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HomeMy WebLinkAboutWest Side Benevolent Circle - 12/31/2021Fte, \j,v J o � (r FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION ' (Application must be submitted at least 30 days before the planned opening41'��)�l l ?�? r' 6"?Nnp Establishment Name Lt)t&� SIC`e &—ne'1den+ C,(t� f&, Inc.. Establishment Address% f Establishment Mailing Address (if different) 12,�OX SotP MarrrJle_td, M 'k oac S Establishment Telephone No 506 .35q 5� -( Applicant Name & Title: 'bRI.LI j Sam P(esi tei"}t nLW hyS�CAt M� Applicant Address 06 Edge.wcod S-I-t'e + Mansfiddl rJacxlB aClness Applicant Telephone No.: (LPIr7 )uq-1 -111I I O 24 Hour Emergency No.: Applicant Email we slde com drrh_Saba t)ya.hco.Eom Owner Name & Title (If different from applicant) LocoAje n of-tJ bq ckm* Quav}ef5 Middle 5GI1 O Owner Address 9440 Ea t- SA -at_+ Mar5,e,16, MA- oaoj-P$ Owner telephone number Ctr*(CLX 0q-6u-. SOS ratnl gorCo Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or eIi An Association partner. Ira A Corporation Name Title Address Ed An Individual Wig A Partnership as Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Sarre_ A,j i -bc�e Address: Telephone No: 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: Food Establishment Information WATER SOURCE: Mqr6fi W ' Abl'iC SChaJS SEWAGE DISPOSAL: M PcS. No. of Food Employees: 5- DEP Public Water Supply No: (If applicable) DAYS/HOURS: TLg56q 5 q-3 We-dJ 2,_.C' P S 10"o'D- IZ',30 6 - $ I$r IP9 Name of Person(s) In Charge Certified in Food Protection Manag ent: Name of Person(s) In Charge Certified in Allergen Awareness Training co((t np- 5 e-noL Name of pest control company routinely inspecting the premises for evidence of pestsSee- 5Gh-r)\ `()es� 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. H Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: rid Annual ® Retail Food $125.00 ilE Mobile Food Consession Temporary Q Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: bP I tot l FOOD TRUCKS $175.00 ® Manufacture Frozen Desserts/Ica Cream $25.00/freezer 9ti Food Service up to 101 -200 $250.00 Temporary End Date: $ gp '� L Food Service up to 201 + $300.00 N Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 to Residential Kitchen $100.00 Rain Date: i=: Q Milk & Cream $10.00 RS Caterer $36.00 Food Operations: Definitions:PHF. Potentially hazardous food(Urneftemperature controls required) (Check all that apply): Non-PHFs- non-potentlellyhezardous food(no (ime/lempereturs unntmisrequired) RTE - resdy-fo-eat foods (Ex, sandwiches, salads, muffins which need no furtherprocessing) IIn Sale of Commercially Pre -Packaged Non-PHFs 7r PHFCooked To Order to Hot PHF Cooked and Cooled or Hot Held !0 Sale of Commercially Pre -Packaged PHFs °❑�, Preparation of PHFs For Hot And for More Than a Single Meal Service Dsilvery of Packaged PHFs Cold Holding For Single Meal Service Ilfi PHF and RTE Foods Prepared For Highly Susceptible Population Facility 3d Sale of Raw Animal Foods Intended iE Reheating of Commercially p y G8 Use of Process Requiring A Variance to be Prepared b Consumer Processed Foods for Service Within 4 Hours To Customer Self -Service and/or HACCP Plan (including bare hand 0 Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only r,❑E'�. Ice Manufactured and Packaged for control) Preparation of Non-PHFs Retail Sale 5i Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging t Cook Chill 14J�Offers RTE PHF In Bulk Quantities 3i Prepares Food/Single Meals for XRetail 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 of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: ;ZluI_A Pursuant to MGL Ch.62C, sec. 49A, I ce and paid state taxes required under law. penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal tD: f�� jj ` I CSignature of Individual or Corporate Name: f — 3q 15-1 a 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 By: Corporate OfAcer (Mandatory, if Applicable) ljau� M mac, ©4— N 15qQ **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:\Usen\slciUe Dmktop\Scotts DocamentMood Establishments- Temp\TAX CERTWICATION FORM.doc 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. akR'�l 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. UY &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 NAIL 1 Ly' X l �l Date: 05 kf at Applicant Name (please print clearly) Mansfield Board of Health Request for Fee Waiver for Food Permit Date ar'-�a6j a I We, cSidt &xw,2kn-L i' (x r jT 1C . (restaurant/ organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. /Ple' ase list the department: I� e 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: are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, Signature �(I Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: INTERNAL REVENUE SERVICE: DISTRICT DIRECTOR S.P.I. BOX 1.680 BROOHLYN, N4' 11:202 Daten,UN 2510 WEST SIDE BE:NEVOUNT CIRCLE INC C/O CAROL_ L.UCAS PO SOX 50.5 NANSF'IELO, IoIA 012048 Dear Appilcant: DEPARTMENT OF THE TREA13URY Employer IdentifIraticm Numbers 04-:3141542 Contact Persona CESM A SARANDO Contact Telephone Number: (7113) 488-52314 Accounting Period Endings Deciamber 3:1 Form 970 Required: Yes Addendum AppIlasa No Based on Informa•tiean suppl led, and assuming your operations mill be as stated in your appiication for recognition of ewoamptlon, we have determined you are exempt from Fsds:ra I income tax under section 501(a) of the Inter•na I Revenue Coda: as an organization 4-ascribed in section We haver farther determined that: you are -not; a private foundation within the meaning of se:ctlo•a 509(0 of the: Codes, because you aria an organization described In sections 509(a) (1) a'nd i70(b) (JJ (A) (vi),. If'y:>ur• sources of support, nr your purp*se:sr.character•: or method of operation change: pieasa let as knoll so sae ca•n consider the effect of the change on your exempt status and foundation status. In the case of an amend- ment to your, organizational document or bylaws, please send as a copy of the amended document or bylaws. Also, you should inform us of all changes In your name or address. As o•f January 1r 190.4a you are liable for taxes under the Federal Insurance Contributions Act (SnClal security taxes) cm remuneration o•f 0100 or more y.au pay to each of y(aar employeeis during a calendar year., You Fire not liable for the tans imposed under, the Federal Unemployment Tax Act (FUTA)., Sind you are not a private •roundation, you are not sub,Ject to the excise taxer. under Chapter 42 of the Codia. Howeaver, you arse not automatical ly exempt from other Federal excise taxes. If you have any quostlams about; excise, employment% or other lrstleral taxes, please let us knew. Gran-tar•s and contributors may rely on this determination unions the, Internal Revenue Service publishes notice to the contrary. Howevers if you lose your serction 509(a) (1) %tatus, a grantor or contributor may not rely .on this determination if he or she yeas in part responsible for, or was aware of, the act or failure to act:, or the substantial or material change on the part of the organization that: resulted In your loss of such status, or if he or she acquired knowtedgts that the Internal Revenue Service had given notice thrat you iaould no longer boa classified as a seactlo-n E109(a)(1) organization. Letter 947(DO/Ci3) -.2- NEST SIDE BENEVOLENT CIRCLE INC Donors may deduct contributions to you a-s provided i•n section 1710 of the Code. 6etque:stst legacies devises transfers or gifts to you or for your use are deductible for Fedor•al estate and gift to:x porpoises If they meet the applicablta provisions of Code sections 20561 121061 and 25,22. Contrlbutlon deductions are allowable to donors only tct the extent that their contributions are giftsss with no considtarmtion received. Ticket pur- chases and similar payments in conJunction with fundralsing events may not nece!ssarl'ly qualify As cleduct:ible contrihutlo•nsi depending on the circum- stances. Sere Revenue Ruling 67-2.461 published in Curaulative Bulletin IT67-2'a on page 11049 which sets forth guidel Ines regarding tive deduc:tihi I lty, as: chat,] - table contributions of payments made, by taxpayears for admission to or other participation in fundraising actiaities for charity. In the Beading of this letter we, have indicated whether you must -file Form 9701 Return of Organization Exempt From Income i'ax. If Yes is indica•tedv you are required to file Form 990 only if your.grtossi recfalpts each year are normally more than $215v000. Nowevers if you recaive a Form 990 package in the ma I I-t p Ieasea f Ile the return even if you do n.)t exceed the gross receipts teist. If you are not required to f I I a v -aInip Iy .attach the Mabel providedt check the boy in the heading to indicate that your annual grosis receipts are normally $215,000 or less, and aisln the return. If a re:turn Is required,, it mu>t be fl led by the 15th clay of the fifth month aftar the end o1 your annual accounting pvriod,. A penalty of $10 a days Is charged when is return Is filed later unless there is reasonable causer for the delay. However, the: maximum penalty charged cannot exceed S57000 or, 5 pear - cent of your- grass receipts for the yeary whichever is less. This penalty may also be charged If a return is no-t completes -so please be sure your return its comp late before you fIie it. You are: not required to fi to Federal inca)met tax returns unlosis you are subject to the tax on unralai.ed business income under section 511 of 'the: Code?. If you are subject to this tax,, yaa must file en income tax return on Fr,rm 99o-'fs Ex.ampt Organization Business Income Tax Return. In this letter rte Arta not determining tahethtar any of your present or propo<.sed activities are unre- lated trade or business as defined in section 51.3 of the Code. You need An empl,aye:r ident'if icat:ion number even if y,)u have no empioyeeis. If An employer Identification number was not ,entered on yt)ur• applications a number will be assigned to you and you will be advised of It:. please use that numbear on at I returns you fi le and in al i correspondence with the Int.arnal Revenue Servlce. In accordanes with eaction 51300) of the Cr ai the e•ffoctivee datle of this determination letter is November 14s1990,. This dssterminati,)n Is biased ton evidence that your funds are dedicated to the purpasas listed In section 501(c)(3) of the Code. To assure y.)ur Letter 947 (DOYC19) -•3- WEST SIDE BENEVOLENT CIRCLE :INC continued eu:emptiona you should maintain records to !show that funds are expended only for those purposes. Xf you distribute fund•a to other organizationsi your records should show whether they are exempt under section 5t51(c) (9A. I•n cases where the rncipientt organization is not taxaempt under sec•tian 501(c)(9), there should be evidfance that the funds will remain dedicated tct the required purposes and that they will be used for those purposes by the recipient. If disc;ribui;ions are made to Individuals, ease histories regarding the reciplent•s should be kept showing namesr addr-esssesr purposes of awards, manner of selections relationship (If any) to member -me officerse trustees or donors of funds to your so that arty and all distrlhutions made to I•ndividwals can be substanti.ataed upon request by the Internal Revenue Service. (Revenue Ruling 54-3041 C.E. I956-2e page MS.) If wa have Indicated in the heading of this letter that; an addendum applies, the enclosed addendum is an integral part oil this letter. Because: this letter could help resolve a,ny questions about your exempt status and foundation status, you should keep it in your permanent records. If you have any questionsi please contact the person whose name .and telephone number are •shtnwn In the htuading of this letter. i �i Sincerely yours, Sugente It. A IA I fex iander 01strIct 01Factor Latter 947 (DO/Cs9) ir \. H> EM " low, ra The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UlfBoston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Anulicant Information Please Print Leeibly Business/Organization Name: L LI* (Si(tK 6emyoK I Ci rck YIG. Addres'si ice.0. 130Y 6otp phone #: 508 33q 33 q r7 Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ S. ❑ 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] $• 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 10Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4. We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.j 12.Q Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomnation **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensationpolicy 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: Insurer's 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 eert�, under the pains and penalties 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 www.mus.gov/dia