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Home My WebLink AboutHourigan Family - 7/9/2019Commonwealth 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: STREET FAIR -FAMILY FUN NIGHT 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:. 197e1.k11:16111VIHe1►1 Whose place of business is: HOURIGAN FAMILY - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: DANA HOURIGAN Permit Expires: July 09, 2019 Food Fee: License Number: FFN - 5 l J/_1W A� BOARD OF HEALTH MtchaeC9-featey, Chairman FOR BOARD OF HEAL'T'TI USE ONLY Date Received Permit Fee Approved By Per i�t # Issu-rt_ Community Event Food Establishment Permit Application (Application must be submitted at least 7 business days before the event date) 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: u Date(s); Event Name: EventLocation:SC� Event time Df( t) Organization Name: 0�0 ji fat i11.0e,04 C C 2) Organization Address:. 3) organization Mailing Address (if different): r 4) organization Telephone No: is \ 7 W l � 1 15 7 5) Applicant Name &Title: 5-ee C:'\06` 7) Applicant Telephone No: Applicant/Owner Email address: S) App' 9)4please Person Directly Responsible ForDnsite Operations: der rb. Fax: lephone No: ve a brief description of the food an dlor drinks to be served: ��e' r.ne i.,f�rmation provided in this application and I affirm that the food _ . and I Ewan instructed by the board of TAX CERTIFICATION FORM IT _ I T 1- .c..., 1. 1 I certify tinder the penalties of belief, have filed all state tax r under law. Signature of Individual or C4-porate Name **Social Security No. (Volnntai y) or Federal Identificatrmi Number *This license will not be issued unl by the applicant. ** Your social security number will k Department of Revenue to determin tax payment obligations. Licensees delinquency will be subject to licen request is made under the authority Chapter 62C, section 49A. netts! iling or ding or This 14611 N Ilepar7nterr! gJ'fndreslrirrl Accidents k;rn _ O%free n/'/n veslrgahons — b 600 Washington Street Boston, AIA 02/// ., rviviv.rnass.govIdin Wurl(et;s' Compensation insurance Affidavit: General Businesses Applicant informatimr Please Print LeE3hiv BLISirICSS/Organization Nmttc: fit,;. �_ -- Address: C'i tv/CInIe.%%in: t?h C4 ,r„('+g"�` �'p'ry^ C�7 ;. fx`.:�A6. Phone 4rc you an employer: t irc.n u,c 1. ❑ 1 nm aemployel with employees (full and/ 5. ❑ Rotail 6. Restaurant/Bar/$ating Establishment or part -lime).' � : ?, I am a sole proprietor or partnership and have no 7, office and/or Stiles (incl. real estate, auto, etc.) corliloyces working for me in any capacity. g❑ EnteNon`profit [No workers' comp, insurance required] 3, ❑ sA+c arc a corporation and its officers have exeicrsed 9, rtaimnent nccir right of exemption per e. 152, § 1(4), and we have 10.0 Manufacturing no employees. [No workers' comp, insurance required]* 11 ❑ Health Care 1. 2 We are a }on -profit organization, staffed by volunteers, y with no employees. (No workers' comp, insurance req.] 12,®^Other /t A, kny applicant that checks box 81 must also till out the section below showing their workem' compensation policy information. 'I I'the Corporate off cers have exempiell themselves, but the corporation has other employees, a workers' compensation policy is required and such an g;mizatjot, should check box N I. am an employer that is providing workers' compensation insurance for my employees. Below is tite policy information.' ismance Company Name: tsur'c-r's Address: Y— ity/State/Zip: Expiration Date: olicy # or Self=ms. Lic. # ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). silure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 F up to $2.50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of lvestigations of the DIA for insurance coverage verification. do herell certify, under tire pains and penalties of perjury that the infornrntioa provided above is true and correct. i'll/ ^ r CL mature' 1j I r Date,: r 1 -- -- — none— Officia/ use only. Do not write in this area, to be cotapleted by city or town q%ficial. City or Town; Permit/License # issuing Authority (circle one): 1. Board of Health 2, Building Department 3, City/'Town Clierk 4. Licensing Board 5. Selectmen's Office 6.Other _ -- Phone M Contact Person: 'I www.nras.gov/dia Mansfield Board of Health Request for Pee Waiver for Food Permit Date « f (< We,c1�t eft} c r t (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason U 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 area religious organization. nthar- Jane Doucette From: Caitlin Barrows <Caitlin@Barrowsins.com> Sent: Friday, June 28, 2019 1:27 PM To: Amy Donovan -Palmer; Jane Doucette Subject: FW: FFN Attachments: 0628191114ajpg;0628191115a.jpg;0628191114jpg;0628191115jpg Mansfield Lemonade stand From: Dana Hourigan [mailto:dlhourigan@gmail.com] Sent: Friday, June 28, 2019 11:32 AM To: Caitlin Barrows Subject: Re: FFN I don't have her email and I've heard she's out of town now! Would you kindly forward these to her? I'm using all of my contacts for good measure! Thanks so much (attached). x, To the library and step on it! On Fri, Jun 28, 2019, 10:53 AM Dana Hourigan <dlhourigan@gmail.com wrote: Thank you. I tried calling but just got vm. To the library and step on it! On Fri, Jun 28, 2019, 10:48 AM Caitlin Barrows <Caitliii@baiTowsins.com wrote: They close at noon. I will call Amy now and see what she says. No worries! Enjoy your weekend Best regards, Cavf{,i,w f3o�rrowv Licensed Agent, Personal Lines Foxborough Office T:(508)543-1101 F:(508)543-1175 46 Central Street Foxboro, Ma 02035 Caitlin a)Barrowsins.com Error! Filename not specified. Great Coverage Starts With Great Advice. htti)://www.barrowsins.comZindex.htmi Error! Filename not specified.Error! Filename not specified.Error! Filename not specified. Error! Filename not specified. Get Connected! DATA PRIVACY AND SECURITY NOTICE: This e-mail message and any attached files are confidential and are intended solely for the use of the addressee(s) named above. If you are not an intended recipient or the authorized agent of an intended recipient, be advised that any unauthorized review, use, disclosure, printing, copying or the taking of any action with respect to the contents of this information is strictly prohibited. If you have received this email in error, please immediately notify the sender via telephone 508-339-7260 or return mail and permanently destroy this e-mail and any attachments pursuant to applicable law. From: Dana Hourigan [mailto:dlhouriganClgmail.com] Sent: Friday, June 28, 2019 10:47 AM To: Caitlin Barrows Subject: Re: FFN Oh, it's due today and I'm out of state. Plus I think town hall is closed on Fridays in the summer. 0 On Fri, Jun 28, 2019 at 9:27 AM Caitlin Barrows <Caitlin@barrowsins.com> wrote: Hi Dana, Here is the application for the health dept. It is kind of silly because I know its just kids giving it away for free! If you want to reach out to Amy at the health dept. she will be able to tell you what she really needs of these does. Best regards, Ca� f3o yr rowY Licensed Agent Personal Lines Foxborough Office T:(508)543-1101 F: (508)543-1175 46 Central Street Foxboro, Ma 02035 Caitlin c Barrowsins.com Error! Filename not specified. Great Coverage Starts With Great Advice. http://www.barrowsins.com/index.html Error! Filename not specified. Error! Filename not specified.Error! Filename not specified. Error! Filename not specified. Get Connected! DATA PRIVACY AND SECURITY NOTICE: This e-mail message and any attached files are confidential and are intended solely for the use of the addressee(s) named above. If you are not an intended recipient or the authorized agent of an intended recipient, be advised that any unauthorized review, use, disclosure, printing, copying or the taking of any action with respect to the contents of this information is strictly prohibited. If you have received this email in error, please immediately notify the sender via telephone 508-339-7260 or return mail and permanently destroy this e-mail and any attachments pursuant to applicable law. From: Dana Hourigan [mailto:dlhouri an gmail.coml Sent: Wednesday, June 26, 2019 6:19 PM To: Caitlin Barrows Subject: FFN Hello, I'm not sure if you followed the story last week of our lemonade stand that got stolen, and the amazing family who built us a new one. We'd like to give back to the town for their generosity and support by offering free lemonade at Family Fun Night. Can we do that? It's a small stand. To the library and step on it! To the library... and step on it! --David Foster Wallace