HomeMy WebLinkAboutOur Daily Bread - 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 - MANSFIELD
Whose place of business is:
OUR DAILY BREAD - MANSFIELD FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
RICHARD KELSAY
Permit Expires: July 09, 2019
Food Fee:
License Number: FFN - 8
WAIVED
BOARD OF HEALTH
MichaeCHeaCey, Chairman
i
L = s
January 4, 2019
The Congregational Church of Mansfield
An Open and Affirming United Church of Christ Congregation
(Also Known As The Orthodox Congregational Church of Mansfield)
17 West Street, Mansfield, MA 02048
Rev. Theodore H. Newcomb III, Pastor
thnewc3@gmail.com
Emma Ceurvels, Director of Church Music
emmaceu"els@gmaii.com
Ed O'Connell, Custodian
edoconneiii7@gmaii.com
Kim Greenberg, Moderator
kimgreenberg@verizon.net
Church Office So8.339-4793
Community Food Pantry 508.339.1343
Church Website http://www.occmansfield.org
Find Us On Facebook!
RE: Our Daily Bread Community Food Pantry of Mansfield Non -Profit Status
To Whom It May Concern:
I am writing on behalf of Our Daily Bread: Friends Caring and Sharing, Mansfield's Community
Food Pantry. The pantry is a mission of The Orthodox Congregational Church of the United Church
of Christ located in Mansfield, MA on our church property. Our church is also known as The
Congregational Church of Mansfield to avoid confusion with the Greek Orthodox Church also
located on West Street in Mansfield.
The Orthodox Congregational Church is a 5oi(c)(3) charitable organization of the United Church of
Christ. The 501(c)(3) designation extends to missions of the church, specifically "Our Daily Bread:
Friends Caring and Sharing." Our non-profit status falls underthe auspices of the Massachusetts
Conference United Church of Christ, our state-wide judicatory.
Donation/grant checks for the benefit of the food pantry can be made payable to:
Our Daily Bread: Friends Caring and Sharing
i5A West Street
Mansfield, MA 02048
If you have any questions about the status of the food pantry, please contact me at the church
office: 508.339.4793. Alternatively, call my cell: 774.z66.3389.1 will be more than willing to assist.
Sincerely,
Rev. Theodore H. Newcomb III
Pastor
"No Ma+ter Who You Are, or Where You Are Oh Life's Journey,
You Are Welcome, {}ere Amory Friends!"
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Date Received Permit Fee Approved By P U# I,SsM
V' 9, 1
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: �/ ,-` Uk)
Date(s):
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Event Name:'
Event Location:
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Event time:
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1) Organization Name: U (�'� ��.I L� Z Lek
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2) Organization Address: I L- A `V GJ t-%A.
3) Organization Mailing Address (if different):
4) Organization Telephone No:
5) Applicant Name &Title: .VI te�lr kk p�et,V , 0-L. 42
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7) Applicant Telephone No: LJ Q - -3'3 cl -- 2 /7 Q 4
8) Applicant/Owner Email address: Z
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9) Person Directly Responsible For Onsite Operations: 1GlI
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Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No:
10 ) Please give a brief description of the food and/or drinks to be served:
i, the undersigned, attest to the accuracy of the information provided in this
establishment operation will corn I with 1 5 C R 590.000 and all other a f
health on how to obtain copies ofi75 CM 59f .000 and�e fedeM Foo�o
11) Signature of Applicant:
tion and I affirm that the food
law. I have been instructed by the board of
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 Individual or Corporate Name By: Corporate Officer (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:\Users\sleite\Desktop\Scoffs Documents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc
The Commonwealth 'of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Address:
City/State/Zip:
Are you an employer? Check the appropriate box:
L ❑ 1 am a employer with employees (full and/
or part-time), *
2. ❑ 1 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 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Phone #:
Business Type (required):
5. ❑ Retail
6. ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
& ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.❑ Health Care
12M Other A CJZ
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
**If the 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 am an employer that is providing workers' compensation
�ihn/surance for my employees. �Below is the policy information.
Insurance Company Name: kj U a I C e v L�O _
Insurer's Address: \ uyvy% , M
City/State/Zip:
Policy # or Self -ins. Lic.
Expiration
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 certify, uj4er the pairj's and penallie7d ojfterjury that the information provided above is true and correct.
3 "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 Person: Phone
www.mass.gov/dia
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
Department 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 have any 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
Forth Revised 5-26-05
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date Z I Q IV6 2-0 0
We,
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:oYt
❑ 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.
�i We are a religious organization.
❑ Other:
Thank you,
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date:
Commonwealth of Massachusetts Lena to: L0493917824
DcpadmwrtorRevcnue Notice Date: Decomber 3, 2018
Christopher C. Harding, Commissioner MATaxpaycrlD: 121,19757
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'FMoww` moss.gov/der
CERTIFICATE OF EXEMPTION
,Ill�u�ll�lu�,i,�J�11��I�IJdnh�ll'lll�l'lldlbllillllh��
ORTHODOX CONGREGATIONAL CHURCH
8 17 WEST ST
w� MANSFIELD MA 02048-2424
Attached below is your Certificate of Exemption (Form ST-2). Cut along the dotted line and display at
your place of business. You must report any change of name or address to us so that a revised ST-2 can
be issued.
DETACH HERE
a"cHQse,a MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-2
�µ w Certificate of Exemption
P ➢i
"t'sxroF�
ORTHODOX CONGREGATIONAL CHURCH MA Taxpayer ID: 12119757
PO BOX 322 Certificate Number: 933763072
MANSFIELD MA 02048-0322
This certifies that the organization named above is an exempt purchaser under Chapter 64H, section 6(d) or (e) of the
Massachusetts General Laws. All purchases of tangible personal property by this organisation are exempt form taxation to the
extent that such property is used in the conduct of the business of the purchaser. Misuse of this certificate by any tax-exempt
organizaion or unauthorized use of this certificate by any individual will lead to revocation. Willful misuse of this certificate is
subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. This certificate is
nun -transferable and may be suspended or revoked for failure to comply with state laws and regulations.
Fffective Date: January 4, 2019 Expiration Date: January 3, 2029
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