The URL can be used to link to this page

Home My WebLink AboutCat Man Cafe 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD SERVICE In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. STEPHEN J. CERULLO, PRESIDENT Whose place of business is: CAT MAN CAFE 16 OLD COLONY WAY PERSON(S) IN CHARGE: STEPHEN CERULLO Permit Expires: December 31, 2016 License Number: FS -7 Food Fee: $62.50 Milk & Cream BOARD OF HEALTH AichaeCACCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that., STEPHEN J. CERULLO, PRESIDENT having a place of business at: CAT MAN CAFE 16 OLD COLONY WAY in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 12/3112016 unless previous to that time is suspended or revoked. Expires 12/31/2016 License No.: FS -7 Scott Leite, Heaah Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit #Issued j FS -7 'i FOOD ESTABLISHMENT PERMIT APPLICATION -- -- �phca�ion must -be sub�m�i teaatIeasT 3_0_crays ueforeftepla—mmejopen�ng date) ---- i 1) Establishment Name CAT MAN CAFE 1) t=staoosnment Haaress 16 OLD COLONY WAY 3) Establishment Mailing Address (if different) 16 OLD COLONY WAY MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-0038 5) Applicant Name & Title: STEPHEN CERULLO 6) Applicant Address 19 WAMPUM ROAD, NORTON, MA - 7) Applicant Telephone No.: (508) 285-7712 24 Hour Emergency No.: (508) 734-0634 (508) 380-9133 8) Owners Name & Title STEPHEN J. CERULLO 9) Owner Address (If different from applicant) 19 WAMPUM ROAD, NORTON, MA Owner's telephone number (508) 285-7712 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association partner. � or p 0 A Corporation Name Title Address ❑ An Individual ��,zr� - 11c� �i C t 0 Ck W, �,Vl d*, ❑ A Partnership �� F�..► AA,/-� A - ❑ Other legal Entity -- - -- - --^ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title !STEPHEN CERULLO Address: 119 WAMPUM ROAD, NORTON MA Telephone No: (508) 285-7712 24 Hour Emergency No: (508) 734-0634 (508) 380-9133 FAX: - E-mail: �HCERULLO(cD-COMCAST.NET Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: i E-mail: FAX Food Establishment Information 14) WATER SOURCE: TOWN l 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 4 17) DAYS/HOURS: 5:30 AM - 12 PM 18) Name of Person In Charge Certified in Food Protection Management: STEPHEN J. CERULLO If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate 19 Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Milk & Cream $5.00 Moblie End Date: I W Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: 21) Length of Permit: 0 Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: I Temporary Time: Rain Date: 23) Food Operations ',(Check all that apply): ❑ Sale of Commercially Pre -Packaged Non -PRFs ❑ Sale of Commercially Pre -Packaged PRFs up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex, sandwiches, salads, muffins which need no further processing) ❑ Delivery of Packaged PRFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - 0 ' h bl F ds Onl W PHFCooked To Order ❑d Hot PHF Cooked and Cooled or Hot Held - for More Than a Single Meal Service Preparation of PHFs For Hot And k Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ---- - - - Intended Susceptible Population Facility ❑ Sale of Raw Animal Foods ntended _ _ to be Prepared by Consumer []--Vacuum Packaging / Cook Chill Customer Self -Service ❑ Use of Process Requiring A Variance CCP Preparation -- Non -PH - ❑ IceManufactured Sale tured and Packaged for 1 contact control) temati ea fame (including public healdth { �- - - Other Food Operations ❑ g ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin � { I Juice Manufactured and Packaged for - --- - ❑ Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date -- - -- - - or Reconditioned Food i To be completed by the Board of Health Total Permit Fee: $62.50 iPayment is due with application ❑waived j I, the undersigned, attest to the accuracy of the information provided in this application and 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 5/90.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under 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. 25) Social Security Number or Federal ID: 04-3576349 26) Signature of Individual or Corporate Name: I � 1 v-> - Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: CAT MAN CAFE ADDRESS: 16 OLD COLONY WAY TELEPHONE AT LOCATION: (508) 339-0038 FAX NUMBER: OWNER OF BUSINESS: STEPHEN J. CERULLO TELEPHONE OF OWNER: (508) 285-7712 FEDERAL ID/SS NUMBER: 04-3576340 FEE: $5.00 PERMIT NUMBER: FS -7 SIGNATURE: (, eco DATE: 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 In ' idual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) i0' cm `35 1 ('3Lith ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name; cti>mtCj �l�.,n O e, A �c� YYlcttv� 1 �S�`q_ Address: \ U i) U) c� �o •� •� City/State/Zip:Gt�nS tL LYS ,Ml} Phone #;()' �� 1 ' CIO Are yop an employer? Check the appropriate box: 1. am a employer with employees (full and/ orart-timet* 2. El a e 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. [YRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1111 Health Care 12.❑ Other *Any applicant that checks box #1 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 employe. Below is the policy information. Insurance Company(��Name: S ec:u r , �i :n Insurer's Address: ��A CNou-L-e- k�crl j&L A. City/State/Zip: ( &C (;.—LE (Z. Policy # or Self -ins. Lic. #, �) C l rt �0 Expiration Date:. t� 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, under the pains anMi f perjury that the information provided above is true and correct Sip -nature: P /A V �a� C �r Date: 6-- /0,--_j0 l Phone #: 1 () � `I? � OU ��( Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www,mass.gov/dia Phone CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: Stephen Cerullo Certificate Number: 638049 Date of Completion: 11/8/2011 Date of Expiration: 11/8/2016 Thr above-named person is hereby issued this certificate ./hr completing an allergen awareness training program recognized by the A9assachrtsetts Department of Pablir Health in accordance with. 105 CAM 590.009(G)(3)(a). This certi/icale will he valid%r five (5) years fiotn date of *completion. Issued By- NATIONAL�<' i ASSOCI 1, N® Massachusetts Restaurant Ass(xiation 800.765.2122 333 Turnpike Road, Suite 102 —m.resraurant.org SourlAxrnwgh. MA 01772 509-303-9905 xtis1v. marestau ranrassoc.or, May/UU/2U1f5 U:21:32 AM PAYCHEX INC 5555555555 2/4 CERTIFICATE 0 LIABILITY INSURANCE 0415/2016DN THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO CERTIFICATE DOES NOT AFFIRMATIVELY OR NE=GATIVELY A DOES ND CERT F T CONH RELOK T S CERTOR PRODOF UCER, INSURANCE 4 ONLY AND CONFERS NO RIGHTS UPON THE deRtIPIOATC H01.0til, *THIS 4END, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LDEEi A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED IMPORTANTi If the cort{fleate holder Is an ADDITIONAL INSURED, the terms and conditions of the policy, certain policies may req Certificate holder In lieu of such endorsement B . the pollcy(les) must be endorsed, If SUBROGATION IS WAIVED, sub got to Are an endorsement, A statement on this Certificate does not confer rlgnhts to the PRODUCER 0 NTACT Paychex Insurance Agency Inc 12. 150 SAWGRASBRDRIVE AGENCY, INC, E . 877-286-5880 585-389-7426 M§AlCorlsopaychwoom ROCHESTER, NY 14620 INSURER($) AFFORDING COVERAGE NAIC VI INSURED INSURER AI Security National Insurance Company 18878 INSURER 01 CHAMBERLAIN AVENUE ENTERPRISES 16 OLD COLONY ROAD INBURER CI MANSFIELD, MA 02048 INSURER D; INSURER EI INSURER F: COVERAGES CERTIFICATE NUMBS : REVISION NUMBER: THIS I$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEL= N HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITH8TANOING ANY REQUIREMENT, TERM OR CON= TION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFF EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN Mi 3RDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, Y HAVE BEEN REDUCED BY PAID CLAIMS. INBR LTR TYPE OF INSURANCE ADDLPOLICY NSR O NU BER POLICY EFF MMIODIYYYY POLICY EXP MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENT0$ MBD IXP (My one peraon) COMMERCIAL GENERAL LIABILITY =]CLAIMB•MADEE=)DCCUR PQRSONAL S ADV INJURY S GENERAL AGGREGATE g EWL AGGREGATE LIMIT APPLIES PSR; POLICY O PROJECT= LOC PRODUCTS - COMPIOP AGO $ $ AUTOMOBILe LIABILITY ANY AUTO ALL OWNED ECHEOULID AUTOS AUTO%WNEp HIRIDAUTO 7 0�� 00MBINIED SINGLE LIMIT 6 Ee eeoltlenl BODILY INJURY (per pereon)S 6001LYI11URY Pcraoold't $ PROPERTY DAMAGE B PerBwIdegl S UMIRILLA LI;; OCCUR EACH OCCURRENCE $ �_ AGGR6GAT6 6 EXCESS UAB O CL9URA8-MADe 010 1 1 RITINTION 9 WORKERS COMPENSATION AND IMFLOYNAS'LIAIILIIY SWC1066706 02/08/2018 02/08!2016 X WC STATU. DTH, E.L. EACH ACCIDENT S '10,000,00 ANY PROPRIETORJPARTNEWEXECUTIVE OFFICIFWAVA/IA IXOLUDIOT (N0Ad0tOry(ANH) 1Y NIA E.L. 0I9EA3E • EA EMPLOYEE $ 100 OQ0.00 E,L.DISEASE- POLICY LIMIT 0 600,000,00 II y11, a6wnbo ywr DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (Altooh ACORD 101, Additions Remarks schedulo, Irmore spm is requtmd) CERTIFICATE HOLDER CANCELLATION Department of Industrial Accldnats 1 Congress Street, SUIte 100 Boston, MA 02114 SHOULO ANY OF THE ABOVE 060CRIDED POLICIES BE CANCELLED BEFORD THE EXPIRATION DATE THSIiEOP, NOTICE WILL Ba OULIVERSO IN ACCORDANCE WITH THE POLICY PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMP085 NO OBLIGATION OR LIABILITY OF ANY HIND UPON THE COMPANY, ITS AOBNTS OR REPRESRNTATIVES, AUTHORISED REPRESENTATIVE ^� e ACORD 28 (2010/08) 1888.2010 ACORD CORPORATION. All rights reserved. The ACORD name and I go are registered marks of ACORD IVIC1y1%JV14U IU V.L 1.04 /-%IVI T—M T UrIMA IIV4 JJJJJJJJJJ CERTIFICATE OF LIABILITY INSURANCE It I JAB DATE(MMIDPA"Y) R045 14/13/201,, THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATIO CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CON REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS MEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES TiTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED HOLDER, IMPORTANT: if the certificate holder I® an ADDITIONAL IN8U terms and conditions of the policy, certain policies may requlr certificate holder In ]leu of such andorsemert(e). D, the potlCy(lee) must be endorsed, If SUBROGATIONJ9 WAIVED, subject to the an endorsement, A statement on this certificate doee not confer rights to the pAwgun PAYCHEX INSURANCE AGENCY INC/PAC 210764 P: F: (888) 443-6112 PO BOX 33015 SAN ANTONIO TX 78265 SOOR LWA NAM 9- FKONV tNC,No, EM) (PIC,NoR (888) 443-6112 AOOREDB' INSLMER(fl)AFFORDING COVAM00 NAICR INBURSRAI Hartford ACoident s Indemnity Co 22357 INRUREO CATMAN ENTERPRISES INC DBA MAIN STREEr CAFE 240 MAIN ST FOXBORO MA 02035 AUTHORIZEDRSPReSENTATIVE - INSURIAD; INSURERCI INRURPR 0: INSURERS INSURIAF: COVERAGES CERTIFICATE NUMBER: I REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR GONDITION CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSU TERMB,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS NCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 8UBJECT TO ALL THE MAY HAV9 BEEN REOUCED SY PAID CLAIMS, INS11TYP901t11VAIPANCS IbD& SOOR LWA pOUCYNr/ 10611 POLIV,UP poLICYISXhMon WAIIr9 AUTHORIZEDRSPReSENTATIVE - COMMERCIAL GENERAL LIABILITY CLAIM11-MAD5 []OCCUR 11I --JJJ 02K AGOR50ATE LIMIT APPLIES PER; POLICY r7 PRO' LJ LOC JECT OTHER; EACH OCCURRSN08 S DAM OaTORE)TEO PRHMISPA bowumpnoe MED EXP (Any en/ Damn) PHRMONAL d AW INJURY GENERAL AO9R60ATE PRODUCTS - COMPIOP A00 e AUTOMOSILE LIADJUTY ANY AUTO ALL OWNRD SCHEDULED AUTOS I AUTOS HIRRDAUT08 NON -OWNED AUTOS COMBINED BINOW LIMIT fee seeldenp AOCIILY INJURY (Pet person) BODILY INJURY (Pet seeldeAI) PROPERIYOAMA08 (Por Raolaom) UMBRELLA UAB "000 LIAO OCCUR CLAIMS -MADE BACH OCCURRENCE 9 A9GR60AT8 OGD REMTION O A II'0RKER1COAIl0N81Ir/AV ANO 940,01`60WAAW" ANYPROPRIET0WARTNWM6CU11V8 YIN OPFICERINIZOIBER IXCLVD907 (Mende)oryfnNN) It yyes, If"" ' under 05SCRIPTION OF OPERATIONS be[DW NIA 76 WEG 216645 O3/Ol/2O]6 D5/01/2-0iT X 0TH• ITATUTE E Ed„ EACHACCIDBNr 100, 000 E.L019EA05.EAEMPLOY88 10100,000 B.L. DISEA6E- POLICY LIMB 1'500, 000 9E66RIP1i0N0P0A✓/RAT10N8/LOCAYIDNB/VEHfCLES(ACOR0101,AdditlonalRemarks6 Those usual to the Insured's Operations. odulo,mey001II/eNsdl(moroeDaoeleroqufrsd) CERTIFICATE HOLDER I CANCELLATION ®1988.2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name ani n logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Department of Industrial Accidents 1 CONGRESS ST STE 100�.r,_,�� AUTHORIZEDRSPReSENTATIVE - BOSTON, MA 02114 ®1988.2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name ani n logo are registered marks of ACORD 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate n 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 not 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 Bali. 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 it 617-727-7749 www.mass.gov/dia Form Revised 5-26.05