HomeMy WebLinkAboutBoston's Baddest Burger/Mainely Lobstah - 12/31/2021i%
FOR. BOARD OF HEALTH USE ONLY
Date Received Permit Fee Approved By .i sued I
Mobile Food Establishment (MFE) Permit Application
(Application must be submitted at least 14 business days before the planned opening ) -
1) MFEName: GGcrBAG f=aaJ oce S7247e�6765 T%lG
p6A, $sxrc119 3gJD6S9b� 21M41/E L7I115i� 7aod %e7vu
2) Applicant/Owner Name & Title: j7r Q,0; c �26Z a
Applicant/OwnerAddress: L/ J=d,cl,.7z4 12&41),, reyB&2V M4 6.;.8.3._S
Applicant/Owner Telephone No: '7 7 41— (p /3 - `r
Applicant/Owner Email address: c7S6 Q % M $->iG r 6 /v)
3) Person In Charge of Onsite Operations & Title:
PIC Address:
PIC Telephone No: Emergency/onsite Telephone No:
PIC Email Address:
4) Location of Service:
Date(s) if applicable:
Event Name if applicable:
Event/ Service Location:
Event/ Service time:
5) Length of Permit:
6) Solid waste disposal plan:
p4 Annual
GO H H c:Z'A� W i4ST�
ED Temporary
OH r,VS419
Dates:
7 Water Source:
8) Sewage disposal plan:
9) Food will be prepared:
ik Onsite for immediate consumption
ED Onsite and held at proper hot/ cold holding temperatures
CD Offsite and held at proper hot/ cold holding temperatures
[--I Offsite, cooled and reheated on site
F--] Other:
10) Please attach a menu ore website link to the menu or give a brief description of the food to be served:
11) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates: _
Food Safety Manager. "t/6 '/-'
Allergen Awareness: t� ��!% dL� C•c.c�7
12) Please describe on site hand washing facilities that will be utilized:
13) Please list all sanitizing solutions that will be on site: 1�
14) Do you have propane, fryolators and/or hoods on your truck? ✓'
If yes, you must first be inspected and approved by the Mansfield Fire Department. Phone number: 508-261.7321
Fire Department Signature of Approval:
15) If applicable, please describe your FOG management plan or attach the written plan:
16) Location of Base of Operations or Commissary:
Please attach copies of Base of Operations or Commissary Permit.
17) Please list additional communities where a food permit is held:
A'1e'0taat)z y ,014
,4ynA4 led
[,the undersigned, attest to the accuracy of the information provided in this application and 1 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 obtaig copies of 105 CIJii R 590.000 and the federal Food Code.
16)Signatureof
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all state tax returns and paid state taxes required under law,
19) Social Security Number or Federal
20) Signature of individual or Corporat
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
0va-vR_9917�/
'Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatary, if Applicable)
*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:Wsets�steite\Desktop\ScotPs Doemmts\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
-= --
l,-
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 Leeibly
Business/Organization Name: 6co39G F«ay Tc�c sr2rrE�xFS �C
Address: `-/ ?C�de WILL 00d /�,
City/State/Zip: fot%3o�c� ,HA 0,703S Phone#: '775'-4/3- 1a-37
Are you an employer? Check the appropriate box: Business Type (required):
l.0 I am a employer with -e2 employees (full and/ 5. Q Retail
orpart-time).* 6. QRestauram/Bar/Eating Establishment
2. Q 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] S. Q Non-profit
3.❑ We area corporation and its officers have exercised 9. QEntertainment
their right of exemption per c. 152, § 1(4), and we have 10.Q Manufacturing
no employees. [No workers' comp. insurance required]** 11.Q Health Care
4. Q We are a non-profit organization, staffed by volmtteers,
with no employees. [No workers' comp. insurance req.] 12Q Other ✓ OO,> ? 20e. `� 6 Tl�2�/-2
*Any applicant that checks box #1 must also till 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 ran an employer that is providing workers' compensation insurance for my employees Below is the policy information.
Insurance Company Name: l l e,E! >` o L /C 4 a b 6 E ID 111901 e�,? el)0 T�
Insurer's Address: 2,74 '41.) ES Sf
City/State/Zip: /21E- it k it 4 o Q o A6
Policy # or Self -ins. Lic. # (0 L IS 9 .p n f— r% Expiration Date: i t +/
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 a 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 Lip 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, under the pains and penalties of perjury that the information provided above is true and correct
Phone #: -7 % 41� 6 /,-?— / �7.3 7
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/dta
1BUS,UVESS CERTIFICATE
TowN OFNORWOOD .
AffT LACK
�,r� �TezvZssue .
-Renewal
File v,r
Date issued
p'xPires cf - - 2,
In conformity wi& the provisions of SfU- Chapter 110 Sec. �, as amended, the undersigned
hereby deelake(s) that the business is conducted under -the title of
" Lta { it 9 � �3 1 ts� 3
(Address) J O d D V Yp j�j fZ } l ��i e C /! NOY
J c5de� {Yid=;
C.7r.Y
By the following named person(s). Include corPorate name and e le j that of a c oY -
��1
f
Nttm%e: '(1'rirat) officer
Residence:.
Signed C /Pdl.tX i d Phone: iq
O,P6 rq ;&12
U �� f oL7iJ" IyG f� C fi. z Sff e
%*r. i:i*r.?%%'.:%%.:'::%%�t%ic%%:c%t'kkrr.%'%-z%�:-4%i'%k%-F9:%%'l.'-Fa:x9:%>[%%%%sr'l."S.'%-l.'*t'Y. %:txX':Yr.'.ti•iY'k'T.'%i•%4.
A certificate issued in accordance with this section shall be in force and effect for four years
,from the'date of issue and shall be renewed each four Years thereafter so long as such business
shag he conducted andshalllapse-and be void unless so renewed
Ora the !d day ofOn_.20�, the above named persons) appeared, before me
who did under oatfi and pwr', Wes of perjury state that the aforementioned information is a eve
and accurate acrunt,
A TxUO Copy (Seatktites rlJi/� V(�YUt�
Title
Town Clark
NaR
TOWN OF NORWOOD
BOARD OF HEALTH
_ N
e Z Commonwealth of Massachusetts
PERMIT TO OPERATE A FOOD ESTABLISHMENT
Maw
DATE: April 18, 2019
FEE
$150.00
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:
GLOBAL FOOD TRUCK STRATIGIES INC
WHOSE PLACE OF BUSINESS IS:
1208 WASHINGTON STREET
NORWOOD, MA 02062
PRIMARY BUSINESS: FOOD SERVICE/CATERER
SECONDARY BUSINESS: FOOD SERVICE
SEATING CAPACITY: 0
SQUARE FEET: 1000 SQ FT
TO OPERATE A FOOD ESTABLISHMENT IN NORWOOD
PERMIT EXPIRES: DECEMBER 31, 2019
NORWOOD BOARD OF HEALTH
rt NQI Tf2kNFLE,
SIGALLE REISS
Follow us on Twitter @NorwoodHD http:health.nonvoudma.gov
566 WASHINGTON STREET— P.O. BOX 40—NORWOOD, MA 02062
TEL. NO. (781) 762-1240 — FAX NO. (781) 278-3000
TOWN OF NORWOOD
o
BOARD OF HEALTH
N
�Fe Zy.
Commonwealth of Massachusetts
NUMBER
100570
DATE: May 1, 2019
FEE
$100.00
THIS IS TO CERTIFY THAT:
GLOBAL FOOD TRUCK STRATIGIES INC
1208 WASHINGTON STREET
NORWOOD, MA 02062
IS HEREBY GRANTED A LICENSE
FOR: MOBILE FOOD PERMITS
THIS PERMIT IS GRANTED IN CONFORMITY WITH THE STATUTES AND
ORDINANCES RELATED THERETO, AND EXPIRES APRIL 30, 2020 UNLESS
SOONER SUSPENDED OR REVOKED.
NORWOOD BOARD OF HEALTH
P.O. BOX 40
566 WASHINGTON STREET
NORWOOD, MA 02062
P IYI�`1. NON T IVSF RAI Lf
SIGALLE REISS, SUPTIDIRECTOR
Follow us on Twitter rer NorwoodHD http:health.nonvoodma.gov
566WASHINGTON STREET —P.O.BOX 40— NORWOOD, MA 02062
TEL. NO. (781) 762-1240—FAX NO. (781) 278-3000
TOWN OF NORWOOD
BOARD OF HEALTH
Commonwealth of Massachusetts
PERMIT TO OPERATE A FOOD ESTABLISHMENT
NUMBER:
100663
DATE: April 18, 2019
FEE
$150.00
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:
GLOBAL FOOD TRUCK STRATIGIES INC
WHOSE PLACE OF BUSINESS IS:
1208 WASHINGTON STREET
NORWOOD, MA 02062
PRIMARY BUSINESS:
SECONDARY BUSINESS:
SEATING CAPACITY:
SQUARE FEET:
FOOD SERVICE/COMMISSARY
0
1000 SQ FT
TO OPERATE A FOOD ESTABLISHMENT IN NORWOOD
PERMIT EXPIRES: DECEMBER 31, 2019
NORWOOD BOARD OF HEALTH
SIGALLE REISS
Follow us on Twitter @NorwoodHD http:health,nonvoodma.gov
566WASHINGTONSTREET —P.O.BOX 40— NORWOOD, MA 02062
TEL. NO. (781) 762-1240 — FAX NO. (781) 278-3000
'Food Establishment Inspection Report —Town of Norwood Npnith nanartmanf — 7514 _79Z9_1 9dn
Establishment:�t.J S $2Gt
Seating Y N
Date: A5 f Page 1 of 3
Address: t2_00 7q—
Time in: � m Time out:
Telephone: 77
Permit No.:
Number of Violated Provisions Related
Foodbome Illness Risk Factors
to and Interventions (Items 1 through29):
Ir—to
Owner:
Person-in-cha�i.-C.�}
Number of Repeat Violations Related
to Foodbome Illness Risk Factors
and Interventions (Items 1 through 29):
Ins pector: U
ML&
Sk FgCTORS,AND PUBLIC
HEALTHit4TERU,ENTIONS
IN = in compliance OUT= out of compliance NIA = not applicable N/O = not observed COS = corrected on -site during inspection R = repeat violation
Status
1 Person -in -charge present, demonstrates
knowledge, and performs duties (PI) 14, t.4
12 1Certifled Food Protection Manaqer (c) 1 101 1 1
Management, food employee and 4i
3 conditional employee; knowledge,
responsibilities and reporting (Pf)
4 JProper use of restriction and exclusion(P)
5 Procedures for responding to vomiting
and diarrheal events (PI)
5 Proper eating, tasting (P) ,drinking, or
tobacco use (c)
17 o discharge from eyes, nose, and f
mnuth (c)
18 9 Hands clean & properly washed (P) (P)
No bare hand contact with ready -to -eat
rind (P)
(Adequate handwashing sinks properly I I
10 sunDlied and accessible (Pt) (c) V'
11 Food obtained from approved source(P) (Pf) ✓
12 JIFood received at proper temperature(P) TO
13 Food received in good condition, safe, &
unnflAtpratpd (P)TO -.
destruction (P)
Compliance Status
IN
out
wn
ero cos
a
Protection from Contamination'
15
Food separated and protected (P) (c)
18
Food -contact surfaces; cleaned &
sanitized (P) (PI) (c)
"`t
t
17
Proper disposition of returned,
previously served, reconditioned &
unsafe food (P)
TimelTemperatarb,Cantrol for Safety
18
Proper cooking time & temperatures (P) (Pf) (c)
19
Proper reheating procedures for hot
holding (P)
J
20
Proper cooling time and temperature (P)
21
Proper hot holding temperature W)
22
Proper cold holding temperature (P)
23
Proper date marking(Pn and disposition(P>
24
Time as a Public Health ControllP)(Pn(c)
Cogsumer'Adyi�ory
25
Consumer advisory provided for raw!
undercooked food(PO
s �Highly�Suscepti6lehopulafion's
`
26
Pasteurized foods used; prohibited foods
not offered IP)(c)
FoodlGoio'rAtlditiues.and7oxi"c'Suhstatt"ces.
27
Food additives: approved & properly
used T)
28
oxic substances properly identified (Pt),
stored(P) & used (Pf)
41
Conformatice-with Approved Pr'acetlures
29processSP9
Compliance with variance(Ps/ specialized
/ HACCP Plan (PDtc)
Official Order for Correction: Based on an inspection today, the items marked 'OUT' indicated violations of 105 CMR 590.000 and
applicable sections of the 2013 FDA Food Code. This report, when signed below by a Board of Health member or its agent constitutes
an order of the Board of Health. Failure to correct violations cited in this report may resultin suspensionor revocation of the food
establishment permit and cessation of food establishment operations. If you are subject to a notice of suspension, revocation, or non -
renewal pursuant to'105 CMR 590-000 you may request a hearing before the board of health in accordance with 1.05 CMR-590-015(6),
Date of Reinspection: Discussion with Person -in -Charge:
Y1a vt 7 pr-- tr e p y cF
PCrj rn��nt xzrv1 ot'i there 2-5r ,�.
rooa cstapusnment inspection tteport —Town of Norwood, Health Department— 781-762-1240
Establishment: �p�1xji—�U Date: Page 2 of 3
GOOD:RETAIL RRAND MASSAGHUSET7S-ON SECTIONS
IN = incompliance OUT= out of compliance NIA=.not applicable. N!O = not observed COS = corrected on site during Inspection R = repeat violation
Compliance Status IN our Nrn I wn cos IS
SAfeFootl,agd_YVater y
30 Pasteurized eggs used where
required (P)
31 Water & ice from approved source(P)
32 Variance obtained for specialized
processing methods (PI)
Po(idTemperatureConfrol:
Proper cooling methods used(Pn(c)
33 adequate equipment for
temperature control (PI)
34 Plant food properly cooked for hot
hnidinn (M
36[Thermometers provided & accurate (P? (u)
`Food IdenBficahon
Food properly labeled(P(l; original
37 rnntainpr (c)
38
Insects, rodents, & animals notp,ya.
present iPe (c) erf
Contamination prevented during
39 food preparation, storage and
display (°)customer self-service(PO, ice(P)
40 Personal cleanliness(PO(c)
41 Wiping cloths: properly used &
stnrart (c)
43 in -use utensils properly stored(c) Nil ffNIN'l
44 Utensils, equipment & linens: %rs
properly stored, dried, & handled(c) 1
45 Single -use / single -service articles:
orooerly stored & used(P)(c)
Food &non-food contact surfaces , OF
47 cleanable, properly designed,
constructed & used (P) (Pn (c)
Compliance Status
IN
OUTTHIATWOFCOS
R
48
Warewashing facilities: tnstalled,
maintained, & used; test str";(Pn(c)
"
49
Non-food contact surfaces clean(c)
�.
P4tysical Fact][ Fes' ,
50
Hot & cold water available;
adequate pressure (Pg
E
51
Plumbing installed; proper backflow
devices (P) (PO (c)
J
52
Sewage & waste water properly
disposed(P)(Pc(°>
y
53
Toilet features: properly constructed,
supplied, & cleaned(Pp(c)
_
54
Garbage & refuse properly
disposed; facilities maintained(c)
55
Physical facilities installed,
maintained, & clean(P) (P<) (c)
55
Adequate ventilation & lighting;
designated areas used(c)
Adtlit9nal keguitements,Ii'ste[m,10¢'CMR'59QOt7
M1
Anti -choking procedures in food
service establishment(c)
M2
Food allergy awareness(c)
1161ewaof'Retaih0iietatlons.;Iis't@d
M3
ICaterer
M4
Mobile Food Operation
M5
Temporary Food Establishment
M6
Public Market; Farmers Market
M7
Residential Kitchen; Bed -and -
Breakfast Operation
M8
Residential Kitchen: Cottage Food
Operation
M9
School Kitchen; USDA Nutrition
Program
M10
Leased Commercial Kitchen
M11
Innovative Operation
Local ftequirenents '
L1
IGarbage Grinder
1_2
Other t(,C--L
,Xyprpof Operation(s):
n r
Type of I pection:
Other Information:
u
% ea
ood Service Establishment
❑ Retail Food Store
❑ Routine
O Re-inspection�0
(
ter
❑ Residential: Cottage Foods
❑ Residential; Bed &
Breakfast
e-operational
❑ Illness investigation
General
'T7,
® -fit --t_ t "
lJ� S
tC
❑ Mobile/Pushcart
❑ complaint
❑ HACCP
A- �j p�
m 'C°it -
"' '7 �1 C/�i� •
❑ Temporary Food Estab.
❑ Other
❑ Other
Signature of Person -in -Charge: ate
Signature of Inspector: D e: �/ & q
i /
MDplimWdfam,—No,waod0312019 ver n
Food Establishment Inspection Report —Town of Norwood, Health Department — 781-762-1240
cstaonsnment: -T/N'5 L">W1i U.f2G6Fj Date: 9 1 q 11 Page _�> of3
lvtnrmssA-9I
Tem erature Observations
Item 1 Location
Tem °F
Item I Location
I Temn IQR
I Item 1 Location
Tem °F
U
EMT -
► 1- L:I u�
MEMO
-�
/ * � wit-.JL C ♦ A
Min Wpa
R NOR
Signature of Person -in -Charge: Date: 9 4 13oi
Signature of Inspector: Date:
MnPH rep.a form—N..i d03I201e m.bn
a.
GLOBALF OP ID: MA
Acoszo CERTIFICATE OF LIABILITY INSURANCE
°ATE IMM°GIYYYn
01102/19
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(les) must he 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).
PRCOMER - Phone:617-489-1213
Cohen -Mlles insurance Agcy Inc
375 Concord Ave, Ste 005 Fax: 617-169-n151
Belmont, MA 024783045
Matt Cohen
CONTACT
PRO E — FAX
D N, _ AID N.:
EMAIL
ADDRESS:
INSURER S)AFFORDING COVERAGE
NAIC 7F
INSURER A: Norfolk & Dedham Group
23965
_
INSURED Global Food Truck Strategies
Kevin Tortorella
4 Fox Hill Road
INSURER8: —
---
INSURER C:
Foxboro, MA 02035
INSURER°:
T __
INSURER E:
_._.
INSURER F:
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.
I S
TYPEOFINSURANCE-
POLICY NUMBER
MOLICYEF
MM/D� E%P
LIMITS
A
GENERAL LIABRDY
X COMMERCIAL GENERAL LIABILITY
CLAIMSMAOE I occur 71
X
39542005A
11111118
11/11 /19
EACH OCCURRENCE
S 1,000,00
PREMISES EaocarrenJ_
MED EXP In"anepersdn)
PERSONAL B ADV INJURY
$ 1,000,000
^-
GENERALAGGREGATE
S 2,000,000
GEN1 AGGREGATE
PODGY
UNIT APPLIES PER:
PRO- LOG
JEC
PRODUCTS -COMPIOPAGG
$ 2,000,00
FOOd Spol
$ 10,000
A
I
,�,�,�AU---TIIIOMOBILE LIABILITY
ANV AUTO
DM
OWNED X AUTOSULED
NON,0WNED
X HIRED AUTOS X AUTOSacddenl
91561848A
03/07/18
03107M9
B de0SIN'LE LIMB,000,00
ILYURY'P.tpALL
ILYINJURY (Pe$
[111PER
TY DPMAGE -
A
X
UMBRELLAUAS
EXCESS LIAR
OCCUR
CLAIMS -MADE
X
U1509307A
11111/18
11/11119
EACH OCCURRENCE
$ 2,000,00
AGGREGATE
DIED RETENnNS
$
A
WORKERS COMPENSATION
ANDEMPLOYERS'LMOILiTY
ANY PROPRIETORIPARTNEWEXECUTIVEY�
OFFICERIMEMBER EXCLUDED?
)Mandatory In NHl
Ifg. d...1be under
DESCRIPTION OF OPERATIONS below
NIA
,w
1V11l18
111Nf19
X WCBTATU- OTH-
LIMIT ER
-
El. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE -EA EMPLOY
$ 1, 000,00
E-L. DISEASE -POLICY LIMIT
$ 1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ADDING 101,Addi(i.n.l Remarks Schedule, K......... N.,.i.d)
City of Boston are an additional insured.
City of Boston
1 City Hall Plaza
Boston, MA
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
Matt Cohen
01988-2010 ACORO'CORPORATION. All rights reserved.
ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD
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Return to:
The Commonwealth ofmassachusefts Wellesley Health Department
,, 90 Washington St
_ 7SepartmentofIndustrialAccidents Wellesley, MA 02481
Office of Investigations
I Congress Street, Suite 100
Boston, MA 0211420I7
wwmmass.gov/dia
Workers' Compensation Insurance. Affidavit: General Businesses
Applicant Information Please Print Leelbly
Business/Otganization Name: C� Gva i�orc Sre>�6uFS t C
Address: U f tte -1 ,24
City/State/Zip; Phone#; P i7- �z `7y
Ar_e��yo�j an employer? Check the appropriate box:
Business Type (required):
1. Lit am a employer with _ employees (full and/
5, ❑ Retail
orpart-tape).*
6, ElRestaurant/Bar/fiatingEstablishment
211 1 am a sole proprietor orpartnership and have no
7. 0 Office and/or Sales (iucl. real estate, auto, etc.)
employees working for me, in any capacity;
$. [� Non-profit
[No workers' comp, insurance required]
3. ❑ We are a corporation and its officers have exereised
9. ❑ Entertainment
their right of exemptionpor c. 152, § 1(4), and we have
10.❑ Manufacturing
no employees. [No workers' comp. insurancerequired]w
4, ❑ We are anon profit organization, staffed by volunteers
I1. In Health Care
with noemployees. [No workers' comp. insuraacereq.]
12JOOther foea 712oelG C.476,v62
*Any applicant that drecks hox#1 mustalso fill out the section belowshowing their Workers' compensation policy information.
**If the ocapomte o0cem have exempted themselves, buttha corporation) is otfier employees, aworkers' componsationpolioy is required and such me
organization should check boic111.
lam an emptoyer that ivproviding workers' compensation insurance for my employees. Uelow isYltepolicy Itformatton.
Insurance Company Name:
Insurer's Address: j "7-5- 66.116r>l -6 X4 11
City/Statemp: 6 EG "'r r' ex/�
Policy# or Self -ins. LID. # W C /S I -7')06 ?I- 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 ofMGL a 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 WORD ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby can*,
that the Information provided above is true and correct.
0
Official use only. Do not lvrtte in this area, to be eompleted by city or town offr"cial
City or Town: PermibLicense If
Issuing Authority (circle one):
1. Board offfealth 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone