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Home My WebLink AboutCrosspointe 5K for Moms in Need - 5/11/2019q Commonwealth 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: TEMPORARY FOOD PERMIT 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:. BOB MUCCI Whose place of business is: CROSSPOINTE 5K FOR MOMS IN NEED MANSFIELD HIGH SCHOOL- 250 EAST STREET PERSON(S) IN CHARGE: BOB MUCCI Permit Expires: May 11, 2019 Food Fee: License Number: T-1 V10 MA7 BOARD OF HEALTH MichaeCHeaCey, Chairman W9 Y 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): May 11,2019` Event Name: Crossponte 5K for Moms in Need Event Location: Mansfield Hogh School Event time: 8-10am 1) Organization Name: Crosspointe Church 2) Organization Address: 26 Edgewood Street, Mansfield, MA 02048 3) Organization Mailing Address (if different): 4) Organization Telephone No: 508-261-2871 5) Applicant Name & Title: Bob Mucci 7) Applicant Telephone No: 617-733-4909 0) Applicant/Owner Email address: rmucci@wolpert.com 9) Person Directly Responsible For Onsite Operations: Bob Mucci Name & Title: Outreach Team Co -Captain Address: 2 Jennifer Way, South Easton, MA 02375 Telephone No: 617-733-4909 Fax: 508-459-4860 Emergency Telephone No: 617-686-6311 10 ) Please give a brief description of the food and/or drinks to be served: Bottled water, packaged granola bars, packaged chips, coffee and donuts for volunteers from Dunkin similar store. I' (+:.5 J (I LA j_eS (-n.vtA , I, 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 nd the federal Food Code. 11) Signature of Applicant:��d� vri� 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. Crosspointe Church, Inc. Signature of Individual or Corporate Name 04-2776784 *"Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (M ndatory, if Applicable) "i *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:\Usm\sleite\Duktop\Scott's Docmnents\Food Establish mints- Temp\TAX CERTIFICATION FORM.doc l rfu l UrrLrrsurs IYGLLLLLL Vf /Il KJJKG/LKJGLLJ 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 Leg bly Business/Organization Name: Crosspointe Church, Inc. Address: 26 Edgewood Street City/State/Zip: Mansfield, MA 02048 Phone #: 508-261-2871 Are you an employer? Check the appropriate box: Business Type (required): 1. [N 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. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ® Non-profit 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' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #1 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Church Mutual Insurance Company Insurer's City/State/Zip: 3000 Schuster Lane Merrill, WI 54452 018792207156456 Policy # or Self -ins. Lic. #_ 12/07/2019 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 ceiWjf .. �andlyer the a and penalties of perjury that the information provided above is true and correct Signature �� r Date: �L31119 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 Phone ® ACORO CERTIFICATE OF LIABILITY INSURANCE DATE (MMIODIYVYII 05/03I2019 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 Church Mutual Insurance Company CONTACT Lucas H Skerven NAME: PHONE 1-800-554-2642 Option 1 aC No: 855-264-2329 noDalEss:a customerservice@churchmuWal.com 3000 Schuster Lane INSURERS AFFORDING COVERAGE NAICp P.O. Box 357 INSURER A: Church Mutual Insurance Company 18767 Merrill WI 54452 INSURED CROSSPOINTE CHURCH INC INSURER B: INSURERC: INSURER D: 26 EDGEWOOD ST INSURER E INSURER F: MANSFIELD MA 02048-2809 COVERAGES CERTIFICATE NUMBER: 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. INSR LTRINSD rypE OF INSURANCE ADDL SUBR VIVO POLICY NUMBER MDO/YYEFF MhVDD�p LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEIX OCCUR ETOR N IED PREMISES Ea occurrence) PREMISES $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL BAm/ INJURY $ 1,000,000 q Y 0187922-02-945931 12/07/2016 12/07/2019 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGO $ 1,000,000 X POLICYDPJE'CT- ❑LOG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident)$ BODILY INJURY (Per person) $ ANY AUTO SODILV INJURY (Per a.B.ot) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE LED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y/N OFF CER/MEMBERE%CLUDrvD ECUTNE ❑ (Mandatory In NH) N/A 0187922-07-156456 12/07/2018 12/0712019 X STATUTE I I ER' H E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASECAEMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 5,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached ifmore space is required) Evidence of Liability Insurance for helping with the 5k Run Event on 05/1/19 located at the Manfsfeld Public School grounds at 6 Park Raw, Mansfield, MA. Commercial General Liability Additional Insured = Town of Mansfield, subject to the coverage provided by the referenced policy. (A220 - SAAP - 518) rnvE unr DER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park ROW AUTHORIZED REPRESENTATIVE Mansfield MA 02048-2433 /i.e ` Ciile!/-Q2 U 1988-2015 AGUKU UUKFURAT iv N. An rights reserveo. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Corporations Division Business Entity Summary ID Number: 000065595 Request certificate i New search Summary for: CROSSPOINTE CHURCH, INC The exact name of the Religious (Chapter 180): CROSSPOINTE CHURCH, INC The name was changed from: EDGEWOOD CHURCH OF CHRIST, INC on 01-28-2019 The name was changed from: CHURCH OF CHRIST IN EASTON on 08-06-1996 Entity type Religious (Chapter 180) Identification Number 000065595 Old ID Number. 000000000 Date of Organization mTlassachusetts: 12 19-1960 Last date certain: Current Fiscal Month/Day: 12/31 n Previous Fiscal Month/Day: 00/00 The ice in Massachusetts. location of the Principal Off Address: 26 EDGEWOOD ST. City or town, State, Zip code, Country: MANSFIELD, MA 02048 USA The name and address of the Resident Agent:. _.__._._,...._..._..._._ �m.��M� __,..,_.__...�_..,._.....N........._ Name: STANLEY HOUSE Address: 212 VIRGINIA AVE City or town, State, Zip code, Country: NORTH ATTLEBORO, MA 02763 USA The Officers and Directors of the Corporation: PRESIDENT EDAWRD D. ROCHA 59 PACKARD ST. CRANSTON, RI 02910 USA ANNUALLY TREASURER STANLEY DRAKE HOUSE 212 VIRGINIA AVE ATTLEBORO FALLS, MA ANNUALLY 02763 USA ------- -----_. SECRETARY .. ----- -. _. ---------- MICHAEL BAILEY —.__.. __ -------- 139 TERRIANNE DR TAUNTON, MA 02780 USA ANNUALLY ----- ------ VICE PRESIDENT .. .__—_ _.--- ..---- JOHN DAVIS MORRISH ----- ------ -._._._ -- --------- 11 SMITH ST. REHOBOTH, MA 02769 USA ANNUALLY VICE PRESIDENT MATTHEW ROBERT LINDEN 529 SOMERSET AVE NORTH DIGHTON, MA ANNUALLY 02764 USA ASSISTANT CLERK STANLEY DRAKE HOUSE 212 VIRGINIA AVE ATTLEBORO FALLS, MA ANNUALLY 02763 USA CLERK ----------- MICHAEL BAILEY ---------------------------------------_..---_..__-__ 139 TERRIANNE DR TAUNTON, MA 02780 USA ANNUALLY DIRECTOR STANLEY DRAKE HOUSE 212 VIRGINIA AVE ATTLEBORO FALLS, MA ANNUALLY 02763 USA DIRECTOR EDAWRD D. ROCHA 59 PACKARD ST. CRANSTON, RI 02910 USA ANNUALLY DIRECTOR MICHAEL BAILEY 139 TERRIANNE DR TAUNTON, MA 02780 USA ANNUALLY DIRECTOR JOHN DAVIS MORRISH 11 SMITH ST. REHOBOTH, MA 02769 USA ANNUALLY DIRECTOR MATTHEW ROBERT LINDEN 529 SOMERSET AVE NORTH DIGHTON, MA ANNUALLY 02764 USA Consent Confidential Data View flings for this business entity: ALL FILINGS Annual Report Application For Revival Articles of Amendment !, Articles of Consolidation - Foreign and Domestic Merger Allowed Manufacturing Q HELPB MENU = Home > Tax xe RtQganization Search > Edgewood Church Of Christ <Back to Search Results Edgewood Church Of Christ EIN: 04-2776784 ( Mansfield, MA, United States Publication 78 Data Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions. On Publication 78 Data List: Yes Deductibility Code: PC Page Lost Reviewed or Updated: 8-Jul-2018 01 P► Share $Print 910@ina fj- OurAgency Know Your Rights Resolve an Issue Other Languages Related Sites About IRS Taxpayer Bill of Rights Respond to a Notice Espanol U.S. Treasury Work at IRS Taxpayer Advocate Service Office of Appeals Ep3Z Treasury Inspector General for Tax Administration Help Accessibility Identity Theft Protection tl-?gN USA.gov Contact Your Local Office Civil Rights Report Phishing PyccwH i Tax Stats, Facts & Figures Freedom of Information Act Tax Fraud &Abuse TiengVitt No Fear Act Privacy Policy INA o Gn SPECIAL EVENTS APPLICATION Town of Mansfield 6 Park Row, Mansfield, MA 02048 Phone:509-261-7372 Fax:508-261-7498 TOWN OF MANSFIELD BOARD OF SELECTMEN S OrP(S �,;k*,=w. n�ansfis,ic3iiiacorsr Upon receipt or this completed application, you will be contacted by the Secretary to the Board of Selectmen for the Town of Mansfield. This application can be downloaded at wsnansf eltr a+a n. Thi application nhustbe received 30 days prior to the event. Please note that submission of this application should in no way be construed as final approval or confirmation of your request Final approval will require sign -off by Public Safety Departments and possible review mid sign -off by the Board of Selectmen and does include filing of and payment for all required permits. Date of Application March 14, 2019 --- — crosspoliite Chufsh 508.261-3871 Applicant Information 26 Edgewood Street (m n c,, address, phone number) Mansfield, MA E]BlockParty lCardival Event Category ❑Circus (please check any and all that apply) ❑ConcertlPerformance ❑farmers' Market/Sidewaik Sale or Flair (with multiple vendors) ❑fine ArtsExhibits ❑ Par€rdesiProeess ion ❑(RLotalofa.Public Building or Facility L'Tl(oaid YacclWalk Other: Crosspointe Birth Right 5k RunMalk Event Detrll (name and short description) 5k Walk Run 8 AM Saturday, May 11,2019 Mansfield Lenny's Loop' Proposed Plate and Location rornairlfacesrwolkc�ili:ise include shuunnish locations, And attachh rnu oEimne. Start Time 8 AM Event Start Time Your evens may i quire pre-inspcchonby TOWa Lu-ITltn a)e day ofthe eve06 Event End Time Finsh Time 10 AM Contact- Bob Mucci Event Contacts (include organizer's name, address, phone, Phone 617-7334909 emailaWweeb-site if applicable) http:llwww.erosspointeme-orgl Following? NO or N If Yes; Free )Mown Sidewalks Wrown.Parldug Lots El Town Commons OTown Rights Of Way Any Of The OTent/s If Yes, how many? ❑Electrical Serve ices/Generators If Yes, piease'provide name of vendor 0TemporaryFencing ❑Amplified Sound (live music ordeejay) lOPublic Dance Floor OStage If Yes, what size If Yes, please )rcvide name of vend(, t lncluiie Any Qf llte []open Flames or Cooking/Propane ❑Carnival or Amusement Rides - NQ OhMatable Amusements ❑flames. ]Live Animals ❑Raffle OSpecial Effects ❑Exterior Lighting Will you charge on admission fee? f Y I or N Attendaarce How many people do you expect to '7t'cad (per day)? 100 you event Pubucity Use High School Parking lots Parking Plan (please provide description)` clean -Up Plan Volunteers (include trash rcmovaUclean up plan, and name of vendor, if a liable Upon review of your application, you may be required to use and Event Securlty pay additional fees for police officers andlor etnergencymedical servicespersounel._ ---- Insurance Please Hato that isu ina re ante a Corlifeato oflttsttranoe; The application process begins when you submit this completed Special Events Permit Application to the Town of Mansfield. Please note that submission of your application should in no way be construed as final approval or confirmation of your request. ilpon receipt of you application, the Town of Mansfield's Secretary to the Board of setm,ttncu will help guide you through the permit process. Copies of your application will be forwarded and reviewed by the appropriate Town departments and divisions. You may be required to Speak before the Board of Selectmen to: explain your event. if your event requires additional permits, licenses, certificates, site inspections or polico detail, you will be notified. In sonic cases, costs are associated. Upon approval by the Board of Selectmen, you will receive a letter of approval. NAME (please print):: Robert P, Mucci � / ----- SIGNATURE: Gl%%��/ Saturday may 2019;8:00 AM to!10:130 AM Lenny's Loop 5K RACEANALK DETAILS Lenny's Loop Start Times 8:00 AM Kid's Fun Run (3 years to 12 years old) 2 age group categories with staggered start: 8:30 AM-:5Kstart Runners aged 3- 7 will begin at conclusion of first wave of runners. Parking All parking will be at Mansfield High School, Kld's Fun Run Staggered start: 8:00 AM for runners aged 8 to 12. Runners aged 3 - 7 will begin at conclusion of first wave of runners. Course will be 9/10 of a mile starting and ending at Mansfield High School. 6', For safety reasons, children 5 years old and younger must be accompanied by an adult. (Adults participating with their children do not need to register for the Fun Run), Bib Pickup Cribs may be picked up at Crosspointe Church an Friday, May 10th from 5-8 PM 5K RunnersMalkers T shirts given to the first 100 5K Adult Registrants! For safety reasons,; runners and walkers with strollers will line up at the back of the pack at the start line. NO DOGS, LEASHED OR UNLEASHED, ALLOWED ON THE RACE COURSE. Waiver placed in Online Registration Process I know that running a road race is a potentially hazardous activity. I or my child will not enter and participate unless medically able, properly; supervised (if executing this on behalf of minor) and properly trained. I assume all risks associated with participating, as well as the risks my minor child may incur, including but not limited to injury, falls, contact with other participants, the:effects of the road and traffic, all being known by me, Having read this waiver and knowing these facts, I for myself, and my heirs and assigns, and anyone entitled to act on my behalf,: do waive and release the Crosspointe Road Race Committee, Birth Right of Taunton, Racewire, USATF, Its employees, directors, assigns and certified of iiclals, the Town of Mansfield and all sponsors, their directors; officers and volunteers from all claims of liabilities of any kind whatsoever arising from my voluntary participation In this race, even though that liability may arise from negligence or carelessness on the part of the persons named in the waiver. I attest that I am above the age of 18 years. By checking this box, you agree electronically that you have read, understood and agreed for (i) the waiver(s) above, (il) RaceWire's Privacy Policy, (III) RaceWire's Terms of Service. You also are 18 or older, or/and`have the authority to register these participants and agree to the waivers) for them as their parent or legal guardian. By registering a child under 13, you are consenting to the collection of the child's information that you are providingfor the purposes of registration. Charity http-,Ilbirthright.org/taunton/ Birthright of Taunton understands the challenges related to unplanned pregnancies. Birthright is available to women for as long as they need them. They offer love, friendship, and support to women who are pregnant or think they may be pregnant. Birthright is interdenominational and is not Involved In political "activities, or lobbying. Birthright's focus is on loving the mother, reminding her that there is hope and ensuring she is not alone. Birth Right also serves Moms and Grandparents after birth or guardianship of a child by providing, counseling, furniture, clothing to size 3, diapers to size 5, formula, baby food, coordination with local food banks and housing and heat coordination with local Community Action Programs (CAP's) RESOURCES REACHINGOUT FRIENDSHIP,LOVE t'roy�wncy,iG�ts. 'air i'+w Moy,iar-boo-uoe teoo ANDHCRE. 8i.amirynup 80bY Jt01V, 'All thrt911AJO,%+N.m4t OUR SERVICESAREALWAYS INFORMATION ABOUT RIFERRAtSFOR FREE OONFIDE,NTIAL ND NC�N*JUDOEMENT ►. c..^�mxe�ayicn'�.fbra'��.}h!._uitic,c:�. :aaU�se..,:--,tMmatvc�c• uy�+cG�:�t On this Mother's Day weekend help us, help Birth Right, assist mothers and their children in living a healthy and fulfilled life. DATE OF EVENT: Town of Mansfield 6 Park Row, Mansfield, Massachusetts 02048 ROUTING FOR Crosspointe Birth Right 5K May 11, 2019 START/END TIME: 8:00am—10:00pm LENGTH OF EVENT: One Day GROUPS (S) INVOLVED: Crosspointe Church CONTACT PERSON: Bob Mucci 617-733-4909 STREET(S) AFFECTED: Starts and Ends at High School using Lenny's Loop APPROVED, BOS, CHAIRMAN APPROVED, POLICE CHIEF APPROVED, FIRE CHIEF OK per restrictions NB 3/18/19 APPROVED, HEALTH AGENT With restrictions, APDP 03-18-19 APPROVED, HIGHWAY APPROVED, PARK & REC IN�G`0014 I[6103 Select Board *any food or drink that is not prepackaged will require a permit from the Health Department. Bottled water and fruit does not require a permit. *Contact Lt. Bain MPD 2 weeks prior to event to discuss event size, detail requirements, etc. *Mansfield Fire is the sole transporting agency for all medical emergencies. Communication for all areas of the route must be Phone (508)261-7372 Fax (508)261-74P8 Email selecthoard@manoeldma.com