HomeMy WebLinkAboutBarrows Ins. Agency - 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:,
CAITLIN BARROWS
Whose place of business is:
BARROWS INSURANCE AGENCY, INC - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
CAITLIN BARROWS
Permit Expires: ,July 09, 2019
Food Fee:
License Number: FFN - 2
PI4e1P/=I01
BOARD OF HEALTH
_MichaeCHeaCey, Chairman
...............
FOR BOARD OF HEAL,ri-i USE ONLY
[Date Received Permit Fee Approved By Permit # 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: ..i-- '�
1
Date(s):
�\
Event Name:
Event Location:
.Event time:
1) Organization Name:
2) Organization Address: 1 ,
als
3) Organization Mailing Address (if different):
4) Organization Telephone No: C 1
O
5) Applicant Name & Title:
7) Applicant Telephone No: C5 er
8) Applicant/Owner Email address: C
`J1
i`'� i \.
l..
9) Person Directly Responsible For Onsite Operations: e0alli
n
Name & Title:
Address:it
C
Telephone No:
121P0
Fax: �� 3 37 �� a
Emergency Telephone No:
10) Please give a brief description of the food and/or drinks to be served:
SlhCl(/Hlne l �0 OL C'a)
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 590.00,0. and the federal Food Code.
11) Signature of Applicant:
TAX CERTIFICATION FORM
I certify render 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.
1,_ 04SLC7 . - mil n,�_ a
Sig nture of Individual or• Corporate Name Bfi: Corporate Officer (Mandatory, if Applicable)
IV
*'Social Security No. (Voluntary) or Federal
Idenlification 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:\Uscialalcltc\DeskkrpVScolPa Doonmen(s\Food Cislnblis6mmus-'I'cny>\'rAX CERTIFICATION Fo1iM.doc
The Commonwealth of'Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
u,p
Boston, MA 02111
www.tnass.govklia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: P4—D2CVS if15 -
Address
City/State/Zip: V MM btlb r 44 bl * Phone
Are you an employer? Check the appropriate box:
Business Type (required):
I.X I am a employer with employees (fall and/
5. ❑ Retail
_
orpart-time),*
2. ❑ I
6. ❑Restaurant/Bar/Eating Establishment
am a sole proprietor or partnership and have no
7. ffice and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
3. ❑ Non-profit
[No workers' comp: insurance required]
3. ❑ We are a corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have
10.❑ Manufacturing
no employees. [No workers' corinp, insurance required]*
4. ❑ We
I l •❑ Health Cafe
are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
12.0 Other
"Any applicant that cheeks box #1 must also fill out the section below showing their workets' compensation policy information. ---
**If the corpo arc officers have exempted themselves, but the cotporatiou has other employees, a workers' compensation policy is required and such so
organizttiou should check box #l.
I can an employer that is provirliag wot•%erw' cuatpeusatiorr irrsaranee far illy employees. Below is the policy urJm•urntion.
Insurance Company
Insurer's Address: 1190
S Oct
City/State/Zip: twfzafc--Uy4;,%,� �Cj/ Q
Policy # or Sell' -ins. Lie, 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerfyJ , under thepains atilt penalties gfperjury that the it{formation provided above is true and correct
3 y •77 to c,
Of
diclal use only. Do not write in this area, to he completed GN city or torroe official,
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office
6. Other
Contact Person
www.mass.gov/dia
Phone
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date (-o -7- 0
We, UMQ)� W/M (restaurant/ organization )
request a waiver of the Food Service Permit Fee for the following reason:
1_1 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 are a religious organization.
Other:
Thank you,
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date: