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HomeMy WebLinkAboutThe Downtown (Taste of Tri-town) - 10/1/2019Date Received FOR Permit Fee WRI IIIIIII.INIMM Approved By Temporary Food Establishment Permit Application``` (Application must be submitted at least 7 business days before the planned opening 1) Establishment Name: %7„ 9 c� w / v � c 2) Establishment Address: 0) 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 564_ 1155-- Z35c 5) Applicant/Owner Name & Title: /L /J „ � i �J^ f 6) Applicant/Owner Address: rr 6,?—f 7) Applicant/Owner Telephone No: 8) Applicant/Owner Email address: 9) Person Directly Responsible For Onsite Operations: Name & Title: e ,ZL - b , 4 e Address: //U Telephone No:� _ 2� 3�J Fax: Emergency Telephone No: �ll2z 10) Event Attending Date(s): Event Name: Event Location: ,aYA e1 C/ r z ,99 6)l Event time: 11) Check one Food Truck Caterer Other: 12) Solid waste disposal plan: 13) Water Source: 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: ¢ewe) Town of Mansfield 6 Pmk Ron), [YlanrflelA, Allasinchusells 02044 To: Taste of the Tri -Town Participants From: Amy Donovan -Palmer, MPH, RS, Health Agent Date: July 18, 2019 Re: Permitting Requirements Dear Taste of the Tri -Town Participants, Health Department Any Donavan Palmer MPFI, RS' Pleallh Agenl Since the last Taste of the Tri -town event, there have been several changes made to the Food Code with regards to permitting. Please review the following requirements to determine necessary documentation based on your operation. No permit is needed if your establishment: • Currently holds a Mansfield Food Establishment permit. • Serves only pre-packaged food that does not require time or temperature control. • Currently holds a CATERER permit in another town. Caterers must submit the following: o A copy of the current Food Establishment/ Caterer permit. o Food Protection Questionnaire for Catered Events. (attached) For all other vendors, please submit ALL of the following completed documentation: • Temporary Food Establishment Permit Application. (attached) • Food Protection Questionnaire for Caterer Events. (attached) • The Tax Certification Form. (attached) • The Worker's Compensation Insurance Affidavit: General Business. (attached) • The Worker's Compensation declaration page. • Fee waiver form. (attached) • Food Protection Manager Certificate. • Allergen Training Certificate. In order to obtain a permit, all documents must be filled out and returned to the Health Department, 6 Park Row, Mansfield, MA 02048 no later than September 20, 2019. Please contact the Health Department with any questions. Phone (508)26/-7366 Pax (508)261-7425 Ernall acpnlnrer@niansfelchua.coru The Commonfpeafth of Massachusetts Department of hidustrial Accidents Office oflitmstigations 600 Washington Street Boston, MA 02111 tprpw.mass.gop/elia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information �1 Please Print Legibly i ilsiness/Organization Nane: 7 G L C Address: 029,2 &0, !' t7l;,) City/State/Zip: 60,6.L j &/9 &Z1,46 Phonelt: 5-09- 2.336 Are you an employer? Check the appropriate box: Business Type (required); I. I am a employer with/ � employees (full and/ 5. ❑ Retail or Part-time).* 6. Westaurant/Dar/Eating Establishment 2.0 t am a sole proprietor or partnership and have no 7. ❑ Office caul/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ 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]** 4.[:] We area non-profit organization, staffed by volunteers, I L❑ Health Gere with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant and checks box If I must also 611 out die section below showing their workers' compensation policy information. **If (he corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organirn(ion should check box 81. I am cru employer thtit is providing lvorkers' cotialwina lion insurance for my employees. Belo(v is the policy irf/orumtion. Insurance Company Name:_ 7-/u hqi(/cl etlS 1 S Iz 2 L'C/ U nn Insurer's Address: /'c% 66X 1115D %%i/ dc11,�j6,,V b Z 3 city/State/zip:z 7 tiyc� C3��f- //-/5Z� Policy # or Self -ins. Lie. # 016 - c3 t[ O t 37-00 1 � -/Uz — iS 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 Gne tip 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 herebt, ceNify, under the pains nn(% pelMIt/es of peijur�that the iii i-Itration provided above is trite rand correct. "I� Phone # b( - 66y_ z 3 3 C�- Official use only. Do no( write is this area, to he completed by city or tmnrr of/icML City or Town: Permit/License it 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 #: 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. cl�_ zo_ iL Signature of Individual or Corporate Name 617 -(3'1(9G X61 **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\sleite\Desktop\ScotCs Doeuments\Food Establishments-Temp\TAX CERTIFICATION FORM.doc NOTICE TO EMPLOYEES �L\ NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/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: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY UB -3J073288 -19-42-G 07-10-19 TO 07-10-20 POLICY NUMBER E5TABROOK & CHAMBERLAIN PO BOX 277 BRIDGEWATER, MA 02324-0277 EFFECTIVE DATES NAME OF INSURANCE AGENT ADDRESS PHONE # THE DOWNTOWN 292 W MAIN ST 292 LME INC DBA NORTON MA 02766 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) MEDICAL TREATMENT 107.11M 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 Workers' 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 NAME OF HOSPITAL w20P1G15 TO BE POSTED BY EMPLOYER ADDRESS I 0 D OD O Q O T m � T 3 —1 O m Z A S � M 0 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Nagle of Recipient: ELIZABETH STENTIFORD Certificate Number: 2421425 Date of Completion: 71=016 Date of Expiration: 7"2J20r Be ab6ve name 1 penon is be, ely issned this certxmte Jar ronapl<rrng an all r�rn navarcaazsr dainanA prognana „ rcrognized hp the Massadrnsetts Deparinimt o(Pnhlk HeA in nriord ante with 105 ClIR 590.009(C)(3)(aj. Djis iertifrnne-will be tnlid lw,(ic, (5)tan's rwn date of rmnplelion. Lx dBy: a' n•� WAN,, hfuMchuscies Re o.,Asm:incion 333 T.lik, Rua, Suitt 102 S.. hb.gh, MA 01772 508-.303-9905 www.maeesnurmcaiwc.usg MV -P NATIONAL. C RESTAURANT ASSOCIATION© 500.765.2122 .vaenscaurmcosg 16 ) Food will be prepared: Onsite for immediate consumption Onsite and held at proper hot/ cold holdin temperatures e and held at proper hot/ cold holding tempera ures si e, ea a on see Other: 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager: !8�HL Allergen Awareness: %3C -Y?( i E17�- 16) If applicable, please describe your FOG management plan or attach the written plan: 19) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit: For food trucks, please list additional communities where a food permit is held and attach copies of the permits: 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 al),other applicable law. l have been instructed by the board of health on how to obtain copies of 105 CMR 599.00P and the federal Food Code. 19) Signature of Pursuant to MGI_ 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 paidsttate taxes required under law. 20) Social Security Number or Federal ID: `Y 7-3 4l 06 6663 21) Signature of Individual or Corporate Name:�`✓cs Food Protection Questionnaire for Catered Events Date of Event: Event Time: 6�%/W - zew-z Location of Event: �11/(sl� t (�_ _f' -Y6 ak-) c2Aeul Y List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating Jr L, Food Manager Certification Person Trained On Site? vI Yes o No Allergen Awareness Menu Label Present? Yes o No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: /L/Si C9�tc%//uy`ie/ %PUiY� Cp�2riC (�5 AIJ%jy(/%>ef List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 41'F? How will the PHF be kept at or above 140°F? olxr o Time of PHF? Setup �Served Removed 7�y� cp e List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. CM c� eo S� �i�yri'�72W Mansfield Board of Health Request for Fee Waiver for Food Permit Date _/ m We, rant/ 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 ✓ Other: TASTE OF THE TRI -TOWN Thank you, NA M L IQ Signatufe �14 flf Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: 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 a joint 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 burn 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 Forth Revised 5-26-05