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Home My WebLink AboutHangar 12 - 12/31/202113 KO FOR BOARD OF HEALTH USE ONLY Permit # Iss 'dam FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 1 Establishment Address !rc sm Establishment Mailing Address (if different) / y Establishment Telephone No T- -9 — "?_C't �t Applicant Name & Title: ("�-� Ci n'a 11, 0, a C—R _d®` Applicant Address _ �'" "� = ",- Applicant Telephone No.: 24 Hour Emergency No.: Applicant Email m C'? crow: Owner Name &Title (If different from Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or * An Association partner. O A Corporation Name Title Address O An Individual f / Z +Zr O FyPartnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ~``T , Address: / 33 '� '> 5-` Telephone No: _VS'' 9 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: 1 4- Food Establishment Information WATER SOURCE: �✓n SEWAGE DISPOSAL: Sg( h DEP Public Water Supply No: (If applicable) No. of Food Employees: I DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: cY Name of Person(s) In Charge Certified in Allergen Awareness/Training V,A eh.," jj Y.—��Y'tv'�''„c•`34'A A'cr', 'T_ Name of pest control company routinely inspecting the premises for evidence of pests -n- v.i�'P i If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. KJA Yes Does this establishment require a FOG permit? L-.' 5 If yes, please attach the FOG permit application. Lgngth of Permit: blishment Type: L11 Annual tail Food $125.00 ?Food ❑ ile Food Consession pa Temporary p ry Service up to 100 INCLUDING NObPHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: t: Food Service up to 201 + $300.00 lei9 Pushcart $50.00 # of Pushcarts: Temporary Time: ® Supermarkets $400 fro Residential Kitchen $100.00 Rain Date: MAR & Cream $10.00 Caterer $35.00 Food Operations: Definition:PHF -Potentially hazardous food(fimeRempen4ure controls required) (Check all that apply): Non-PHFs- non-potentally hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) s( '❑-,I Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ,-❑.'�. Hot PHF Cooked and Cooled or Hot Held *(Sale of CommerciallyPre-Packaged PHFs �•.; g � Preparation of PHFs For Hot And for More Than a Single Meal Service !<J Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly I1 Reheating of Commercially � Sale of Raw Animal Foods Intended Susceptible Population Facility Processed Foods for Service Within 4 Hours to be Prepared by Consumer rif Use of Process Requiring A Variance Customer Self -Service ill Customer Self -Service of Non PHF and Non- and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only ED Ice Manufactured and Packaged for control) T9 Preparation of Non-PHFs Retail Sale P Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale r=1 Vacuum Packaging /Cook Chill 0 Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the Information provided in this application and affirm that the food establishment operation will comply with 1Q5 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 05 CMR 590.000 and the federal Food Code. r Signature of Applicant: 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. Social Security Number or Federal to: Signature of Individual or Corporate Name: ,AJR-t,*q-& / P'" Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Address: ) 3` Mailing Add Phone/Fax Number: Email: Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: &" <) 7itr'L Name of Company scheduled to pump external grease trap quarterly: 101-4-'/ YYh— L Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the infor7tionbmitted in these documents is true, accurate and complete. Signed iC'i_�i_e Date Print Name o"� /�—��4ZX Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): '�z0- Normal Hours of Food Preparation/Service: Monday 17A, 4), ti V Nt Tuesday �� vV� - a ) M Wednesday Thursday '`r„�., fr\, Friday -d? YM- Saturday '-f JVy( � �, Sunday ea ,d.v=?, Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU / 3 compartment sink Handwashingsink / vl Commercial Dishwasher Al - Barsink Mop Sink yi A- Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? Yes No If yes, at what station/sink? ` 5, 426, t ,'5 -,h1I C 2 r' m. fO 0A Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? d A K Tr G.s If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owners Address: ),L —,d d eA"e'r ;.�V, - Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from 1 Where is the grease storage unit locatec How often is this grease storage unit err Please list the vendor who removes the TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature iW ((C� si� a ea Z ICJ Date: Applicant Name (please print clearly) WA!�b cY z �4�C',u c,_i TAX CERTIFICATION 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 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\s(eite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc A`bRhr CERTIFICATE OF LIABILITY INSURANCE MM DAT,12/o2/zo 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 NAME: John J. Lamb Insurance Agency Inc. A/CNR. E,e. 781-749-6960 plc No: 781-749.8822 24 North Street Hingham, MA 02043 - 'lambinsurance.com ADOREss: _karin INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Nautilus Ins. INSURED INSURER 8 t Progressive Casualty Insurance Co INSURER_ C ; The Hartford HANGER 12 RESTAURANT LLC 265 FRUIT STREET MANSFIELD, MA 02048 INSURER D; - 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INR TYPE OFINSU RANCEkUULSUBR INSD Me POLICY NUMBER POLICY EFF MMIDD POLICY EXP MWDDIYYYY LIMITS A x COMMERCIAL GENERAL LIAaIUTY CLAIMS -MADE OCCUR BPP-$8,000 Y NN1099333 03/07/20 03/07/21 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 50,000 x MED EXP (Any oneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN. AGGREGATE LIMIT APPLIES PER: x POLICY ❑ JECT LOD OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNEB X SCHEDULED AUTOS ONLY UTOS AUTOS A HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Y 01955327.0 04/11120 04/11/21 COMBINED SINGLE LIMIT Eaaccident $ x BODILY INJURY (Per person) _ $ 100,000 BODILY INJURY (Per accident) $ 300,000 PROPERTY DAMAGE Peraccident § 100,000 UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN ANY OFFICEOPRIETEREXCLUDRAE ECUTIVE� (Mandatory In NH) If es, describe under DESCRIPTION OF OPERATIONS below N/A 6S60UB-1K22992.0.20 03108/20 0310812, X PER TA"" STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEFA $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 I F J DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Restaurant- 265 Fruit Street Mansfield, MA 02048. Liability on the commercial general liability policy extends to outside seating area. The commission and its individual members, the Airport Manager and the Town of Mansfield are added as additional insured In regards to the commercial general liability & commercial auto policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield, Public Health Department ACCORDANCE WITH THE POLICY PROVISIONS. & Mansfield Airport Commission AUTHORIZED REPRESENTATIVE 6 Park ROW Mansfield, MA 02048 Jeanne McPhail ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 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 Business/Organization F--A Address: �+�� / 0e s7--ls�_-r City/State/Zip: aiUU Dao-d�Phone#: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2. ❑ I 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 empolovees. [No workers' Como. insurance rea.l Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 LF Health Care 12.❑ Other *Any applicant that checks 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 workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' . hisurancefor my employees. Below is flee policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # 0 Z,0 oil , 1102 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 Investieations 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 aryd correct. Phone #: t ,l r1 9`X/ @ _iY% , 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.govolia FOR BOARD OF HEALTH USE ONLY Permit# Issued r. FOOD ESTABLISHMENT PERMIT APPLICATION ` C (Application must be submitted at least 30 days before the planned opening date Establishment Name How�� Establishment Address I c ru c uer Sr Establishment Mailing Address (if different) Establishment Telephone No ro� Applicant Name & Title: Applicant Address Applicant Telephone No.: 24 Hour Emergency No.: Applicant Email Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or H An Association partner. H A Corporation Name Title Address E An Individual H A Partnership H Other legal Entity Person Directly Responsible For Daily Operations ( ner, person in charge, supervisor, manager etc.) Name & Title: �� (ry ke I1)dwCiy ( Uwh-el Address: �J 4f 2�(� St . Fo ,x 6/-d Telephone No: 1� (f� 3(r q tjr��l Ll ( 24 Hour Emergency No: FAX: E-mail: Ha rry )a k 0) 00 . C 0 vl Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: P6-17r Kt 1101, c Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests an If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. 9 Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual �etail Food $125.00 Mobile Food Consession 0 Temporary Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 .� Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00lfreezer Temporary End Date: Food Service u to 201 + 300,00 P $ 0 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 `❑1 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(timellemperature controls required) (Check all that apply): Nan-PHFs -non-potentially hazardous food(no time4emperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) 0 Sale of Commercially Pre -Packaged Non-PHFs Q PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held 0 Sale of Commercially Pre -Packaged PHFs i3 Preparation of PHFs For Hat And for More Than a Single Meal Service • Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended 0 Reheating Commercially Susceptible Population Facility of b Processed Foods for Service Within 4 Hours to be Prepared y Consumer Use of Process Requiring A Variance (❑'--; Customer Self -Service =f Customer Self -Service of Non PHF and Non- and/or HACCP Plan (including bare hand contact alternative, time as a public health Perishable Foods Only E] Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale 0 Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging / Cook Chill }`a Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Ell Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the accuracy of the information provided in this application and 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 Qf 105 CMR 590.000 and the federal Food Code. Signature of Applicant: 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. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 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. r Signature of dividu 1 or Corporate Name o.a? U au **Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, 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:\Users\sleite\Desictop\Scott's DocumentMood Establishments- Temp\TAX CERTIFICATION FORM.doc /LC l.b/LU/LVLLWCULL/L bf 1Yl UJJ UI. /LLLJCLLJ o� Department of Industrial Accidents Office of Investigations Ulf 600 Washington Street Boston, MA 02111 tvww.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ��ur�� S ''�G1 e- Address: City/State/Zip: Met h f ri e I j I MR i�<� ()N� Phone Are you an employer? Check the appropriate box: Business Type (required): I.❑ I am a employer with employees (full and/ 5. V❑rRetail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.4 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. ❑ Non-profit 3.❑ [No workers' comp. insurance required] 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 4. ❑ no employees. [No workers' comp. insurance required]* We are non-profit by 11❑Health Care a organization, staffed volunteers, 12.❑ with no employees. [No workers' comp. insurance req.] Other *Any applicant that checks 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 workers' compensation policy is required and such an organization should check box #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Nan Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. 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 certify, under lire pains andpenalties ofperjury that the information provided above is true 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 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: