HomeMy WebLinkAboutMansfield Women of Today - 12/31/2021Date Received Permit Fee Approved lu lsst
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Community Event. Food. Establishment Permit Applica�iV�f
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(Application must be submitted at feast 7 business days before the event datThis application should only be used by organizations that are not food establishments b
distribute non -potentially hazardous food or drinks at a local community event.
Community Event:
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Date(s):
01119
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Event Name:
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Event Location:
Event time:
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1) Organization Name:
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2). Organization Address:
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02OLil
3) Organization Mailing Address (if different):
4) Organization Telephone No: S M) - 3
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6) Applicant Name & Title: '{ 5 ` 1
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7) Applicant Telephone No: �p 13 b
8)Appricant(Owner Email address: f),,\S-ft
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9) Person Directly Responsible For Onsite Operations:
Name &Title;KVIA,AY,)
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Address:.
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Telephone No:
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Fax:
Emergency Telephone No:
10) Please: give a brief description of the food and/or drinks to be served:
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I,. the undersigned, attest to the accuracy of the information provided in this application. and I affirm that the food
establishmentoperation will comply with 105 CMR 690.000and all other applicable law. .I have been instructed by the boardof
health onhow to obtain copies of 105 CIY R 690,000 and the federal Food Code,
11) Signature of Applicant:
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date 51 � I ZI
we,
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.
❑ We are a religious organization.
❑ Other:
Thank you,
Signatur `.
TT U C I4 (lam
Title
`Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:
Signature:
The Commonwealth ofMusachusetts
Department oflndustrialAccidents
Office of Investigations
Ulf 600 Washington Street
Roston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Wahas�t 6 � A W" bf
Address: P - 0 . l7 U)( 2'�5
City/State/Zip:.
Phone
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑
I am a employer with employees (full and/
5. ❑ Retail
2. ❑
or part-time).*
I
6. ❑ RestaurantlBar/Eating Establishment
am a sole proprietor or partnership and have no
7.El Office and/or Sales (incl, real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required]
8. ❑ Non-profit
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. El Manufacturing
4.
no employees. [No workers' comp. insurance required]*
We are a non-profit organization, staffed by volunteers,
11. ❑Health Care
with no employees. [No workers' comp. insurance reo.l
12.0 Other
'Anyapphcantmat checks box Rl must also: fill out the sectionbelow showingibeir workers' compensation policy information,
"If the corporate officers have ekempted themselves, but the corporation Gas otbar employees, a.workers' compensation policy is required and such an
organization should check box 1l1.
I am an employer that is providing workers' compensation imurance for my employees. Below is Ike policy information,.
Insurance Company
hisurer's
Policy # or Self4i s. Lic.
Expiration Dater
�_- - =rs' r n policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL 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.eopy
do hereby certify, under the pains and penalties ofliedury that the information provided above is true and carreck
Offuial use only. Do not write in this area, to be completed by city or townofficial
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3, City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6, Other
Phone
www.masa-.gov/dia
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 By: Corporate Officer (Mandatory, ifApplicalile)
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.
CAUsees\sleitMmktop\Scoffs-DocmnentsTood Establishments- Temp\TAX CERTIFICATION FORM.doc