The URL can be used to link to this page

Home My WebLink AboutMansfield Youth Football & Cheer - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit# Issued l 15 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening t Establishment Name: Mansfield Youth Football and Cheer Establishment Address: 250 East Streety� Establishment Mailing Address: PO Box 92, Mansfield, MA 02048 Establishment Telephone No: 781-389-9259 Applicant Name & Title: Scott Smith, President Applicant Address: 7 Martha's Way, Mansfield, MA 02048 Applicant Telephone No.: 781-389-9259 24 Hour Emergency No.: 781-389-9259 Applicant Email: klavigne22@yahoo.com Owner Name & Title (If different from applicant) Mansfield Youth Football and Cheer Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 19 An Association partner. VA Corporation Name Title Address 0 An Individual 0 A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Ken Lavigne, Concessions Manager Address: 5 Whitetail Lane, Mansfield, MA 02048 Telephone No: 617-777-8211 4 Hour Emergency No:617-777-8211 FAX: E-mail: ken.lavigne@marriott.com Alt E-Mail: MansfieldYouthFootballandCheer@gmail.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Town SEWAGE DISPOSAL: Septic DEP Public Water Supply No: (If applicable) No. of Food Employees:6-8 DAYS/HOURS: Saturday & Sunday 7am-9pm Name of Person(s) In Charge Certified in Food Protection Management: Ken Lavigne Name of Person(s) In Charge Certified in Allergen Awareness Training: Ken Lavigne Name of pest control company routinely inspecting the premises for evidence of pests: A&D Pest Elimination If there is seating for 25 peog le or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. 1VYes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: Annual Era Retail Food $126.00 .0�3. Mobile Food Concession R Temporary Wood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream Temporary Start Date: [`sa Food Service up l0 101 -200 $250.00 $25.00/freezer Temporary End Date: E7 Food Service up l0 201 + $300.00 0 Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 63 Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Q Caterer $35.00 Food Operations: DeffnilIons:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no timeRemperature controls required) RTE- ready-lo-eat foods (Ex. sandwiches, salads, muffins which need no further processing) {Sale of Commercially Pre -Packaged Non-PHFs 1V PHFCooked To Order FQ Hot PHF Cooked and Cooled or Hot Held Q Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And for More Than a Single Meal Service EJ Delivery of Packaged PHFs Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Sale of Raw Animal Foods Intended Reheating of Commercially lobe Prepared Consumer Use of Process Requiring di Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand er Q Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Q Preparation of Non-PHFs Retail Sale � Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chill ft Offers RTE PHF in Bulk Quantities sa Prepares Food/Single Meals for Retail 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 1,06 CMR 690.000 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: Pursuant to MGL Ch.62C, sec. 49A, I certify Wder the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: TAX CERTIFICATION FORM I certify trader 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. Mansfield Youth Football and Cheer <� Signature of Individual or Corporate Name 043-227070 '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 trader the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desktop\Scoh's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wtvivanass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeP_ibly Business/Organization Name: Mansfield Youth Football and Cheer Address: PO Box 92 City/State/Zip: Mansfield, MA, 02048 Phone #: 781-389-9259 Are you an employer? Check the appropriate box: L n I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ 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. ❑Entertainment 10.❑ Manufacturing I Ln Health Care 12.❑ Other *Any applicant that checks box #[ 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. #_ 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 certify, tinder the pa�fnut penalties of perjury that the information provided above is true and correct August 27, 2021 781-389-8259 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 S. Selectmen's Office 6. Other Contact www.mass.gov/dia Phone 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 a joint 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 bum 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 Foam Revised 5-26-05 AIMIll 0.0 Safety Insurance ddd Safety Property and Casualty NEW POLICY 09/21/2020 ITEM ONE - Named Insured and Address RONALD EMMA 25 EDWING DRIVE BRIDGEWATER MA 02324 POLICY PERIOD: Policy covers FROM 09/21/2020 TO NAMED INSURED'S BUSINESS: FORM OF BUSINESS: INDIVIDUAL DECLARATIONS MASSACHUSETTS PAGE BUSINESS AUTO COVERAGE FORM t Office/Agent: 45 62996 Policy No: 5914741 COM 00 Producer Name and Address TWINBROOK INS/BROWN & BROWN MA 400 A FRANKLIN ST BRAINTREE MA 02184 Telephone 781-843-7000 09/21/2021 12:01 A.M. Standard Time at the Named Insured's Address stated above X-1 COMMERCIAL IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. ITEM TWO - SCHEDULE OF COVERAGES AND COVERED AUTOS This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "Autos" shown as covered "Autos". "Autos" are shown as covered "Autos" for a particular coverage by the entry of one or more of the symbols from the COVERED AUTOS Section of the Business Auto Coverage Form next to the name of the coverage. LIABILITY INSURANCE COVERED AUTOS LIMIT COVERAGES mry of one or more of the symbols amtl,sCOVERED AUTOS Section of The most we will pay for any one me Business Auto Coverage Form show which autos are covered autos.) accident or loss PREMIUM zo, o0o EachPerson Compulsory Bodily Injury 7 $40, 000 Each Accident $706.00 Personal Injury Protection 7 $ $8,000 Each Person $52.00 Optional Bodily Injury 7 SEE SCHEDULE Each Accident $2, 946.00 Property Damage (COMPULSORY LIMIT $5,000) 7 SEE SCHEDULE Each Accident INCL Auto e Ica Payments Insurance 7 $ SEE SCHEDULE Each Person $24.00 Uninsured Motorists COMPULSORY LIMITS SEE SCHEDULE Each Person $20,000/$40,000 7 SEE SCHEDULE Each Accident $24.00 SEE SCHEDULE Each Person Underinsured Motorists 7 SEE SCHEDULE Each Accident $124.00 PHYSICAL DAMAGE INSURANCE Actual Cash Value or cost of repair, whichever is less, minus the deductible for each Covered Auto. Comprehensive Coverage 7 SEE SCHEDULE Deductible $496.00 Specified Perils Coverage Deductible Collision Coverage 7 SEE SCHEDULE Deductible $1, 137.00 Limited Collision Coverage Deductible oss o se - Rental Reimbursement 7 SEE SCHEDULE FOR LIMIT $180.00 Towingand Labor 25 for each disablement of a "auto" private passenger Forms and Endorsements attached to this Coverage Form: PREMIUM FOR ENDORSEMENTS $250.00 MM9923 0998 MM9911 1011 CA0001 1001 IL0021 0498 IL0017 119e ESTIMATED TOTAL IL0003 0498 STN107 0106 SCA2386 0106 SCA005 0417 MM9913 0998 MM9954 0998 MM9939 0998 MM9917 0998 PREMIUM $5, 939.00 SEE ADDITIONAL INFORMATION Countersigned by: ANhodzetl Representative BATCH SEQ. REP CURR DATE AGENT RUN SEQ, END NO. F LAST DATE CDT ECO 002 0 268 0 000 00 V 000 MM UU U1 Ug Ub INSURED FMC3DC 02/24/97 Mansfield Board of Health Request for Fee Waiver for Food Permit Date 8/27/2021 We Mansfield Youth Football and Cheer 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: &e are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, Signature President Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: Town of Mansfield 6 Park Raw, Mang field, Massachusetts 02048 Health Department 4n0, Donovan -Palmer; jWPH, RS Heahh Agent New Food Service Establishment Permit Process To apply for a permit please submit all documentation and payment to the Health Department. Please note that ALL of these documents must be submitted each year for the filing to be complete. Incomplete filings will be returned and no permit will be issued. 1. Food Establishment Permit Application (Attached) 2. ServSafe / Food Safety Manager Certificates 3. Allergen Awareness Training Certificates 4. Tax Certification Form (Attached) 5. Workers' Compensation Insurance Affidavit: General Business (Attached) 6. Workers' Compensation policy declaration page 7. Fats, Oils, and Grease Discharge Permit Application (Attached) 8. Town bylaw sign off sheet (Attached) Please note, the Health Department is communicating with permit holders through email. Please be sure to include a valid email address for all positions. If there are any changes in contact information (i.e. new PIC, new email address), the Health Department must be notified within 10 business days. The following Town of Mansfield Regulations and Bylaws are attached for your reference: • Food Protection Regulation • Fats, Oils, and Grease Regulations • Plastic Waste Reduction Bylaw • Straw/Stirrer Reduction Bylaw • Polystyrene Container Reduction Bylaw Please schedule a pre -operations inspection at least 1 week before the anticipated opening of the establishment. Please email the Health Agent directly at ADPalmer@Mansfieldma.com. The following documents must be on site during inspection. 1. Written Illness Reporting Policy with respect to diseases transmissible through food (Example attached) 2. Vomit and Diarrhea Clean up Procedure (Example attached) 3. Pest Control contract and/or receipts from routine inspections of the premise. Please contact the Health Department if I can be of any further assistance. Phone (508)261-7366 Fax (508)261-7425 Emailadpalmer@manjielcbna.com March 7, 2018 Mansfield Youth Football and Cheer EIN #04-3227070 PO Box 92 Mansfield, MA 02048 Dear Football Administrator, This letter is in response to your recent request with regard to your 501(c)(3) application for subordinate status under American Youth Football, Inc. American Youth Football, Inc. has received and submitted a request to the Internal Revenue Service, adding your organization to our roster of subordinates. As such, your organization may rely on this letter and conduct itself in accordance with the practices of a 501(c)(3) tax-exempt organization. Contributions to your organization are deductible under section 17.0 of the Code, and you are qualified to receive tax-deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2252 of the Internal Revenue Code American Youth Football is recognized as a 501(c)(3) tax-exempt organization and holds central organization status. Our tax ID # is 31-1484747 and our group number is 5277. Subordinates are required to include this number on their Form 990 as filed with the IRS. As a 501(c)(3) tax-exempt organization you are required to file with the IRS an annual report on Form 990, 990N or Form 990 EZ. This filing and any and all donation receipts should bear your organizations EIN# and not that of American Youth Football's. Sincerely yours, Adam Laufer Executive Vice President & General Counsel alaufer@americanyouthfootball.com American Youth Football, Inc. www.americanyouthfooball.com 1000 South Pointe Dr. ATH-9 Miami, Florida 33139 A� Q® CCC...••• CERTIFICATE OF LIABILITY INSURANCE DATE 123/2 /YYYY) OS/23/2021 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(ies) 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER The Hills Insurance Agency, Inc. P.O. Box 157 NPMEADT Robyn McCarthy AID. N , (781) 585-4410 FAX Nnj: (781) 585-8011 Erobyn@hillsia.com A o-MAIL 5 hillsia.com : Y @ INSURERS AFFORDING COVERAGE NAIL q INSURER A: HUDSON EXCESS INS CO 14484 Plympton MA 02367 INSURED INSURER B : INSURER C Mr. Perfection Inc dba Loco Larry's Taco Truck INSURER D 71 Carver Street INSURER E : 1 INSURER F: Halifax MA 02338 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 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 LTR TYPE OF INSURANCE ADDL SUBft POLICY NUMBER MMIDOPOLICYIYYYY EFF EXP MMIPOLDD/YYYV LIMITS A X COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE I OCCUR HBDIO045960 11/12/2020 11/12/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea acw arcs $ 100,000 MED EXP (Any one arson) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑PRO- JECT LOD OTHER: GENERALAGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGO $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY f AUTOS ONLY COMBINED En accidentSINGLE LIMIT $ BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONSS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNERIEXECUTIVE Y/❑N OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA A STTUTE FOR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ EL DISEASE - POLICY LIMIT $ 7 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additloral Remarks Schedule, maybe attached If more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Robyn McCarthy Mansfield MA 02048 rc) 19RR-2015 ACORD CORPORATION- All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD to 0 N T k Z \D Z O Q X wr u_ m Ov w � f� Q O U E o W r N le w 0 W u w W V z M� z W z W 3 d z eW V W g � o N �N r.C: .i:j .O a U 14, a N z � U � q Q 0 •� m �, a a fi � M o ^O (� o ti d