **Social Security No. (Voluntary) or Federal Identification Number *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:\Uses\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc 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 Applicant Information Please Print Legibly Business/Organization Name:L City/State/Zip: 1',10e i-oo0�'J-0 d r vC� Phone #: Are you an employer? Check the appropriate 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. ❑ 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. [No workers' comp. insurance required] g• ❑ Non-profit 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, ff with no employees. [No workers' comp. insurance req.] 12.E�Other ,� �ab st2./1GG FrC3C G'� *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. Ian: an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: c /r/1 r� z S A 6Cam( G �� Insurer's City/State/Zip: l4 ./ Policy # or Self -ins. Lic. # (.[ c /_,� q �S n (b /4 Expiration Date: /. l 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 pain dpenalties ofperjury that the information provided above is true and correct. v6; 7 Phone #• !" /a�,_ 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 GLOBALF OP ID: MA DATE(MWDDNYYY) v -- GtK 11FIGATE OF LIABILITY INSURANCE 01/02/19 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(ies) must 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 endorsements . PRODUCER Phone: 617�89-1213 Cohen -Mlles Insurance Agey Inc 375 Concord Ave, Ste 005 Fax: 617-489-0151 Belmont, MA 02478-3045 Matt Cohen NCONTACT AME: PHONE FAX —� N° `t' E- AIL ----- _ _ ADDRESS: INSURER(S)AFFOROING COVERAGE INSURED Global Food Truck Strategies Kevin Tortorella INSURERA: Norfolk & Dedham Group INSURERS: 23965 INSURER C: 4 Fox Hill Road Foxboro, MA 02035 INSURER D : INSURER E: INSURER F CUVI=KAUCA CCKIirit A it munudhN: Oevlmnnr wusoco. THIS IS 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. INSIR LTR TYPEOFINSURANCE DDLISUBRPOLICY POUCYNUMBER EFF IMAM POUCYEXP MMIODNWY LIMITS ALGEN'LAIGGREGATE GENERAL LIABWTY RCIAL GENERAL LIABILITY IMS-MADE O OCCUR _ X R1542005A 11/11/18 11111119 EACH OGWRRENCE S 1r000,000 PREMISES Eaa occ�unence S 50,000 MED EXP (Any ane person) $ 5,000 PERSONAL B ADV INJURY S 1,000,000 _ GENERALAGGREGATE S 2,000,00(1 LIMIT APPLIES PER: PRO LOC PRODUCTS-COMPIOPAGG S 2,000,000 Food Spoi S 10,000 A AUTOMOBILE LIABILITY ANY AUTO �— ALL OWNED SCHEDULED AUTOS X AUTOS AUTOS �X� HIRED AUTOS I X NOWOED AUTOS I 91561848A 03/07/18 I 03107119 1 COMBINED SINGLE LIMIT Ea accitlent S jQQg,000 BODILY INJURY (Per person) $ — mi BODILY INJURY (Ppratlen0S —'-' PROPER DAMAGE Per acciEere —_ S -- $ q X UMSRELLAUAB EXCESS LIAR OCCUR CLAIMS -MADE X U1509307A 11/11/18 11/11/19 EACH OCCURRENCE S 2,000,000 H AGGREGATE DED 1 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOMPARTNEWEXECUTIVE OFFICER/MEWER EXCLUDED? (Mantletary In NH) If yes, tlemribe under DESCRIPTION OF OPERATIONS below NIA �. WE159306A 11111/18 11111119 X I WC STATLL I OTH- O 1 ITS ER E.L. EACH ACCIDENT _ S 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E,L. DISEASE -POLICY LIMIT I S 1r000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101, Adtliti°nai Remarks Schetlule, if more space is requlredl City of Boston are an additional insured. City of Boston 1 City Hall Plaza Boston, MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Matt Cohen t71988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD x N r Z m N z 0 A z AT D m q, oK Ulm, Pig- 0,m mRva d h Z mm t, t�y°op,�CG t; 9 b7 m to N DO 03 O Lym Kp�p "0 NW .0 Q'O �Ort, e�mf o pa +� 0� m N O .m N .W � a ^XO wy mp p N f�i' p.., m m Ms o w {a O m�j O .�Y ay. pj M ij6,�yAa 03 M ts N'rt ' m rs 1 N m m tsoyaa w"�.n"•' C o � Qq V O N- u NGm fm,m'm't m N b C "� � 0 o 4i � �. G �`y. ❑. m Y to ryyrtv. G�O mmAl za y iy y ..17 m C m r0`7. : to mo a IIt Cr mom Signature of Licensee ..... rZr,.ly.:4.:.-:��:.... .' !-.Gi. If ................... 9 4\% \ bKf a&%} \ \!, ) ©`� $(! 7 $ ! \ )\\ z » / 2 & / \ \ / & M 0 ) / ? � # y e d \ \ \ � ) \ \ \ § I � ►� I I a I .I ROD oF.ra,t TOWN OF NORWOOD F� BOARD OF HEALTH N Commonwealth of Massachusetts PERMIT TO OPERATE A FOOD ESTABLISHMENT NUMBER: 100589 FEE $160.00 DATE: April 18, 2019 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: GLOBAL FOOD TRUCK STRATIGIES INC WHOSE PLACE OF BUSINESS IS: 1208 WASHINGTON STREET NORWOOD, MA 02062 PRIMARY BUSINESS: FOOD SERVICE/CATERER SECONDARY BUSINESS: FOOD SERVICE SEATING CAPACITY: 0 SQUARE FEET: 1000 SQ FT TO OPERATE A FOOD ESTABLISHMENT IN NORWOOD PERMIT EXPIRES: DECEMBER 31, 2019 NORWOOD BOARD OF HEALTH SIGALLE REISS Follow us on Twitter (NorwoodHD http:healtlixonvoodmo.gov 566 WASHINGTON STREET—P.O. BOX 40—NORWOOD, MA 02062 TEL. NO. (781) 762-1240 — FAX NO. (781) 278-3000 TOWN OF NORWOOD BOARD OF HEALTH Commonwealth of Massachusetts NUMBER 100570 FEE $100.00 DATE: May 1, 2019 THIS IS TO CERTIFY THAT: GLOBAL FOOD TRUCK STRATIGIES INC 1208 WASHINGTON STREET NORWOOD, MA 02062 IS HEREBY GRANTED A LICENSE FOR: MOBILE FOOD PERMITS THIS PERMIT IS GRANTED IN CONFORMITY WITH THE STATUTES AND ORDINANCES RELATED THERETO, AND EXPIRES APRIL 30, 2020 UNLESS SOONER SUSPENDED OR REVOKED. NORWOOD BOARD OF HEALTH P.O. BOX 40 566 WASHINGTON STREET NORWOOD, MA 02062 'PERMITSf NON -TRANSFERABLE 1= SIGALLE REISS, SUPTIDIRECTOR Follow us on Tivitter r@r NorivoodHD http:heiltli.noitivoodmn.gov 566WASHINGTON STREET— P.O.BOX 40— NORWOOD, MA 02062 TES. NO. (781) 762-1240 — FAX NO. (781) 278-3000 OF,P`ORlGp�O. TOWN OF NORWOOD 2 BOARD OF HEALTH Commonwealth of Massachusetts PERMIT TO OPERATE A FOOD ESTABLISHMENT NUMBER: 100663 DATE: April 18, 2019 FEE $150.00 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: GLOBAL FOOD TRUCK STRATIGIES INC WHOSE PLACE OF BUSINESS IS: 1208 WASHINGTON STREET NORWOOD, MA 02062 PRIMARY BUSINESS: FOOD SERVICE/COMMISSARY SECONDARY BUSINESS: SEATING CAPACITY: 0 SQUARE FEET: 1000 SQ FT TO OPERATE A FOOD ESTABLISHMENT IN NORWOOD PERMIT EXPIRES: DECEMBER 31, 2019 NORWOOD BOARD OF HEALTH SIGALLE REISS PERMITS NON -TRANSFERABLE, Follow us on Twitter @NorwoodHD http:healthmorwoodmn.gov 566 WASHINCTON STREET— P.O. BOX 40 — NORWOOD, MA 02062 TEL. NO. (781) 762-1240 — FAX NO. (781) 278-3000 � MA-CR# P e eral Fire Extinguishers, Inc® P.O. Box 905 ® 314 Broadway a Taunton, Massachusetts 02780 (508) 822-1961 ® FAX (508) 822-0546 I Customer: cu7 C(o(eS otZC�� Date: Address: City/State: ak ¢O ®_ System Mfg.' & Type: &45 j .. Phone: t = ;_? tL% .___--____-- New/Hydro Date: Contact Name: �- CYlinder(s) Size(s) and Type: 40 2—.3 ' Annual: _ Semi: - Recharge: Install: _ —. Location of System: Fag 'T _ CHECKLIST. ✓ = GOOD, X _ PROBLEM, — DOES NOT APPLY 1 • v, SYSTEM C LINDER 2. ✓ CYLINDER 3G� � EIGHT �L 12. ^ ALARM CONNECTION 3. CARTRIDGE WEIGHT o� 13. "' ELEC. SHUTDOWN 4. ✓CONTROL EAD CONTROL PANEL 5. ✓ SHUT OFF ALVE 15. ZONE 1 STEADY SIGNAL 6. u DISCHARG (NOZZLES 6A. Cleaned 16. ZONE 2 PULSE SIGNAL 7. -- PIPE 17. TIME DELAY SECS I 6B. Replaced 18. "— HORNS &LIGHTS iRK '--SMOKE 8. DETECTIOCTIO N I 19. DETECTORS 9. _L RECOMMENDHOOD/DUCT BE CLEANED 20. 'RELAY SWITCHES __...' 10. ✓ CABLE I 21 ABORT BUTTON 11, 'CABLE PU L STATION 22 —SOLENOID RELEASE FUSIBLE LINKS: REPL 'CED yt e QUANTITY 'WO' J Iq COMMENTS: Tv 5 i Service Technician:[ i Customer: (PRINT) Service Technician:Z (SIGNATURE) P Custorrler: ' �, Service Technician Licen e #: _ �l" _ ( SIGNATU RE) _ Date: Witnessed By AHJ:— NOTE: If the hoodl.e local codes; haust duct and Fire System do enelal Fire Extinguishers earinnt not comply with N.F.P.A. 96, 17, 17A and all state ,and function of the! fire Protection 00"lipment. and will not assume responsi!?i0ty for the prnnel N v 0 A E a a Utm N N y Y C C 2 N N U L Y - c00v o ) m LL U O N 0 -y m Zo c� E Q I_ N m J O O 0 .0 a o D O N .mc E E m a n 5 Y E c 3 N > 2 N N J o w E c Z a m Y o f p i a v 0 0 O U O y LL m m rn j ti C C {p 0 0 p E L° m N 100 E OI L 'C N o c E a 3 y o f o c m m pd 0 a N p o TY o E m p U N a N C V N U � c N N •- W m E v y 0 E m L O r O pU U m 0 N 3 N Q U Q C U N J Y p C v N T C 2 N n rn° p a 3 rn 2 � u N N s C IDC C 2 G J S n p C O' O t0 N i G a�0i c n a f O A T° Y @ a c.i E = Y = m = c J T O LCO � � j O O y E $ rn T m ° m rn O w J 3 E O E A ! Q O j V N Y m` L D a = m G u d m C O p N O. y O N O m N O H .ONOa JV>c0 W �00 ¢ 'i01 N p N N .0 Qa ID C . N i O V p 6j If Or LL- 2m�N12y ? O wWO C3 Z WImVm 0o > Ov 'm O 0 w N-c a omEmo mM 0 o p wo :o3:�QO E�o O 0co i`. mm . m m P ..' wOmE m=Y>nm- ami .nc �aEi mo Yaar rno m c � tmpE Z oii Oot�mo :EroEv O E -IU q L c : co ED O u �.! N f no Subway Steve Adams Development President July 2, 2007 To whom it may concern, I have been developing SUBWAY® franchises in Alaska for over 20 years. Kevin Tortorella was my first franchisee and had the highest standards for training and store operations. Leadership, dedication, organization and community spirit —these are the qualities Kevin demonstrated as a SUBWAY' owner. Kevin started a SUBWAY' in Kodiak in 1989. He ran that store exemplarily. He went on to own six SUBWAY'stores in Fairbanks from 1991 to 2005. During that time, Kevin Tortorella worked his way to the peak of his profession. One of Kevin's Fairbanks franchises was distinguished as No. 1 in North America for 1996 and 1997. When Kevin opened SUBWAY''s Wal-Mart location in Fairbanks, the restaurant led the world in sales for locations of that kind. s Kevin put in the extra attention to detail that made his stores great. He personally managed the construction of every franchise. Kevin led 110 employees and 6 managers to achieve 3.5 million in annual sales. His experience in business and management will benefit any employer. OSincerely, Steve Adams President, Subway Development 4229 Laurel Street • Anchorage Alaska • 99508 Phone: 907.563.4228 - Fax: 907.563.4288 NUMBER MFT19-040 THE COMMONWEALTH OF MASSACHUSETTS Town of Avon % 0 _[.5i1", 3-1 1 Mobile Food Establishment Permit FEE $100.00 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the Massachusetts General Laws a Permit is hereby granted to: Global Food Truck Strategies, Inc. 1208 Washington Street Norwood, MA 02062 To Operate a Mobile Food Establishment in Avon, Massachusetts Permit expires on: December 31, 2019 Town of Mansfield 6 Park Aom, Mansfield, Massacbusetts 02048 Health Department Amy Donovan -Palmer, MPH, RJ4 Healtb Agent Massachusetts state law requires food establishments to obtain a permit from the local board of health. A food establishment is defined as an operation that: "...stores, prepares, packages, serves, vends food directly to the consumer, or otherwise provides food for human consumption such as a restaurant; satellite or catered feeding location; catering operation if the operation provides food directly to a consumer or to a conveyance used to transport people; market; vending location; conveyance used to transport people not including farm trucks; institution; food bank; residential kitchens in a bed -and -breakfast operations; residential kitchens for a cottage foods operations and ....... relinquishes possession of food to a consumer directly, or indirectly through a delivery service such as home delivery of grocery orders or restaurant takeout orders, or delivery service that is provided by common carriers." Please use the following checklist to ensure you have all the necessary documentation for a complete food establishment application: ❑ Food Establishment Permit Application. ❑ All Food Service establishments must attach copies of Serve Safe and allergen training certificates. ❑ If there is seating capacity for 25 or more, include anti -choking training certificates. ❑ Tax Certification Form. ❑ Worker's Compensation Insurance Affidavit: General Business is required. It must be filled out by the organization that is actually vending the product. ❑ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). For new Food Establishments, please contact the Health Department to determine if a Facility and Operating Plan is required. In order to obtain a permit, all documents must be filled out, signed and returned to the Health Department, 6 Park Row, Mansfield, MA 02048, If your establishment is cooking food and has indoor seating, you must obtain a common victualler license from the Selectmen's Office. Any filing for that does not meet these requirements will be returned and no permit will be issued. Sincerely, Amy Donovan -Palmer, MPH, RS Health Agent Phone (508)261-7366 Fax (508)261-7425 Emailadpalmer@rnanieldma.com