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Home My WebLink AboutScouts BSA Troop 51 - 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:. OUR DAILY BREAD Whose place of business is: SCOUTS BSA TROOP 51 - MANSFIELD FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: Permit Expires: JUIy 09, 2019 Food Fee: License Number: FFN - 9 WAIVED BOARD OF HEALTH _%IichaeCJ-feaCey, Chairman FOR BOARD OF HEALTH USE ONLY =Received Permit Fee Approved By Per nit # Issued 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: 1'1fr571N.W Yfj&%ILI it)f tjIb{!® Date(s): 3) Organization Mailing Address (if different): 4) Organization Telephone No: '568 9 ?1)- 3 yam® Event Name: 7) Applicant Telephone No: 50 8 1 y-4 3 ya Event Location: mold � J Event time: ® 1) Organization Name: JC'Q 0'7JJ��g .S 2) Organization Address: -7o ?C -j'1S(q , \ P • Ffsr�l �= �-� r /Il "P y3 3) Organization Mailing Address (if different): 4) Organization Telephone No: '568 9 ?1)- 3 yam® 5) Applicant Name & Title: &D UI4 aZ124'j o oz—_> 7) Applicant Telephone No: 50 8 1 y-4 3 ya 8) Applicant/Owner Email address: 'E h (J('Ja'512'W00-> 9) Person Directly Responsible For Onsite Operations: Name & Title: t U Address: O • Telephone No: Fax: Emergency Telephone No: 7 8 9 Y.;l, 3 ya S 10 ) Please give a brief description of the food and/or drinks to be served: '.. 111 t44W 1 cc I, the undersigned, attest to the accuracy he information provided in this ap lication and I affirm that the food establishment operation will comply w' 5e¢MF}159Qt00�an`i'all otfjler appWable law. I have been instructed by the board of health on how to obtain copies of 7= .040 lffe deral od C e 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. ��o;9`1S `JS4) �Rf.191� s Signature of Individual or Corporate Name By: Corporate OL4er (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. C:\Usen\sleite\Desklop\ScotVs DocumenlsTood Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 wa,mmass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information 2Please Print Legibly Business/Organization Name: 5e paiS !JS%i i (2-pDT Address: 10 re) 1 1150 Z Z.I% 1 P) i Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with 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, j:D Of e and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] t��/ 8. Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment Zth it right of exemption per a 152, § 1(4), and we have 10E] Manufacturing o 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.] 12.0 Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If are corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # I. I any an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:_ Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. #_ Attach a copy of the workers' Expiration Date: policy declaration page (showing the policy number and expiration date). Failure to secure coverage a uired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500. or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $ . 0 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 ee nil t e p ins and pen ties of perjury that the information provided a ove is true and correct. ci,ir,AnrrP x,-.�rsam.. < / 9 3 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 www.mass.gov/dia Phone 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 Deportment 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 sure 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 haveany 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 Fomr Revised 5-26-05 Mansfield Board of Health Request for Fee Waiver for Food Permit Date 7 8/1? We, � (restaurant/ 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: Imo" We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * Sr • m t(L7S CA; (Yat -)c G-fj2cef RWe 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, Signature C(AO-7-W,') 82G i Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: