HomeMy WebLinkAboutJack Conway & Co. - 12/31/2021T
Date Received Permit Fee
OF HEALTH USE
Approved By
Permit #4§sued
Community Event Food Establishment Permit Application
(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:
Date(s):
Event Name:
l
Event Location:
--�
fl I
Event time:
1) Organization Name:
i
(.•�C.
2) Organization Address:
���t�,.� !-. ��(,"
3) Organization Mailing Address (if different):
4) Organization Telephone No:'-
��
5) Applicant Name & Title:
" -,
7) Applicant Telephone No:
6) Applicant/Owner Email address:
9) Person Directly Responsible For Onsite Operations:
Name & Title:
/^
Address:
1
Telephone No:
Fax:
Ct,
Emergency Telephone No:
5 6)
10 ) Please give a brief description of the food and/for dyrinnks to be served:
'-./r IV rV ` ee K�E 3
I, 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 of10f�gMR 590.000 andlthe)federal Food Code.
11) Signature of Applicant:
The Commonwealth ofM. assachusetts
Department oflndustrialAccidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
r=s" www mass gov1t is
Workers' Compensation Insurance Affidavit: General Businesses
Ap Ln 'cant Information Please Print Leelbly
Business/Organization
Phone #: _18/ - '721,0 45?6
Are you an employer? Check the_Wpropriate boa:
Business Type (required):
1. ❑
I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. Restaurant/BarBating Establishment
2. ❑
I am a sole proprietor or partnership and have no
?. 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.F]
We are a corporation and its officers have exercised
9. n Entertainment
their right of exemption per c. 152, § 1(4), and we have
100 Manufacturing
no employees. [No workers' comp, insurance required]**
] L❑ Health Care
4.�
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
12.n Other
*Any applicant that checks box #1 must also All out the section below showing their workers' compensation poUcyinformatiom
**Ythecorpotate otlicemhave exempted themselves, but the eotpotsaonhas other employees, a workers' compensation policy is mquvod and such an
organ ntion should check box #l.
I am an employer
tP +d� 8 p rion Insurance for my employees. Below Is the polky information.
Insurance man Name; 1 n�rkers om enact C
Insurer's Address: [7 0 7C l' d 3(i
City/State/Zip: —_-.C� '! / g p�1� /
Policy # or Self -ins. Lic. #Ih,lL- -lots - 6 'ley 7 fj �� Expiration Date: % % Z-0 2 Z_
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby cerilfy, antler ih ns andpenalaes ofperjury that
Phone#: / 7C-1
Oj*1al use only. Do not write in this area, to be completed by city or town gpichrl
City or Town: Permit/License
Issuing Authority (circle one);
1. Board of Health 2. Building Department
6. Other
d above is true and correct
C,/ZvPL/
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Contact Person: Phone
JACKCON-01 D R
CERTIFICATE OF LIABILITY INSURANCE DA612812021
sr2arzgzt
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer tights to the certificate holder in lieu of such endorsements .
PRODUCER T CT
Walter May Ins Agy Inc PHONE - FA% _
188 Whiting St ac No Ea: (781) 749-4310 (Ydc NeZ{781) 74_9.1714
NI h M
ng am, A 02043^E$s;
m o(�alwa termaymsurance.com
NSL URERISI AFFORDING COVERAGE __.
NAIC0
INSURER A: Hanover Insurance Company
122292
INSURED
INSURER S: Safety Property R Casual
12808
Jack Conway B Co. Inc.
INSURER C: Associated Industries of MA
123140
137 Washington Street
I INSURER O: CNA
. . I
Norwell, MA 02061
_ -
INSURER E _
INSURER F :
REVISION NUMBER:
COVERAGE CER IFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS i,
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.
INSR TYPE OF INSURANCE ADDLSUBR pOLICYNUMBER
_
POLICY FIEFPOLICY EXP _—^ LIMITS
I WtAIPO1YYYYJ.l—
A I X 4 COMMERCIAL GENERAL LIABRITY
OCCUR
EACH OCCURRENCE $
DAMAGE
11000,000!
CLAIMS MADE Xj ' ZON2869967,.
1/1@021 1I1r2022 REMI&C51ak«Curmn<eJ , a
100,0001
�.
,MEO CxP IAOY onepasan) 3
10,000:
'
PERSONAL A AOV INJ MY $
1,000,OOOi
GEN'L AGGREGATE LIMIT APPLIES PER: I
F POLICY 7--li j LOG
f GENERAL lA•CREGATE $
[
2,000,0001
2,000,0001
I I
PRODUCTS - COMP/OP AGG E
OTHER'
$
B AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
11E39ESIQem1 b
1,000,000ANY .
AUTO16236906
11112021 1/1/2022 LBODILY INJURY L p ) S
OWNED SCHEDULED
AUTOS ONLY AUTOS +
I-
BODILY INJURY To, rcrlj_3
-PROPER
H NpN J1,1 p
....{ AUTOS ONLY .' AUTOS ON�V I
pA1dAbE
IF EU _ 3
UMBRELLA LIAR _ OCCUR !
EXCESS LIA6 DHN3066209
rnrN GCouRPcnpE $
111/2021 11112022
6,0001000,
.CLAIMS-MAbE
AGGREGATE , g
6,000,000
C COMPENSATION
-'
PER -OTI, -$
AND EMPLOYER'LIABILITY
N �VWC-0-023499-2021A
APPRIETO/PARTNRIEECUTIVE
&TATUIEY/N
1I1I2021 112022
600,000'
I NIA
CL EACHACageNTO,g
IMenCEng�p
etory
If yes, descnba uMer
I
IEL DISEASE EAEMPLOYEE $
500,000',
1,000,000
DESCRIPTION OF OPERATIONS below
D Errors and Omissions RFB-113O 6313-20
_ rL915EEASE_.P OLICY L WO $
1 7/26/2020 W26/20 1 Aggregate ate
2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACCRD 101, Addillonal Remarks Schedule, may be Mulched 11 more apa00 Is roqulmd)
Town of Mansfield
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
REPRESENTATIVE
ACORD 26 (20161031
tnsa.2nls ArnNn r•.neonlaennu eu aanre see.,.ea
The ACORD name and logo are registered marks of ACORD
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 torporate Name
"*Social Security No. (Voluntary) or Federal
Identification Number
( e
B CorlxatoOf{icer(Mandatory,ifAloplicable)
60✓ el 8t,
*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,
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date 6?d D'
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:
li' / We are not charging a fee for food/drink being served.
❑ We are a religious organization.
❑ Other:
Thank you, /41�
red
Title
"Please provide proof of valid 501(c)(3) status
BOH Use Only
_ Approved
Denied Reason:
Signature: Date: