HomeMy WebLinkAboutOur Daily Bread - 12/31/2021FOR BOARD OF HEALTH
Date Received Permit Fee
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Per it # Issued 311
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):
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Event Name:
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Event Location:
Event time:
1) Organization Name: U t✓ �� L ,fZG
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2) Organization Address: / rj `� cJ-7
3) Organization Mailing Address (if different):
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4) Organization Telephone No: rf7��� � � — 1 274
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5) Applicant Name & Title: o L-L- �—� /_�_ ✓� /`
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7) Applicant Telephone No: /� p � _ Z 5-6 l
8) Applicant/Owner Email address:
9) Person Directly Responsible For Onsite Operations: 1
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Name & Title:
Address:
Telephone No:
Fax:
Emergency Telephone No:
10 ) Please give a brief description of the food and/or drinks to be seed:
I, the undersigned, attest to the accuracy he information pro
establishment operation will comply wit 5 CMR 5�,Pf.00f1 and
health on how to obtain copies of 105 590.00 1 n e fed/
11) Signature of Applicant:
Code.
ition and I affirm that the food
law. I have been instructed by the board of
Mansfield Board of Health
Request for Fee Waiver for Food Permit
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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.
Y We are a religious organization.
❑ Other:
Thank you,
1 AIGym� XI 4,41' L((
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature:
Date:
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 ajoint 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 burn 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;
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Fonn Revised 5-26-05
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p- www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: OU 12 /%X Z Y /5 fZt A l` 7A.,v S L 6L �� /d t '2 1
Address: �5 ✓t \�%c S !! %. 1` i r`tv IP7 i C-L j()
City/State/Zip: i rt AN S r /L 4 0 02-o 4 9, Phone #:
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑ 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.
8. fg Non-profit
[No workers' comp. insurance required]
3. ❑ 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.r;� We are a non-profit organization, staffed by volunteers,
I I•❑ Health Care
urance with no employees. [No workers' comp. insreq.]
12.0Other
"Any applicant that checks box #I 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 #I.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/state/Zip:
Policy # or Self -ins. Lic.
Expiration
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 cert04 under the pains andpeiplties ofperjury that the information provided above is true and correct.
2 9 110A1Z- ?oz I
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PermitiLicense #
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.mass.gov/dla
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.
t& L l P t, 0
Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
*"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:\Users\sleite\Desktop\SWIt's Docmnents\Food Establishments-Temp\TAX CERTIFICATION FORM.doc