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HomeMy WebLinkAboutJimmy's Pub & Restaurant - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name 7fh(s 5 ` U. 12.Gbm� Establishment Address 14tNoH "' ' Establishment Mailing Address (if different) Establishment Telephone No SOS • 334 • R`t� S Applicant Name & Title: Gl<r �i ��'�TOS OLO 1� Applicant Address 23 FQCreDvreTC+btt Nuj;O.4 " s� 02AS(e Applicant Telephone No.: Sbd `E51 ' SS''tS 24 Hour Emergency No.: SA+tc- Applicant Email GDPP,,MS (5L.% oc 5�OA<(• Owner Name & Title (If different from applicant) Owner Address e Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or E] An Association partner. 134�Corporation Name Title Address O An Individual Sd+tia fa-4 arxsvc O A Partnership Ed Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: S� tG pS 4J)pVG Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Kolue, Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: y 4 � SEWAGE DISPOSAL: a ✓ No. of Food Employees? � ",At saaw ee< DEP Public Water Supply No: (If applicable) DAYS/HOURS: (o qp� (p µOU W-'. Name of Person(s) In Charge Certified in Food Protection Management: /vt/1-rieie ; /�44vhed Name of Person(s) In Charge Certified in Allergen Awareness Training /�i C'�'f"j P /e )f 4++A J e Name of pest control company routinely inspecting the premises for evidence of pests WPC ?CST +'Te k vk 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. V'?es Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: e Annual Retail Food $125.00 , I Mobile Food Consession (❑'d Temporary Food Service up to too INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 E3 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: R-15ood Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: [] Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Caterer $35,00 Food Operations: Definitions:PHF - Potentially hazardous Food(fimeltemperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous/ood(no limaltemperature controls required) RTE - ready-lo-eat foods(Ex. sandwiches, salads, muffins which need no furtherprocessing) H Sale of Commercially Pre -Packaged Non-PHFs dPHFCooked To Order Hot PHF Cooked and Cooled or Hot Held I� Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service [F2 PHF and RTE Foods Prepared For Highly P'7 Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended a Reheating of Commercially to be Prepared by Consumer I] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service Customer Self -Service of Non PHF and Nan - contact alternative, time as a public health Perishable Foods Only ITJ Ice Manufactured and Packaged for control) ''❑"-3 Preparation of Non-PHFs Retail Sale IJ Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 0 Vacuum Packaging !Cook Chill 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 wit CMR 590.000 and all other applicable law. I have been Instructed by the board of health on how to obtain c s of 1 dMR 590,000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 9A, i ce and paid state taxes required under law. under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: Signature of Individual or Corporate Name: 0(b SL 3P1y; m( 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. U...... .. . oto, Si• 7043 **Social Security No. (Voluntan/) or Federal Identification Number (i /— By: or (Mandatonj, 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\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Z4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leaib►y Business/Organization Name: Address: 141 Nat'Ctr(14o� M0St1 City/State/Zip: HrusS�lir-LA MOSS 02D4P Phone #: 15C& $39•J7i5's Are you an employer? Check the appropriate box: Business Type (required): 5. ❑ Retail 1. 21 am a employer with 3d employees (full and/ or part-time).* 6. [3'Aestaurant/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. 8• ❑ Non-profit [No workers' comp. insurance required] 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12.❑ Other with no employees. [No workers' comp. insurance req.] *Anv **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 H 1. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: nA QG Op t, MCAt4A0'=S 0C G(WUP S6Sc Insurer's City/State/Zip Policy # or Self -ins. Lic. # oly (" S 0Z % 1;V uw Expiration Date: O t /at� 2.0 L 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 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 cgrtt n*r the pains and penaldes ofperjury that the information provided above is true and correct. Phone # si�4�'�is► SS'IS C4 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/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS r Business/ Food Establishment Name: `� r Address: I I•(' 1 NO-OMWA-� bZ Mailing Address: i�i t r� •a later St Phone/Fax Number: 50b,'939 •'?')S5' oft CPX Sorz 334 SQL 2 Email: GDAWMS (S L30. �fKlM�. ecs.-a Contact Person/Title for Grease Traps: G�-OaG£ (7 •PANTOS QW l em /+ J Name of Company scheduled to pump internal grease trap(s) monthly:l�il Name of Company scheduled to pump external grease trap quarterly: 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 ackno le a he information submitted in these documents is true, accurate and complete. Signed Date Print Name C:c( ki ID YAwt6S 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): �yy Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday 6WsS(') Thursday 11— 16 Sunday %2,. (6 Tuesday 2-.CZ 76 i0to Friday tZ TO 10 cn" V MSS Time-5 Wednesday 2o6o YC, (6*60 Saturday t2,• n (O 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 Handwashing sink ✓ Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Z Fryolators Grills or Ovens Z Exhaust Hoods '1 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): tyatyAYL ctmteaA y Is dinnerware pre -rinsed before being washed? w�_ Yes If yes, at what station/sink? ptyapWp AEA A.OA WC ij Grease Traps 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 I)IN* Atl;jtere. } at#+r< 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)? rj -()i'yAt k. ' Yes No Size tq WD gallons Where is the existing outdoor GRU located? -AWJL OF 13011uj 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: 6coaC-£ 0. PAAT05 Property Owner's Address: Z3 FdtEEtkt+1 TjsC t( n1d(LF6tyC C12115�0 Property Owner's Telephone Number: S(yZ4Sl SS'IS Yellow Grease Waste Do you store yellow grease waste from fryolators? �eb cur ppt a zAJ taws Lwd- Where is the grease storage unit located? i3pC1G of (�Ut��ts� How often is this grease storage unit emptied? WC41 S Please list the vendor who removes the waste: 13pYlJl 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. I 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. ,57!b-1 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. 1 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 Date: // LO Applicant Name (please print clearly) GEORL4- D • P06"T'O t, cedikolion pfote6on manager , c M for FA Prolecfron I-4 OQ E 11812024 DATE OF E X P I R AT 10 N 'on requirements. S'trv3at ericireflC EN {\\ � ƒ , � z§� /\[\ T ■ / / ■ \ 2 B \ I rol rml r7l � rTl z ,M .► 7� r7l z til � � \) � � � IV. -Um Go to aPP Se m .......... CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: EVELIA CALDERON Date of Completion: January 3,2020 Date of Expiration: JmmaO, 2,2025 AlitiC �do6e. ..... )!H 0" 1 1,0,1,Gih !,, h -,'03 '�w," A, , 0 1),; CERTIFICATE OF ALLERGEN AWARENESS TRAINING Konvofltadplmt: uuvzimueium Ctlfiti,Imt, iNtIIIII'm IN, III tiow ni .... ......... .. Ile IAMI I 'tip '-p- w U V uz 1� z r� V J W z w P4 z w w 0 Q� J lVV 1� h o u z Q U Q W .0 c o .y c ti N O ^ O ✓ U Cry' O �a (% P u M y x 1 er �-n O i a o �o N 3 ,y � O o � nz o h �i A� EI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 10/28/2020 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 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 endorsament(s). PRODUCER NAME CT Shannon Cassidy Morse Insurance Agency, Inc. JAM, No, E t: (508) 238-0056 FAX(508) 230-8367 285 Washington Street E-MAIL shanoncassid ins.cem ADDRESS: ny@morse INSURER(S) AFFORDING COVERAGE NAIC Is North Easton MA 02356 INSURERA: Norfolk & Dedham Mutual Fire Insurance Company 23965 INSURED INSURER 8: MA Retail Merchants WC Group Inc. DGP&SONS, INC. DBA JIMMY'S INSURER C; 141 N. MAIN ST INSURER D INSURER E : MANSFIELD MA 02048 INSURER F: rtGv NIuw N V IY16CK: 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 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. ILTR TYPE OFINSURANCE POL CY EFF OLCYEXP SD WVD POLICY NUMBER MM/DDIYYYY MWDDffY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR EACH OCCURRENCE $ 1,000,000 C' TO — PREMISES fEe occurrence) $ 250,000 MED EXP (Aw one parson) $ 10,000 A R2019891A 02/05/2020 02/05/2021 PERSONAL&ADV INJURY $ GENERALAGGREGATE $ 2,000,000 GENTAGGREGATE X LIMITAPPLIES PER: POLICY ❑ PRO-JECT LOC PRODUCTS - COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY OWNED AWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOSONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea acode 1 $ BODILY INJURY (Per Pelson) $ BODILY INJURY (Per accident) g PROPERTY DAMAGE Peraocldenl $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEO RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYCERIMEETOLUPARTNER/EXECUTNE M (Mandatory In NH) E%CLUDED? (Mandatary In NH) If yes, describe under v _ XSTA UTE ERH $ B NIA 014000502192120 01/01/2020 01/01/2021 E.L. EACHACCIDENT $ 1,000,000 E.L. DISEASE. EA EMPLOYEE 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below A Liquor Liability R2019891A 02/05/2020 02/05/2021 Aggregate 2,000,000 Each Occurrence 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Town of Mansfield 6 Park Row Mansfield MA 02048 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 OO 1988-2015 ACORD CORPORATION. All rinhtA AUUKU Z6 (Zulu/U3) The ACORD name and logo are registered marks of ACORD Form ' Request for Taxpayer (Rev. Cato ber2018) identification Number and Certification Give Form to the requester. Do not Department of the Treasury Intemal Revenue Service ► Go to Www.irs.gov/FormM for instructions and the latest information, send to the IRS. 1 Name (as shown on your Income tax return). Name Is required on this line; do not leave this line blank. Pf 1NTU S 2 Business name/disregarded entity name, If different from above l7GP+'SO1i1S Ot3ATIHWJS�(jb$STGM�?1LST 3 Check appropriate box for federal tax classification of the person whose name Is entered on line 1. Check only one of the 4 Exemptions (codes apply only to a following seven boxes, certain entitles, not individuals; see instructions on page 3): o rv� ❑ Individual/sole proprietor or ❑ C Corporation �J S Corporation p p ❑ Partnership ❑ Trust/estate asingle-member o LLC Exempt payee code (if any) ❑ Limited liability company. Enterthe tax classification (C=C corporation, S=S corporation, P=Partnership)► �o Note: Check the appropriate box In the line above for the tax classification of the single -member owner. Do not check LLC if the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC Is Exemption from FATCA reporting 'c c another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that code (if any) .0 t is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other (see instructions) 1- ¢to Wtoe C"Is Me ftl wwlswe u, U.S.) 6 Address (number, street, and apt. or suite no.) See Instructions. Requester's name and address (optional) 14l NOM MPi+J SCr,2ce—L 6 City, state, and ZIP code "Wsf=tlew t%ass • U2A4rr 7 List account number(s) here (optional) Number 1 t Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this Is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Instructions for Part 1, later. For other entities, It Is your employer Identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account Is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Under penalties of perjury, 30M©©M©©O© or MUMAMEMMI 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) Indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, �yo`u are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. v,yn I Slgnatureof Here U.S. person► Date►if//i/2,U General instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and Its Instructions, such as legislation enacted after they were published, go to www3rs.gov/Forni Purpose of Form An Individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer Identification number (EIN), to report on an Information return the amount paid to you, or other amount reportable on an information return. Examples of information returns Include, but are not limited to, the following. • Form 1099-INT (Interest earned or paid) • Form 1099-DIV (dividends, Including those from stocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only If you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What Is backup withholding, /a ter. Cat. No. 10231X Form W-9 (Rev. 10-2018)