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HomeMy WebLinkAboutCongregational Church - 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:. CONGREGATIONAL CHURCH OF MANSFIELD Whose place of business is: CONGREGATIONAL CHURCH OF MANSFIELD - FAMILY FUN NIGHT PERSON(S) IN CHARGE: MATTHEW & JENNIFER JOHNSON Permit Expires: July 09, 2019 Food Fee: License Number: FFN - 4 BOARD OF HEALTH Michae(Hea(ey, Chairman FOR BOARD Or HEALTH USE, ONLY EDatoeived Permit Fee Approved By Permit # Iss, tort t. 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: �_64nlI t tAVI Nj ' Date(s): ""r• Event Name: Event Location: Event tlme:, p Q ymtVGrt, / "' R p• tA9. 1) Organization Name: �a �—!6 nre 2) Organization Address: L t`+ 3) Organization Mailing Address (if different): NIA 4) Organization Telephone No: 50 � " q ,.- 4791 5) Applicant Name&Title: fjehn,� • i �,,,jUYl i1 �f f"L� ) VO>1)Cr�V _�' 7) Applicant Telephone No: -7-74 .. Uo .. RI 0) ApplicanNOwner Email address: t H1 ' LitLH �+o ,�-�-100K . 9) Person Directly Responsible For Onsii+to Operations: VCn Name & Title: Ivmfet r S Address: 3ogL�`� Telephone No: I �- �,.G 0 Fax. Emergency Telephone No: r e1 CJ o e r ,sm .- a34 3 •a _ y i y 10) Please give a brief description of the food and/or drinks to be served: • L.e.wtona.de. i n laurge cii�!�er+scrs �mad�., �owr. car�5 f a�F�S ire �° � 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 106 CMR $90.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 10h 0.000 ancj,44 federal Food Code, 11) Signature. ofAppticantr 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. inahve0f Individui/r Corporate iNhmc vol" j2Cit. 4L Copp. C%� a- Mn rseld V 16G5 "Social Senlrity No. i Vohatta y) or Federal Mevtifiorliou Number Bp: Corporate Officer (Adandalory, if Applicable) 13-/9s7aa1 *This license will not -be issued unless this certification clause is signed by the applicant. *Y' 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 -I heh .dcite D,Awp Food Eitabbalnnemc- Tan)l'AN C61C1 I FICA 110N FORM duc The Commonwealth gfMissachusells Department ofludustrial Accidents Office gfInvestigations 600 Washington Street Boston, MA 01111 w viv.nlassgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lel>_ibiv Business/Organization Are you an employer? Check the appropriate box: Business Typo (required): i,❑ I not a employer with _ employees loll and; ?• ❑ Retail orpurl-time).' 0. ❑ Restaumli Bar/Eating Estahlkhmcnt _'. ❑ I nm a sOlc proprietor Or partnership and have oo 7. Office and/or Sines (incl. real estate, auto, etc.) cmployccs working I'or me in any capnc it}'. [No workers' comb. insurance required] a. :'on -profit 1. ww'c are a corp01'aliori and as, officers hake cXe'elsed r/. [] Eowrlainvocnt their right of exemption pci c. 1 52, 51(11, and we have I (1.El ;vlantilaewring w employees. [No workers' comp. instairice reyuiredj'::• 11.❑ Health Care d. wire mo a non-profit organization. staflctl by voluol s, will) no employees. [No workers' comp. insurance cell.) 12.© Other .. _... _ \ny arphmolt Ih of chock. hat �I mud s1>n lilt oil the wows hrloa n11MVmX Ihcir Is kit MS, cruupcusmovn pohap mlimnaoon. —II am empow to oll wee, haw ewillpled Ihamselves, IIIa the cnrrurullun ha, nl her cmplo�cu. a Ifnrkvn' oampalsali nn puhp, n lnluireJ mod such do vnamoi/al unl should checl: III, al I rill an etaplgver drat is providing workm•s' canrpensalion insurrrrrcr Jbr nil• clop/orce.9. Melon. is the polite' /nfarnraaon. Insurtmee Company Nnmc: Insurer's Address: City: State'Zip: .. „ Policy d or Self -ins. Lic. b Attach a copy or the worlters' enmPensatinn Palk}' declaration page (showing the police number and expiration date). Failure to secure coverage as required under Scctioa 25A of MOIL c. 152 can lead to the imposition ol'eriminal pcnullies of s line up tit'51,500MO and%or one-year imprisontnenl, :ts well as civil penalties in the limn ofa, STOP WORK ORDER anti a fine of up to 3150.00 if day against the violator. Be advised that if copy of this statement may be forwarded to the Office of Inyestigalions of the DIA Ibr insurance coyera,_>,e verification. I do herekr eertiJy, pVtde(rhe pains cord penrdriex of parjury that tire, in formation prorided above is true caul corrert r(tolle'g: Official rise only. Do nor write in this area, to be completed by cior ar town affieird. City, or Tow'u: Permit/License Issuing Authority (circle onw: I. Board of Ilcalth 2. Bttilding Dcpornnent 3, C'itytTuwv Clerk d. Licensing Board S. Selectmen's Office 6. Other Contact t ersou wkrkcums> hovhfia Phone M f � . Mansfield Board of Health Request for Fee Waiver for Food Permit Date (o Q We, 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. e are a religious organization. Other: Thank you, et ig aturle VCJ14fc. e' Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: