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Home My WebLink AboutChabad Jewish Center - 7/9/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health 1 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:. RABBI YOSSI & TZIVI KIVMAN Whose place of business is: CHABAD JEWISH CENTER OF MANSFIELD - MANSFIELD FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: RABBI YOSSI & TZIVI KIVMAN Permit Expires: July 09, 2019 Food Fee: License Number: FFN - 3 WAIVED F1671 0Zo7iff:I4e141aI AichaeCWealey, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Iss d E 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: Date(s): c `i"tc -) =� 2) Organization Address: Event Name:iY 3) Organization Mailing Address (if different): Event Location: 4) Organization Telephone No: n 7 Event time: 1) Organization Name: `^ c `i"tc -) =� 2) Organization Address: 3) Organization Mailing Address (if different): 4) Organization Telephone No: n 7 5) Applicant Name & Title: 7) Applicant Telephone No: ^ - - r 8)ApplicantlOwnerEmail address: '�;�� ?�ti��1,m 1,�' � � CCm 9) Person Directly Responsible For Onsite Operations: Name & Title: `7 \Y Address: Telephone Na Fax: Emergency Telephone No: 10 ) Please give a brief description of the food andlor drinks to be served: \(yn,cc ' �c � c Ccrcc - 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 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: 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 idividual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, ifApplicable) *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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Stree4 Suite 100 Boston, M4 02114-2017 r = www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH TEE PERMTFTING AUTHORTTY. Applicant Information Please Print Legibly Business/Organization Address: WTI Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2:0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3, ❑ We are a corporation and its officers have exercised Their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]' 4. [XWe are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. Restaurant/Bar/Bating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. [[✓]/Non-profit 9. ❑ Entertainment I0. ❑ Manufacturing I L ❑ Health Care 12.❑ Other tAny applicant that checks box # I must also fill out the secdon below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the carporadon has other employees, a workers' compensation policy is required and such an organization should check box''#1. f am an employer that is providing workers`' comp nation insure ce fol• my employees. Beloyw is the policy information. Insurance Company Name: (. i � I J, insurer's City/State/Zip: Policy # or Self -ins. Lits. #- 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 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 maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify ,under the pains and penaldes ofperjury that the information provided above is true an correct T 1 �( 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 Person: Phone#: www.Tnns.gov/dia Information and Instructions Massachusetts General Laws chapter I52 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 ajoint 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, Iinweyer, 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 bouse 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 `either 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. Tf 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 sbould be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Sbould 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 fisted below. Self-insured companies sbould 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. Tbo 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 contactyou regarding the applicant Please be sure to fill in the permit/ticense number which will be used as a reference number. Tin 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 thebity 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 ficense or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,.MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 Mansfield Board of Health Request for Fee Waiver for Food Permit Date We, AV \,C 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: Y/ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * 1Yve are donating ALL proceeds earned directly to a 501(c)(3)^organization. Please list the organization: (1 Y ❑� C i w�C �� r� �� ❑ We are not charging a fee for food/drink being served ❑,,We are a religious organization. ❑ Other: Thank you, Sign% Title �) *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: