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Home My WebLink AboutPalagis Ice Cream (Summer Concert) - 8/15/2019Commonwealth 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: TEMPORARY FOOD PERMIT 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:. ALEX ARTEAGA Whose place of business is: PALAGIS ICE CREAM - SUMMER CONCERT SOUTH COMMON - SIX PARK ROW PERSON(S) IN CHARGE. ALEX ARTEAGA. OWNER Permit Expires: August 15, 2018 Food Fee: $50.00 License Number: T-20 BOARD OF HEALTH MichaecHeatey, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Temporary Food Establishment Permi p 0 (Application must be submitted at least 7 business days e the F Permit # Issued date) 1) Establishment Name:(/,I G I t .Z ce « .rL Establlphment Address: h� . G -S- Gv i U L/✓ 2 FG 49 Establishment Mailing Address (if different): Establishment Telephone No: Ldd 9,2 2) Applicant/Owner Name & Title: C� l) 4GIly opt Applicant/Owner Address: 3 t7 ` �LJ�i fl✓ Applicant/Owner Telephone No: 6 �A ` Applicant/Owner Email address: 666AAA 3) Person In Charge of Onsite Operations & Title: ��P� PIC Address: /7 lC oz PIC Telephone No e D f 61.20 Emergency/onsite Telephone No: PIC Email Address: ! . / f ,- ' e " " e O 4) Event Attending: 144 A/ tr- !Q 60 A L'p1t C(f ✓ Date(s): 19 GC G Event Name: Event Location: �/ � � 41 Event time: 5) Check one F` to" Food Truck %C o C,t e4," 11/1 vc44 o Caterer o Other: 6) Solid waste disposal plan: 7) Water Source: 8) Sewage disposal plan: 9 ) Please give a brief description of the food to be served: ie-o 6f1P/41" /Y6v�Gf�Cr �v� 0dv o� 10) Food will be prepared: o Onsite for immediate consumption o Onsite and held at proper hot/ cold holding temperatures o Offsite and held at proper hot/ cold holding temperatures o Offsite, cooled and reheated on site o Other: 11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: Food Safety Manager:i� Allergen Awareness: 4 12) Please describe on site hand washing facilities that will be utilized: 13) Please list all sanitizing solutions that will be on site: 14) If applicable, please describe your FOG management plan or attach the written plan: 15) 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 Base of Operations or Commissary permit: 1, 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 all other applicable law. I have been instructed by the board of health on how to obtalp �C!as 105 C��M//R 590.000 an4the federal Food Code. 19) Signature of Applicant:_ �2 Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed al(state-taKlreturns and paid state taxes required under law. 20) Social Security Number or Federal ID:,/ 1) 5 C) Ll 0 V// 21) Signature of Individual or Corporate Name: 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 By: Corpora Officer (Mandatory, ifA "Social Security No. (Voluntary) orFedera 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. Ine i.ommonweann ojrvltwsacnusen 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 City/State/Zip:�P , Phone r r, 0 2 Y eP /-; 02,Pe`4) Are you an employer? Check the appropriate box: Business Type (required): 1. [yI am a employer with 15 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]** 1 L❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *My 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 out an employer that is providin workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: t/ e 5" q —4 Insurer's Address: I / /%/' 2 / ?.fo 4 e Oti (f f1 2, City/State/Zip: Policy # or Self -ins. Lie. #_06 -r / / 2 Expiration Date: V /,2 1/ 2 a Attach a copy of the workers' compensation policy declaration page (showing the policy number . nd a(piration 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 ofperjury that the information provided above is true and correct 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 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 score 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 'omr Revised 5-26-05 Date: March Z1, 2019 Policy Number: 0000065312 u Mutual Insurance Co. Policy Information Page 1 Account Holder: Palagis 2000 hnc Agent Name: Maurice R Loiselle Agency Inc Address: Palagi's Ice Cream Agent Address: PO Box 1148 55 Bacon Street Pawtucket, RI 02862-1148 Pawtucket, RI 02860-4537 Phone: (401)723-8510 Agent Number: 00142 NCCI Carrier Code: 30325 Named Insured: Palagis 2000 Inc Dec Type: Amended Group Affiliation: Endorsement Reason Other Non Premium Change Transaction Date: 03/21/2019 Policy Number Endorsement Effective Date Endorsement Expiration Date Account Number 1 0000065312 1 04 11/2019 1 04/11/2020 1 20497400 2 Policy Period From ITo 04 11 2019 1 04 11 2020 1 12:01 a.m. standard time at address of named insured 3 A. Workers' Compensation Insurance: Part one applies to the Workers' Compensation law of Rhode Island. B. Employers' Liability Insurance: Part two applies to work in Rhode Island. The limits of our liability are: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY IN URY BY DISEASE $500,000 POLICY LIMIT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE C. Endorsements & Schedules: Endorsement Endorsement Endorsement Endorsement BE_00_00_01 - WC and BE 00_00_01A - BE_00 00 06 - Officers and BE_00_00_40 - OFAC Trade Employers Liability Policy Cancellation Endorsement Other Exclusion Sanctions Notice and Endorsement Endorsement This is not an Invoice Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconmulual.com Underwriting: 401.825.2667 1 Toil Free: 1.888.886.4450 BE_00_0 Page \\\\ \ ƒ(ƒ\ \ ;eG \ (\5\ \ / Z W 0 m . � Z d d m C W I ® LL Ol CO) = r x �j < .P