HomeMy WebLinkAboutC & C Ice Cream Truck -12/31/2021Jul/20/2Q21 12:37:48 PM
Date Recel*d.i
Steward Health Care 5086983298
FOR BOARD OF HEALTH
X
AUG 19 202i 1
2/8
Mobile Food Establishment (MFE) Permit Application
(Applicationmust be submitted at least 14 business days before the planned opening date)
1) MFE Name:. fi C .If
2) Appiicant/Owner Name & Title: a"Id
ApplioanVOwnerAddress: � � sl ^- of...
Applicant/Owner Telephone No: �2 6O
AppllcenVOwner Emall address:
NC r rP r✓
3) person In charge of Onsite Operations & Title:
PIC Address:
PIC Telephone No: Emergancylonelte Telephone No: �r
PIC Email Address:
4) Location of service:
G l C( (•
D
Date(s) If applicable: t y
Event Name If applicable: C
Event/ Service Location: l� a nJ
Event/ Service time:
S) Lengthof Permit:
6) Solid waste disposal plan:
CI Annual
/ ►i( ("
7) Water Source:—vf
8) Sewage disposal plan:
6) Food will, a prepared:
Onsite for Immediale consumption
m Onsite and held at proper hot/ cold holding temperatures
p offelte and hold al proper hot/ cold holding temperatures
m offsite, cooled and reheated on site _
Q Other: tom°-11-C rc r•�. i - -
10) Please attach a menu or a web site link to the menu or give a brief description of the food to be served:
,v ct,c AWc- r
C1
Jul/20/2021 12:37:48 PM Steward Health Care 5086983298
3/8
11) If PHF Is being served, please list the person who has completed the following training$ and attach appropriate
certificates; t
Food Safety Manager: l
Allergen Awareness: rj 1e
12) Please describe on site hand washing facilities that will be utilized: p /�
13) Please list all sanitizing solutions that will be on site:
V�t�C
14) Do you have propane, fryolators andlor hoods on your truck?
if yes, you must first be inspected and approved by lha Mansfield Fire Department. Phone number: 508.261 7321
Fire Department Signature of Approval:
18) If applicable, please describe your F.OG managembnt plan orrattach the written plan: I
18) Location of Bass of Operations or Commissary:
Please attach copies of Base of operations or Commissary Permit
yn
17) Please list additional communities where a food permit Is held: // {�`E'Wi✓t
NPAUAQ In
I, the undersigned, attest to the accuracy of the Information provided In this application and I affirm that the.food
establishment -operation will complywith 105 CMR 590.000 and all other applicable law. I have been Instructed by
the board�of health. on how to obtain ooples of 108 CMft� qoo and the�deral Food Code.
18)Slgnature of
Pursuant to MOL Ch. 82C, sec, 49A, I certify under the penalties of per)urythat 1, to my best knowledge and belief,
have flied all state tax returns and paid state taxes required under low.
n r
1s) Social security Number crFederdlID; 0da�-vf 6 3 r `�
20) Signature of Individual or Corporate
J
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 ndi idual or Corporate Name By: Corporate Officer (Mandnt'ory, if Applicable)
�cP��ff�
""Social Security No. Woluntanj) or Federal
ldantification 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:WseBWei101De5kwplSee1's DaeuwenuWoud Es1a61iAmeNs-TampWAX CERTIFICATION FORM,dou
b/b 96ZE969909 eaeO 441e9H WemelS Wd WVVZb bzoZ/OZ/Inf
Jul/20/2021 12:37:48 PM Steward Health Care 5086983298 7/8
The Commonwealth of111assachusetts
Department of Industrial Accidents
Office oflnvestigations.
600 Washington Street
Boston, MA 02111
www,mass.govIdia
Worker's' Compensation Insurance. Affidavit: General Businesses
Applicant Information r Please Print LeLyibiv
Business/Organization Name:
Address;
Plione #: C)
Are you an employer? Check the a0propriate box:
1. ❑ I am a e tsyer with employees (full and/
a• time)."'
2 atn s sale proprietor or partnership and have no
employees working for me, in any capacity.
[No workers' comp. insurance required]
3.7 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 employees. [No. workers' comp. insurance req.]
Business Type (required):
5. Retail
6, Restaurant/Bar/Eating Establishment
7, Office and/or Sales (incl. real estate, auto, etc.)
8. Non-profit
9. 7 Entertainment
10.0 Manufacturing
•Any upplioam that checks box 91 must also fill out the section below showing their workers' compensation policy information.
""lithe corporate officers have exempted themselves, but the corporntion'hus other employees, u.wurkers' compensntion policy is required imil strain (in
organ xatioushould check box #I.
I am an employer that is providing workers' compensation insurance for Illy amployees. Below is tie policy infarination.
Insurance Company
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 MOL c, 152 tali 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 it fine
of up to $250.00 it 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 ilo hereby certify, tint ter t Its andpanallial.jifpaijuily that the Inforniodon provided ab ve is tr a and correct.
St lure:
ate;
Phone #: an at
official use only. Do sot write lit this area, to be completed by cio, or totwn official.
City or Town: Perinit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3, City/Town Clerk 4. Licensing Board S..Selectmen's Office
6. Other
Contact Person: Phone #:
www.mass.gov/dia
Jul/20/2021 12:37:48 PM Steward Health Care 5086983298
4/8
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 indAuull or Corporate Name By: Corporate Officer {Mandatory, if Applicable)
""Social Security No..(Voluntaq) or Faderal
Identification Ntdnber
'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:11JxerxWleac�DexkwplScuu's DouumanisTuad Eriahlishmems- TeatplTAX CERTIFICATION FORM -clue
Jul/20/2021 12:37:48 PM Steward Health Care 5086983298 5/8
W-9
Request for Taxpayer
Give Form to the
Form
Identification Number and Certification
requester, Do not
(Rev. October 2018)
send to the IRS.
Depanmepl'gl the Treasury
in Io nI Revenue service
P. Go to www.1raiVov1FormW9 for Instructions and the latest Information,
1 Name (ass wn on your Income totum). Name required on this line; do not leave this line blank.
2 Business name/de,regardoo entity name, ff different from above
aCheck appropriate box for federal tax olaaslfcallon of tt tare& on line 1. Chock only one of the
4 Exemptions (codes apply only to
certain entities, not individuals; one
Q�
d
following seven boxes,
❑ El Corporation ❑ Pormerahlp ❑ Trust/eetale
instructions on page a):
p
Individualreols proprietor or C Corporation
a .1tingle-membet
LLC
Exempt payee.code Of any)
❑ Limited liability company. Enter the tax classification (CAD corporation, 6=9 corporation, P.Parmarship)►
`0 2
Note: Check the apprupriele box In1he line above for the tax classification of the singlo-member owner. Do not eheox
Exemption from FATCA reporting
LLC if the LLC Is classified as a single -member LLC that In disregarded from the owner unless the owner of the LLC Is
LLC,Ihat
oade grany)
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Othenvlse, a single -member
0
Is disregarded Item the owner should check the appropriate box for thgtax classification of Its owner.
❑ 01her-isee Instructions) I.
rtypl'aI>a@WnO Talll•OutlpWxIY IM va)
(j
a Address (number, street, and apt, or ewte no.) See Instrualions.
RequaslePs name and addreee (optionaq
0 Olty, crate, and ZIP code
7 Ust account umbor(a) here (optional)
—_
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 socialsecurity number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, sea the Instructions for Part I, 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.immore then one name, see the Instructions for line 1. Also see What Name and
Number 7o Glve the Requester for guldelineson whose number to enter.
Under penalties of perjury, I tartly that:
1. The number shown on this form is my correct taxpayer`identlficatlon 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 suhjecHo 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 it 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 oross out hem 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 reel estate transactions, Item 2 does not apply. For mortgage Interest paid,
acquisition or abandonment ofsecured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than Interest and dividends, you are not required to sign the cerlificatlon, but.you must provide your correct TIN. See the Instructjona for Part II, later.
Here
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted,
Future developments. For the, latest Information about davelopmenle
related to Form W-9 and Its Instructions, such as legislation enacted
after they were publlohsd, go to ynvwJrs.gov1FormW9,
Purpose of Form
An Individual or entity (Form ME requester) who is required to life an
Information return With the IRS must obtain your correct taxpayer
Identification number (TIN) which may be your social security number
ISSN),, individual taxpayor Identification number gTIN), 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
rettime.ltfolude, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, Including tboserfrom 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 109,0-5 (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form' 1,098 (home mortgage interest), 1099-E (student loan Interest),
1098-T (tultlon)
• Form 1099-0 (canceled debt)
• Farm 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only If you are a U.& 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 Whet Is backup withholding,
later.
Cat. No. 10231x Form W-9 (Rev. 10.2010)
Jui/20/7-021 1237,48 PM Steward Health Care 5086983298
M-1
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'. Theapplicant and associate corporation are subject to fines associatedwith
violations,
Plastic Waste Reduction
No retail esta f(hment In the Town of Mansfield shall provide thin-film, single -use plastic check-out
gs to cu mers.
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 blod.egradable; compostable
alternatives, Compostable materials must meet ASTM (American Society of the International Association
f esting a d Materials) standards for compostability.
I have received a copyof 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 s raws and plastic stirrers shall not be used or dispensed or sold except upon request in
conjunction wi the serving by business establishments or at any town -sponsored event of liquid,
sl�wryZfroze semi -frozen, or other forms of beverages to the public for consumption.
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
Applicant Name (please