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HomeMy WebLinkAboutNeighbor Brigade - 7/9/2019'µ�ntio iGAa_ . FOWWARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Firm Community Event Food Establishment Permit Application (Application must be submitted at least 7 business day-bgfprq.Megygnt date) This application should only be used by organizations that are not fOp3 establisfimen t elan to distribute non -potentially hazardous food or drinks at a local commi " y dwnv 3 2419 Community Event: Ess" Date(s): q Event Name: 3) Organization Mailing Address (if different): -Everdtocation, 5) Applicant Name & Title:. Event time: _ 1) Organization Name: 2) Organization Address: 3) Organization Mailing Address (if different): 4) Organization Telephone No: 5) Applicant Name & Title:. 7) Applicant Telephone No: 8) Applicant/Owner Email address: ��� �by b� 9) Person Directly Responsible For Onsite Operations: Name &Title: Address: N Telephone No: (7 st _ S r) . Fax: ;-)\ Emergency Telephone No: �\ct 10) Please give a brief description of the food and/or drinks to be served: X, 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 of90.000-th eral Food Code. 11) Signature of Applicant: n" A dA" 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 orcorporate Name By: Corporate Officer (Mandatory, if Applicable) -QtJ 29-1871(,fa *'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. C1UsmWehe\Dosktop\8wWs OooumentsTood F.Atabli9hmmts- TempITAX CERTIFICATION FORMdoo The Commonwealth of Massachusetts Department of Industrial Accidents Off%e of Investigations 600 Washington Street Boston, MA 02111 IN www.»utss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print I.eeibly Business/OrganizationName: NC CY1�Ce�12_ Address: /(Z> —7 3 V City/state/Zip: kvt <�Y 72 g Phone #: '%i l — 32_ — 6 5 by Are you an employer? Check the appropriate box: Business Type (required): I I am a employer with employees (full. and/ 5. ❑ Retail _ _ or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2. ❑ I am a sole proprietor or partnership and have no 7 ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8.WL on -profit [No workers' comp. insurance requited] 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and -we have - 10:0 Mamifachning no employees. [No workers' comp. insurance required]* i 11. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑Other with no employees. [No workers' comp. insurance req.] . *Ary applicant that cheeks box 41 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 wotken' compensation policy is required and such on organization should check box k I. I are an employer that isproviding workers' eonyrensadon insurance for my employees, Below is the policy information. Insurance Company Name: A4_ -"C a� Insurer's Address: 2f-5 �Jf a. -j G_Nc�44_^ . City/statetZip: ('aj&t• }t4 6211Y �+ Policy # or Self -ins. Lic. # 2 VITY, IS -91q 2is-Cp / Expiration Date: ^ 1� 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 apr to $250:00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investieations of the DIA for insurance coverage verification. 1 do hereby eerdfAunder the of peduty that the information provided above is true and correct Phone A: __ %h'! — 33 z u r _a c 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, C1ty/Towa Clerk. A Licensing Board S.. ?electmea'sOtlice 6. Other Contact Phone Mansfield Board of Health Request for Fee Waiver for Food Permit Date (o -2 -?—(Y_ We, �JPl�,rnbor 62' 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: XWe 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. x Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, �2 .— yY Signature GG t✓KP� Title "Please provide proof of valid 501(c)(3) status BOH Use Only — Approved Denied Reason: Signature: Date: INTERNAL REVENUE SERVICE P. O. BOX 2508 CINCINNATI, OH 45201 Date: JUL 15 2010 NEIGHBOR BRIGADE INC C/O PAMELA WASHEK 18 WILLARD ST WAYLAND, MA 01778 Dear Applicant: I DEPARTMENT OF THE TREASURY Employer Identification Number: 27-1871610 DLN: 17053159323000 Contact Person: ROGER W VANCE ID# 31173 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170(b) (1) (A) (vi) -Form 990 -Required: - -- Yes Effective Date of Exemption: February 8, 2010 Contribution Deductibility: Yes Addendum Applies: No We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c)(3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c)(3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221 -PC, Compliance Guide for 501(c)(3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Letter 947 (DO/CG) _2_ NEIGHBOR BRIGADE INC We have sent a copy of this letter to your representative as indicated in your power of attorney. Enclosure: Publication 4221 -PC Sincerely, Robert Choi Director, Exempt Organizations Rulings and Agreements Letter 947 (DO/CG) ACORa CERTIFICATE OF LIABILITY INSURANCE DATDY 06E/27/27/201199 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Charles River Insurance Brokerage, Inc. 5 Whittier St., 4th Floor Framingham MA 01701 CONTACT Thomas J VocatuYa PHONE FAX AIC o Falb (508) 656-1400 A1C No: (508) 656-1499 E-MAIL koehau hneae charleariverineurance ADDRESS: g YR INSURERS AFFORDING COVERAGE NAICH INSURERA: Philadelphia Indemnity Inauran 18058 INSURED Neighbor Brigade, Inc. INSURERS: EACH OCCURRENCE $ 1,000,000 INSURER C INSURER D; PO Box 735 _ INSURER E: Maynard MA 01754 12/01/201812/01/2019 INSURER F: COVERAGES CERTIFICATE NUMBER: cert ID 3220 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. F INSURANCE ADDLSUBR ° O POLICYNUMBER POLICY EFF MMIDD POLICY EXPLIMITS NMIOD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �DAMAGE ADE I ~ I OCCUR PHPK1894386 12/01/201812/01/2019 TO RENTED PREMISES(Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 r PERSONAL&ADV INJURY $ 1,000,000 LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 PRG E LOC ECT PRODUCTS-COMP/OPAGG $ 2,000_,000___ OTHER:I I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ BODILY INJURY (Par person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLYk AUTOS BODILY INJURY(Peraccident) $ _ HIRED NON -OWNED AUTOS ONLYAUTOS ONLY PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAH OCCUR EACH OCCURRENCE_ $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N STATUTE ER E.L. EACH ACCIDENT $ OFFICERIMEMBEREXCLU EDKECUTIVE ❑ MIA (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE- POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below $ S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Page 1 of 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Page 1 of 1 Jane Doucette From: Amy Donovan -Palmer Sent: Tuesday, July 2, 2019 11:01 AM To: Jane Doucette Subject: FW: Family Fun Night I'm not sure if you've been included in this exchange. Neighbor brigade does NOT need a permit. From: Amy Donovan -Palmer Sent: Tuesday, July 2, 2019 10:57 AM To: 'Mansfield MA Neighbor Brigade' Subject: RE: Family Fun Night No permit needed. Amy From; Mansfield MA Neighbor Brigade[mailto:mansfieldma(a)neighborbrigade.org] Sent: Tuesday, July 2, 2019 10:55 AM To: Amy Donovan -Palmer Subject: Re: Family Fun Night Hi Amy So would we not need a permit then if we are doing a bake sale? Thanks Breanna On Tue, Jul 2, 2019, 10:13 AM Amy Donovan -Palmer <adnahmer(aamansfieldma.com> wrote: Hello Brenna, Quick question: are you preparing this food at home? I think you would fall under this definition: A residential kitchen if only FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD is prepared for sale or service at a function such as s religious or charitable organization's bake sale if allowed by LAW and if the CONSUMER is informed by a clearly visible placard at the sales or service location that the FOOD is prepared in a kitchen that is not subject to regulation and inspection by the REGULATORY AUTHORITY; If you do, then you would just need a small card stating that the food is prepared in a kitchen that is not subject to regulation and inspection by the BOH. Let me know if you have any other questions or if you don't meet that definition. Best, Amy Amy Donovan -Palmer, MPH, RS Health Agent W IF*.= Mansfield, MA 02048 Phone: 508-261-7366 From: Mansfield MA Neighbor Brigade[mailto:mansfieldma@neighborbrigade.org] Sent: Friday, June 28, 2019 3:51 PM To: Amy Donovan -Palmer Subject: Family Fun Night Hi Here is the completed form. Thanks Breanna ---------- Forwarded message --------- From: Breanna Pungitore <lpunig tore ( healthimperatives.org> Date: Fri, Jun 28, 2019, 3:41 PM Subject: To: mansfieldma(]clneighborbrigade.org <mansfieldmag ei hbg orbrigade.org> Breanna L. Pungitore Senior Domestic Violence Shelter Advocate/Housing Specialist Health Imperatives Penelope's Place 942 West Chestnut St, Brockton, MA Phone # (508) 588-2042 bpung_itore@healthimperatives.org www.healthimperatives.org -----Original Message ----- From: ppscanner healthimperatives.org[mailto:ppseanner@healthimperatives.org] Sent: Friday, June 28, 2019 3:25 PM To: Breanna Pungitore Subject: ECOSYS M3540idn [00:17:c8:0e:9d:a41 Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it, If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Sofhvare as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data, Specializing in; Security, archiving and compliance. To find out more Click Here. Jane Doucette From: Amy Donovan -Palmer Sent: Tuesday, July 2, 2019 11:01 AM To: Jane Doucette Subject: FW: Family Fun Night I'm not sure if you've been included in this exchange. Neighbor brigade does NOT need a permit. Amy From: Amy Donovan -Palmer Sent: Tuesday, July 2, 2019 10:57 AM To: 'Mansfield MA Neighbor Brigade' Subject: RE: Family Fun Night No permit needed. Amy From: Mansfield MA Neighbor Brigade[mailto:mansfieldma(abneighborbrigade.org] Sent: Tuesday, July 2, 2019 10:55 AM To: Amy Donovan -Palmer Subject: Re: Family Fun Night Hi Amy So would we not need a permit then if we are doing a bake sale? Thanks Breanna On Tue, Jul 2, 2019, 10:13 AM Amy Donovan -Palmer <adpalmer(u�mansfieldma.com> wrote: Hello Brenna, Quick question: are you preparing this food at home? I think you would fall under this definition: A residential kitchen if only FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD is prepared for sale or service at a function such as s religious or charitable organization's bake sale if allowed by LAW and if the CONSUMER is informed by a clearly visible placard at the sales or service location that the FOOD is prepared in a kitchen that is not subject to regulation and inspection by the REGULATORY AUTHORITY; If you do, then you would just need a small card stating that the food is prepared in a kitchen that is not subject to regulation and inspection by the BOH. Let me know if you have any other questions or if you don't meet that definition. Best, Amy Amy Donovan -Palmer, MPH, RS Health Agent 6 Park Row Mansfield, MA 02048 Phone: 508-261-7366 From: Mansfield MA Neighbor Brigade[mailto:mansfieldmaCclneighborbrigade.org] Sent: Friday, June 28, 2019 3:51 PM To: Amy Donovan -Palmer Subject: Family Fun Night Hi Here is the completed form. Thanks Brearma ---------- Forwarded message --------- From: Breanna Pungitore <bpun itore healthimperatives.oeg> Date: Fri, Jun 28, 2019, 3:41 PM Subject: To: mansfieldma(a�,neiahborbrigade.org <Iiransfieldma ( neighborbrigade.ore> Breanna L. Pungitore Senior Domestic Violence Shelter Advocate/Housing Specialist Health Imperatives Penelope's Place 942 West Chestnut St, Brockton, MA Phone # (508) 588-2042 bpun 'tore healthimperatives.org www.healthimperatives. org -----Original Message ----- From: ppscannerLa healthimperatives.ore [mailto:ppscanner a healthimperatives.or>,] Sent: Friday, June 28, 2019 3:25 PM To: Breanna Pungitore -Subject: ECOSYS M3540idn [00:17:c8:0c:9d:a4] Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. Date Received Permit Fee MxiUMI 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: Date(s): QI Event Name: 4) Organization Telephone No: ! J Event Location-, Event time: 8) ApplicanttOwner Email address: f) Organization Name: IVc! k6z�,- 13 2) Organization Address: To ,il* / t 3) Organization Mailing Address (N different): 4) Organization Telephone No: ! J 5) Applicant Name & Title: 7) Applicant Telephone No: 8) ApplicanttOwner Email address: 9) Person Directly Responsible For Onsite pelraitions: Name & Title: t E p Address: GS s t A flZ7 Telephone No: _ �OLif Fax: Emergency Telephone No: 10) Please give a brief description of the food and/or drinks to be served: \\} Ke ffJ or��S�.t\x��p� Go�����i br20_6 - Gv?c4�¢�tiee 1, the undersigned, attest to the accuracyof the Information provided in this establishment operation will comply with 105 CMR 590.000 and all other app health on how to obtain copies of SMR 590.000 and thg fatieral Food Cc 11) Signature of Applicant: tion and I affirm that the food low. I have been instructed by the board of TAXCERTIFICAUON FORM I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of rncfividual or -Corporate N mce Bq. Corp rateoorp macer Wandatory, if Appiicabte) 'Social Security No. i oiuntary) 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;1Users�vleitelDesktap\Sa�tt'n 1JooumonlslRtwei F.atablishmems• I'emp%TAX CERTIFICATIONFORMSoo The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 011ll www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information 1 1 Please Print Legibly Business/Organization Name: Nt't�k� rLc�c�2 -73a Phone#: �781' 325-35 Are you an employer? Check the appropriate box: Ix I am a employer with employeea(full and/ Business Type (required): 5. Q Retail _ or part-time).* 2. Q I 6. Q Restaurant/Bar/Eating Establishment am a sole proprietor or partnership and have no 7. Q Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. insurance 8.�Non-profit [No workers' comp. required] Q 3. Weare a corporation and its officers have exercised 9. Q Entertainment their right of exemption per c. 152, §1(4), and,we have IO Q t4arrufaChrrmg no employees. [No workers' comp. insurance required]* 4.0 We are a non-profit organization, staffed by volunteers, 1LQ health Care with no employees. [No workers' comp, insurance req.] 12.❑ Other kAny applicant that checks box N 1 must also fill out the section below showing their workers' compensationpolicy inforawtiom .•u the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such on organization should check box kl. 1 am an employerihat isprovidfng workers' compensation insurance for my employees Below is the policy information. Insurance Company Name:... A6" r (?/ Insurer's Address: 25 I J fr ,j Gr �c /c3—�✓i City/State/Zip: Skt Policy # or Self -ins. Lic. # Expiration Date: E: 36 r 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 STOP WORK ORDER and a fine of ap to 5250:00 a day against the violator. Be advised, that a copy of this statement maybe forwarded to ft Office of Investigations of the DIA for insurance coverage verificnrinn ofpedury that and correct 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 L. Building. Department 3. Ctiy.lTown Clerk 4, Licensing Board 5, Selectmen's. Office 6. Other Contact Person: Phone #: Mansfield Board of Health inky - Date (o" 2-% - We, 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: XWe 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 SOH Use Only _ Approved Denied Reason: Signature: Date: