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HomeMy WebLinkAboutMansfield Youth Baseball (Concession) - 12/31/2021Id, FOR BOARD OF HEALTH USE ONLY Permit # Issued ' FOOD ESTABLISHMENT PERMIT APPLICATIONr (Application must be submitted at least 30 days before the planned opening date) Establishment Name Mansfield Youth Baseball (Concession Stand) Establishment Address PO BOX 702, Mansfield, MA 02048 Establishment Mailing Address (if different) 267 Otis Street, Mansfield Ma, 02048 Establishment Telephone No Applicant Name & Title: Adam Schlosser, Director of Concessions Applicant Address 27 Farm Pond Path, Mansfield MA 02048 Applicant Telephone No.: 857 636 0640 24 Hour Emergency No.: 857 636 0640 Applicant Email casch@mlt.edu Owner Name & Title (If different from applicant) Mansfield Youth Baseball Owner Address PO Box 702, Mansfield, MA 02048 Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or X An Association partner. Ed A Corporation Name Title Address An Individual FBI A Partnership N Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Adam Schlosser, Director of Concessions Address: 27 Farm Pond Path, Mansfield MA 02048 Telephone No: 857 636 0640 24 Hour Emergency No: 857 636 0640 FAX: E-mail: casch@mit.edu Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Mike Menard Address: 397 Elm St., #3, North Attleboro, MA 02760 Telephone No: 508 740 7239 24 Hour Emergency No: 508 740 7239 FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Town DEP Public Water Supply No: (If applicable) No. of Food Employees: 4 DAYS/HOURS: MAY-JUL: Weekdays 5-8p, Saturdays 10a-5p. SEP-OCT: Weekend 9a - 5p Name of Person(s) In Charge Certified in Food Protection Management: Mike Menard Name of Person(s) In Charge Certified in Allergen Awareness Training Mike Menard Name of pest control company routinely inspecting the premises for evidence of pests AAA Pest 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. ® Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: A Annual [51 Retail Food $125.00 ® Mobile Food Consession 0 Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 no Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ® Food 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: fU Supermarkets $400 ®Residential Kitchen $100.00 Rain Date: [Qi Milk & Cream $10.00 rl Caterer $35.00 Food Operations: Deflnitlons: PHF- Potentially hazardous food (time/temperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous/ood(no time/femperdfure controls required) RTE - roady-fo-eat those (Ex. sandwiches, salads, muffins which need no further processing) DI Sale of Commercially Pre -Packaged Non-PHFs X PHFCooked To Order ® Hot PHF Cooked and Cooled or Hot Held ❑bl Sale of Commercially Pre -Packaged PHFs ER Preparation of PHFs For Hot And for More Than a Single Meal Service {g Delivery Packaged PHFs Cold Holding For Single Meal Service � PHF and RTE Foods Prepared For Highly of Susceptible Population Facility ® Sale of Raw Animal Foods Intended Reheating of Commercially 9 Y to be Prepared by Consumer 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 Non- contact alternative, time as a public health Perishable Foods Only ❑rg Ice Manufactured and Packaged for control) ❑� Retail Sale Preparation of Non-PHFs ®Offers Raw Or Undercooked Food Of 0 Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ® Vacuum Packaging /Cook Chili nfA Offers RTE PHF in Bulk Quantities ® Prepares Food/Single Meals for tU 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 conies of =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: 037-52-8677 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. CCU., C,, Signature of Individual or Corporate Name 037-52-8677 "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:\Usem\sleite\Desktop\Scotrs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization N Address: PO Box 703 Mansfield Youth Baseball City/State/Zip: Mansfield, MA 02048 Phone #: 857-636-0640 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ 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 3.0 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.❑ Other *Any applicant that checks box #t 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 #l. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Robert W. Eames Insurance Insurer's Address: 126 North Main Street City/State/Zip: Mansfield, MA 02048 Policy # or Self -ins. Lie. # 6S62UB-7H97841-7-17 Expiration Date: 3/22/2021 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 the ins and penalties ofperjury that the information provided above is true and correct C;onsturP- �961, Date: 5/13/21 857-636-0640 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 Phone #: Contact www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Form Revised 5-26-05 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 www.mass.gov/dia 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. X 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. X 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. X 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 Date: Applicant Name (please print clearly) C. Adam Schlosser 5/13/21 INTERNAL REVEMB SERVTCT DEPARTMENT OF TRU TRRASURY P. Q. Box 25.48 C:INCINNATI, 014 45201 Employer Identification Neunber: Data::JUN O L� 1� 22-2473644 DLL: 17DS3074392041 MA17SFIL+LD YOUTB 'DASEAALL INC: Contact Person: PO BOX 702 MAXWELL. SULLIVAN I1V 31r,96 MANSFIELD, MA P�1048 Contact Telephone Number: (877) 829-5500 Accounting Period End:i:ngt .September. 3.0 Public Charity Status: 509(a) (2) Falln 990 Reauired: Yes Effective,Date of Exemption: April 14, 2008 -_ Contribution Deductibility: Yes Addendum Applies: Yes Dear 7applicant: We are pleased to inform Voll chat upon review of your application for tax exempt status ue have determined that you are exempt from Federal income tax under Section 501(e)(3) of the Internal Revenue Code. Contributions to you are deductible under seCt'i.oY.t 170 of the: Code. you are also C-.1ified to receive t.ax deductible %>eouests, devises, transfers or gifts under section 3n55, 21o6 or 2522, of. the code. Because this letter could help resolve any questions regagding your exempt status, you should keep it in your permanent records. O rgao t%at ions exempt under section 501(c)(3) of the Code are further classified as either public charities or private foundations, We determined that you axe a public. charity under the Code section(s) listed in the heading of this letter. Please See ssclosed. Publication 4221-PC, Compliance Guide for 901(a)(3) Public Chcrlties, for Some helpful i.nformatiou about your responsibilities as an exempt- organisatikn. F.Uclosure: Publication 422i.-PC Sincerely, _ Lois G. Lerner Director, Exempt Organizations Letter 947 (DO; CG) MANSNLi+T,l) YOU'I„i 3ASEBAL,T., INC YOUR CIRGANI7.ATI04 WAS ',*?9VTo UPMY. EXFT4PT AS A IIUR.0P=NATB IIN A GRQUEP vXGMrTION. YOUR TRDIVIDUAL X9MPT]:,3tT _MS I;I'E'ECTIVP•, A.PRIL 15, 2008, ''ME DATE YOU WECEDR)w FR.GiN MP CROUP iirRMl?TTQ;Y. Latter 947 Mansfield Board of Health Request for Fee Waiver for Food Permit Date May, 13 2021 We Mansfield Youth Baseball League (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. " Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, C /\ Signature UUUU"''���---------- Director of Concessions Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: