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Home My WebLink AboutJack Conway Realtor - 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:. SHERRELLPREFONTAINE Whose place of business is: JACK CONWAY REALTOR - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: SHERRELLPREFONTAINE Permit Expires: July 09, 2019 Food Fee: License Number: FFN - 6 [INT-VECO BOARD OF HEALTH _%iichaeCHeatey, Chairman a FOR BOARD OF HEALTH 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: �l�m) / ,: a N ,�, H •r Date(s): .Tul o i 9 Event Name: A PR i L —VA/ All # f Event Location: fq ,,t/ 5 - ,r-e,li- Event time: _ q : p © m • 1) Organization Name: J Ch GK C,0 qVt., ek ---&m (�\n, r 2) Organization Address: ,�(jI�Q � S f re 3) Organization Moiling Address (If different): 4) Organization Telephone No: 6 3 • c) _ 6)(;:% c5;1 . 8) Applicant Name & Title: 7) Applicant Telephone No; & & F _ j V "A - 3 k• g p 8) AppilcantfOwner Email address; IS „� O CA CICC0'L!✓ V. eV e"' g) Person Directly Responsible For Onsite Operations: Name &Title: / S (t t• ife w% rw,4 .e ' Address: Telephone No: a �' �•� Fax: Emergency Telephone No: !f•' d . r7 ,7 .!p 10 ) Please give a brief description of the food andfor drinks to be served: Con-e 5' -r 1, the undersigned, sites establishment operation health on how to obtain 11) Signature of Appi he food icted 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. ignature of Individual or Corporate Name 0� — 03 13 ql, "Social Security No. (Voluntary) or Federal Identification Number �-yn� p,ea c. Goynl .e L 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. CAUseWs1eite\De9k10p\Scott's Documenu\Food EsmbEshmets- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: J a Address- ) 3 _�" IAl A _5 �I e vt Phone #: 7,ei - i - acl d Are you an employer? Check the ppropriate box: Business Type (required): Al , d I am a employer with 0 7 employees (full and/ 5. ❑ Retail or part-time),* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no 7, [VOffice and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• ❑ Non-profit [No workers' comp. insurance required) 3. ❑ We are a corporation and its officers have exercised 4, ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.[] Manufacturing 4. ❑ no employees, [No workers' comp. insurance required)* We by l l.❑ Health Care are a nonprofit organization, staffed volunteers, with no employees. [No workers' comp. insurance req.i 12.0 Other _ *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate of c rs have exempted themselves, but the corporation tins other employees, a workers' compensation policy is required and such an organization should check box #1. I ant an employer that is providing��,w�oorkers' compensation insurance for my employees. Below Is the policy information. Insurance Company Name: Zjt/ ///,. /)eo--1j 4 _ Insurer's Address: .5 1/I P /,<+ ,ja l0, p, O•OX L/U:76 City/State/Zip: _ 8 J2 b W622AI IY* _ 0/ RV 3 — O 51-ty Policy # or Self -ins. Lie. # V W ( — /ro — �a r� i� aWQI¢ Expiration Date: t b IC-2o 06 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 MOL 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 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 cerN,&, under the pains and penalties ofperfury that the information provided above is true and correct Phone #: " % F'"% fD / 6 to V6.9- Official use only. Do not write in this area, to be completed by city or town officlat 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 Phone JACKCON-01 DMERRITT .4ot2v 4 CERTIFICATE OF LIABILITY INSURANCE DaTE lmm owrrrvl sr10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policlas may require an endorsement. A statement on this certificate doss not confer ri hts to the certificate holder in lieu of such endorsements , PRODUCER _ CT Walter J May Ins Agy Inc 188Whitin9 St Hingham, MA 02043 PHONE Nc.No,e.e;(781)748-0310 F % 1a�c,Nem(781)749.1714 a ,S,info@Waltermayinsurance.com INSURER(S) AFFORDING COVERAGE NgtC q INSURER A! Hanover Insurance Company 22292_ INSURED INSURER 8: MAPFRE Insurance Corn pony T_ 23876 INSURER c:Associated Industries of _ Jack Conway & Co. Inc. 137 Washington Street Norwell, MA 02061 INSURER O:CNA - ---- --------- INSURER E: INSURER F: COVFRAnFR r=IOTIC!CATC NIHi IBSR• nw n..,r.0 ............. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMCDA80VE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTWiTH RE$PECTTOWHICH THIS CERTIFICATE MAY 6E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OFINfiURANCE ADDL SUER POLICYNUMBER POLICYEFF P LI EXP LIMITS A X COMMERCIAL GENERAL EACH OCCURRENCE 3 1,000,000 CLAIMS -MADE OCCUR D MAG-TO flENTED DN2859967 1/1/2019 111/2020 �_ a i00.606 IAED E%P An o,w r5on S 10,000 - PERSONAL&ADVIItJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: a GENERAL AGGREGATE S 2,000,000 PR OUC�00lAPA]P AGO 3 2,000,000 POLICY JELQT LOC _ 3 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 $ a DILY INJURY a rson 5 ANY AUTO BGDLHC 1/30/2'19 1130/2020 �pTU ONLY X AUOTNOSWUTL�EDDp BOODILY INJURY Pere and X. SOp�pS Mb %ONLY MUTO O Y PPe�a Ea'rRaen DAMACE $ -- -EACH OCCURRENCE S—_._._ S 6,000,000 A X UMBRELLALIA6 X OCCUR EXCESSLipe CLAIMS -MADE DN28$9967 1/1I2079 11112020 AGGREGATE 3 DED RETENTION$ _ $ �� C WORKERS COMPENSATION PER OTH- ANDEMPLOYEftS'LIABILITY YIN E.L. EACH ACCIpENT __ $ 100,000 ANY PROPRIETORPARTNERr ECUTIVE OFFICER rVj BER EXCLUDED' antlatq NHI NIA C-100.6023499.2019A 1/112019- 11112020 E. .DISEASE -EA MPL YE 100,000 Il yes. deaclibe under E.L. DISEASE-POIICYUMIT S $00,000 DESCRIPTION OFOPERAVONSIo1w D Errors and Omissions RFB-113875313.18 7/26/2018 7/26/2019 Aggregate 2,000,000 09$CRIPTIONOFOPERAMONS/LOCATIONSIVEHICLES (ACORD 101, Additional Remuke Schedule, may be aaachad lfinerd apace la mqulndl M SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, ACORD 26 (2016/03) ©1988-2015 ACORD CORPORATION. All riahls reservad The ACORD name and logo are registered marks of ACORD Mansfield Board of Health Request for Fee Waiver for Food Permit Date We, 1 C { (�6Yd U� t-N "� (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: ❑ 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: 9 We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, I//O S,veett GD�Nr� Title `Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: