HomeMy WebLinkAboutMWOT (Touch a Truck) - 9/21/2019Community Ec t Fund Application- No PHFs.pdf
814119,12:29 PM
FOR BOARD OF III;iALTII USA ONLY
Date Received Permit Fee
Approved By 1,I
AU6
Community Event Food Establishment P60ni.
(Application must be submitted at least 7 business days before the
This application should only be used by organizations that are not food establishments but plan to
distribute non -potentially hazardous food or drinks at a local community event.
Community Event: , +
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Event Name:
-- (ci6 'a TZ
Event Location:
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Event time:
1) Organization Name:o
2) Organization Address: i
oX 2 rA U
3) Organization Mailing Address (if different):
4) Organization Telephone No: 0 ,c 3��
5) Applicant Name &Title: '�� GLFY'Ot't�2-S��(�1/L{�ur�
7) Applicant Telephone No: 3
a) Applicant/Owner Email address: � p
9) Person Directly Responsible For Onsite Operations:
Name & Tithe:
r - �5 (1
�7
Address:
) l.1 l�� ri1M�
Telephone No:
ri / q _ 2 '2 Fax:
Emergency Telephone No:
CAAAA A,
10) Please give a brief d esscsip�tionn ofthe food andlor drinks to be served:
Q r lr -(/ i D/ l/
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 obtain copies of 105 CMR 590.000 and the federal Food Code.
11) Signature of Applicant:
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W;�i®®�Terri $1(eraraase
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M347-701a
Ii➢TERnAL REVERUE sFRvICE
DISTRICT DIRECTOR
P 0 Box A-3290 DP-N 22-2
CHICAGB� IL 60690
Gate: NOV 17 19
LW-'TEO STATES ROMER OF TODAY
FOUNDATION
ATTN MRS FRENCH
1304 N MASH2eRGTON
JONESBORO, AR 72401-2564
Dear Applicant®
_- _Loy vVllP
DEPARTMENT OF THE TREASURY
r'
EmpIP-Dyer Identification Number.
Contact-PersonT _.
MRS. R_ COOLEY
Contact Telephone Hurfhers
(912) 336-%273
Addendum Applies;
nn '
Eased Ors the 'ofoma'tlou you recently submitted, He have classified
your organization as one that is not a private foundation within the meaning
of section 509(a) of the Internal Revenue' Coda because you are described in
sections 509(a) (1) and 170(b) (%) (A) (vi).
Your esaempt atatras under section 501(a) of the Internal Revenue Code as
an organization described in 501(c)(3) is still in effect. ,.._
This classification is based on thA assumption that -your operations will
continue as you have stated, If your sources of support, or your purposes:
characters ar ecethrd of operation changes plaus.e let us know SO we can consider
the 'effect of the change on your exempt status and foundation status.
This supersedes our letter dated Oct. 15, 19y2_
Grantors and cOutributGrs May rely on this determination unless the
Internal Revenue Service publishes notice to the contrary.. Kowever, if you
lose your section 509(a)(1) status, a grantor or contributor may not rely on
this determination If he ar' she was in.part responsible for, or was aware rfp
the act or failure t&'act, or the substantial ar material change on the part of
the orgganization that resulted in yovar loss of such 'status, or if he or She -
acquired knOuledge that the Internal Revenue SerVice had given nr,tice that YOU
euld no longer be classified as a section 509(a)(1) orgganization.
If we have indicated in the heading of this letter that an addendum
applies, the addendum enclosed is an integral part of this letter,
Because this letter could help resolve any questions about your private
foundation status you should keep it in your permanent records.
Letter 107$(DO/Cu)
UNITED STATES WOMEN OF TODAY
If you have any questions, please contact the person uhoSe name and
telephone nuoher are shoHn -above.
I
Sincerely yours, -
1
Marilyn W. Day
District'Directur
Letter iQ73.Ot3l�07 -`
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C:rt;= srslesErDa�-tep Scatta Doaaaents Food .Establishments-T_etnpseLY CERr=C TION FOILRtdac
The G'ommonsvealth ofil-&ssachusetts
Department oflndtis&ialAccidettts
Office of Invesdgations
600 Fi`ashzng#on S&M
Boston, M4 02111
svtsay.n=s govldia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le2ibiy
Business/Organization
MMECIMMM
Are you an employer? Check the appropriate box:
Borinen Type (required):
1. D]
I am a employer with emplc}es (full and:
5_ n RetaiF
otpart-time).*
6. PRestaurantBariEatingEscrbhshment
2. ®
I am a sole proprietor or partnership and have no
7. 0 Office andior Sales (incl, real estate, auto, etc.)
employees %%othing for me is any, capacity.
& El Non-profit
[No workers' comp, insurance required]
3.. D]
We are a corporation and its officer% have exercised
9. Q Entertainment
then right of exemption per c. 151 y§1(4): and %ire have
lo_(l Manufacturing
,,_j
no employees. [No worker' comp. insurance required]'
I LEI Health Care
d.)T(1
�
We are a non profit organization, stafi`ed by t-alunteer�
110
with no employees. [No %porkers' camp. insurance req.]
0ther
'im• applicant that dwd4i box al tuun also all out the sacrion below tboll* their %poricue' campen usu policy infoansam
-If the corporate afficm ha-e exempted flxamselcas, but the corporation has ocher emplmzes, a naskaes' compensation polio•• is tecraind and nch an
oreaoizattca sbould cbeci: boa -1.
I ain an entplat'er Mat is providing workers' contpensabott htanran ce for mp enipkrees. Selmv is Ate policy i j'orntadon.
Insurance Company Nar
Insurer's Address;
citpstate Zip;
Policy 'I or Self --ins. Lic.
Expiration Date:
Attach a copy of the workers' compensation policy declaration page (shon inn 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 -near imprisonment, as %%•ell as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S'50,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DU for insurance coverage verification-
1 do hereby, cerdf'v, under Ate omits and uetta&ks of nerniry Aral Ate infortuardon prodded abovir is bite and correct.
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Page 4 of 5
Official use muLr. Do not write 8t di is area, to be com kii-d by e* or town official
City or Town:
Permit/Lkense t1
Issuing Authority (circle onc)a
1. Board of 1Tealth ?. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact
Phone
nv w.mu9.gov: au
Information and Instructions
11assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an ernplaree is defuted as ",..every person i a the service of another under any contract of hire,
express or implied, oral or written_
12
An emptier is defined as "an individual, partnership, association, corporation or other legal entity, or any taco 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 titan three apartruents and who resides therein, or the occupant of the
dwelling house of another who employs perzAms 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."
MOL 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, MOL chapter 152, §25C(r) states "Neither the commonwealth not 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 haw a been presented to the contracting authority."
Applicants
Please fill out the vrorkew c=pens stcn 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 attfle number listed below. Self insured companies should enter their self-insurance license number oathe
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 Invettigaticros has to contact you regarding the applicant,
Please be sure to fill in the perimulicense number which will be used as a reference number. In addition, an applicant that
must submit multiple permitlicense 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. IMiere a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (e_ a dog license or pennitto burn leaves etc.) said person is NOT required to complete this
a9idaviL
The Office of Investations 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.
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Page 5 of 5
the uepa ent 3 a=ess, teiepnone MW tatnumv :
The Commonwealth ofNlassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, N24 02111
Tel. # 617-727-4900 ext 406 or 1-8774NiASSAFE
Fax 0 617-72 7-7749
ti4tivtv.suass. Qovldsa
Form Reviud 3.26�03
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Date
IM
Mansfield Board of Health
Request for Fee Waiver for Food Permit
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:
P 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,
o
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
Community Event Food Application- No PHFs.pdf
8/4/19, 12:29 PM
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 hridividual or Corpora& Name or ate Officer (Mandatory, if Applicable)
"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.
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