HomeMy WebLinkAboutRobert Sibilia, DMD - 12/31/2021Fie \A/A iJ J
FOR BOARD OF HEALTH
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Date Received Permit Fee
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rmit # Issued
Community Event Food Establishment Permi lication
(Application must be submitted at least 7 business days before the event date)
This application should only be used by organizations that are not food establishments but plan to
distribute non -potentially hazardous food or drinks at a local community event.
Community Event: m �' y U n
Date(s):
6-7 13
Event Name:
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Event Location:
(�UC' T AIN '7i NA (000/ig
Event time:
1) Organization Name: 2 a 1 r �` r �, i• I� _
2) Organization Address: �J� N � °e `�� H/A G Gt{u
3) Organization Mailing Address (if different): f't zvnx 4 �t 7 1 �A
4) Organization Telephone No: p 8 _ -3 6q 3 I
5) Applicant Name & Title:
7) Applicant Telephone No: 5-63 11 __ ( g
8) Applicant/Owner Email address: 11) *0 r �—o b"-� Co ryl
9) Person Directly Responsible For Onsite Operations: k
Name & Title:
Address:
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Telephone No:
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faFax:
b8 -33y- p:7 j �C� �tul- ICoV
Emergency Telephone No:
y C1 3 _ 4
10 ) Please give a brief description of the food �and/or drinks to be served: o,14-c1_ rd )A,.�,,,A' ...&--S-a -C-"Tl Y '"?iYi'`15T--d✓a�L 4... 9J'd / jj
1, the undersigned, attest to the accuracy of the information provided in this application and I 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.
11) Signature of Applicant: (211,0e-1- i(,Y V0-1
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
"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\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date
O'l O%
1)-641
We,
2v b e r
1
( a h ; t�
ij,t�l. �. (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:
N We are not charging a fee for food/drink being served.
❑ We are a religious organization.
❑ Other:
Thank you,
Signature
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature: Date: