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HomeMy WebLinkAboutCheng Du 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 ESTABLISHMENT 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:. TI (SONNY) TANG, PRESIDENT Whose place of business is: TANG SZ, INC., dba CHENG DU RESTAURANT 249 NORTH MAIN STREET PERSON(S) IN CHARGE: TI (SONNY) TANG Permit Expires: December 31, 2016 License Number: FS -63 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH MichaeCMcCCean, 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. TI (SONNY) TANG, PRESIDENT having a place of business at: TANG SZ, INC., dba CHENG DU RESTAURANT 249 NORTH MAIN STREET 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 1213112016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -63 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 - - - - --- - -- - - --- - ---- _ FS 63 -- _- FOOD ESTABLISHMENT PERMIT APPLICATION �Ap cation muses be su&miffecl a-t7east mays bemire -the planned opening dale) 1)"Establishment Name TANG SZ, INC., dba CHENG DU RESTAURANT �2) Establishment Address 249 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 249 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5946 5) Applicant Name & Title: TI (SONNY) TANG - 6) Applicant Address 6 JUSTIN DRIVE, MANSFIELD, MA 02048 1 7) Applicant Telephone No.: (508) 337-8659 CELL (508) 451- 24 Hour Emergency No.: (508) 337-8659 (508) 451-6387 CELL 6387 8) Owners Name & Title TI (SONNY) TANG 9) Owner Address (If different from applicant) 6 JUSTIN DRIVE MANSFIELD, MA 02048 �4 _Owner's telephone number (508) 337-8659 I 10) Establishment Owned By. 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name Title Address � ❑ An Individual _� --Tiffin_(-�--_����l�cr - - -- ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ITI (SONNY) TANG Address I6 JUSTIN DRIVE, MANSFIELD, MA 02048 Telephone No: �- (508) 339-5946 24 Hour Emergency No: (508) 337-8659 (508,,1451-6387 CELS l FAX:I(508) 451-6387 - � I E-mail. 'MISSYTZ2@AOL.COM Alt E -Mail -- -- --- — - - - 13) District Or Regional Supervisor (if applicable) Name & Title: IMELISSA TANG Address: Telephone No: FAX: 6 JUSTIN DRIVE, MANSFIELD, MA 02048 24 Hour Emergency No: MISSYTZ2@AOL.COM 269-9769 E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 8 17) DAYS/HOURS: MON-THURS 11:30 AM -10 PM FRI 11:30 AM -11 PM SAT 12 PM -11 PM SUN 4 PM -10 PM 18 Name of Person In Charge Certified in Food Protection Management: TI TANG If more than 3 individuals are certified, complete list is on file. I 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): - - T - - - 20) Location: Permanent Location 22) Establishment Type - r -- - j ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Milk & Cream $5.00 Moblie End Date: FVJ Food Service up to 100 or I ❑ Mobile Food & Consession $37.50 Moblie Comments: � UP to 10' PHF display $62.50 �- ❑Manufacture Frozen Desserts/Ice Cream �I - - 21) Length of Permit: ❑ Food Service up to 101 -200 $12.50/freezer Annual or up to 25' PHF display $75.00 ❑ Pushcart $12.50 # of Pushcarts: Seasonal E] Food Service up to 201 + E] Residential Kitchen $50.00 or 25'+ PHF display $137.50 ❑ Retail Food $50.00 Seasonal Dates: r❑Temporary E]Food Service - Institution ❑ Retail Snack Food $12.50 Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions: PHF Potentially hazardous food (time/lemperature controls required) 23 P Non-PHFs - non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non -PRFs R PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held i P g - g - - -�--- for More Than a Single Meal Service 9 Y Cold Hldin — --- - - - - t ❑ Sale of Commercially Pre -Packaged PHFs Pre aration of PRFs For Hot And Fr Snle Mal Sery Delivery of Packaged PHFs Susceptible Population Facility acili - - -- �❑ Sale ofoRaw Anoimafl Foodselntende'de ❑PHF and RTE Foods Pre rCetd'llFor i ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Coo Processed Foods for Service Within 4 Hours -- -- - - - - - ___ - ----- ---- - - - Use of Process RequiringGA Variance ❑ Customer Self -Service of Non PHF and Non- (� Customer Self -Service I and/or HACCP Plan (includingbare hand Perishable Foods Only - - -- - - -1 contact alternative, time as a public health ❑ Ice Manufactured and Packaged for ) control ❑ Preparation of Non-PHFs Retail Sale Other Food Operations F1Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin — - ❑ Offers RTE PHF in Bulk Quantities Prepares ventsFood/Single Ins Meals for Catered Events or Institutional Food Service � ❑ Retail Sale of Salvage, Out -Of -Date - - - - or Reconditioned Food To be completed by the Board of Health - - -- -Y PP Total Permit Fee: $62.50 Payment is due with application waived ❑ 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 CMR90.000 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: 04-2655616 26) Signature of Individual or Corporate Name: 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: TANG SZ, INC., dba CHENG DU RESTAURANT ADDRESS: 249 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-5946 FAX NUMBER: (508) 451-6387 OWNER OF BUSINESS: TI (SONNY) TANG TELEPHONE OF OWNER: (508) 337-8659 FEDERAL ID/SS NUMBER: 04-2655616 FEE: $5.00 PERMIT NUMBER: FS -63 SIGNATURE: DATE: �g_l_ / e) _ 'j qK 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 (Mandatory) t7'_� 1 1 _' �_ lt�_ � - By: Corporate Officer (Mandatory, if applicable) , '/'� z '1 6- 5- ** 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 49/x. May 19 16 07:43a Tang Family 1-508-337-8659 p.1 The Commonwealth of Massachusetts Department of Industrial Accidents Of• ftt:e of Investigations 600 Washington Street Boston, MA 02111 www.masS-gov/dia Workers' Compensation Insurance Affidavit: General Businesses Avyllicant Znformration Please Print Le 'bl Business/Organization Name: � LP Address: �� �/ /V kle2l T ry • i a /' .r i .1 L . 9 , f, 1)'.1.1-9 Olvy,,Ct, t*w ape r 7'.1 . i / Are you an employer? Check the appropriate box, I.0 I am a employer with employees (full and/ or part-time),* 2. ❑ 1 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. I52, §I(4), and wobave no employees. [No workers' comp, insurance required1* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req,] Business Type (required)'. 5. ❑ Retail 6. �estaurant/Bar/Eating Establishment 7. n Office and/or Sales (incl, real estate, auto, etc.) 8, ❑ Non-profit 4. ❑ Entertainment 10, ❑ Manufacturing I I.❑ Health Care l2.❑ Other *Any applicant that checks box # 1 must also fill out the soction below showing their warkers' compensation poncy mlvrmnuwn sqf tho corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is iM red and such an organization should check box 91. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy information. Insurance Company Name: T �eo 17cel EN .- n Insurer's Address: City/State/Zip:fMr?T�o%�� Policy # or Self -ins. Lia. # [' ;� of Expiration bate:- je_' / — 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, 13e advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for inswance coverage verification. I do hereby certify, under the pains aced penalties of perjury that the Information providers above is true and carrec4 Signature: Phone # D �f _ 3 0ftj'ci4r1 use ontp, Do not write in this area, to be completed by city or town official; City or 'T'own; Permit/License # issuing Authority (circle one): 1. Board of Health 2, Building Department 3. CklTown Clerk 4. Licensing Hoard 5. Selectmen's Office 6, Other Contact Person*PBone il: www.mass.govldia May 19 16 07:44a Tang Family 1-508-337-8659 p.2 DATE (MMMDIYYYY) 4� ® CERTIFICATE OF LIABILITY INSURANCE 5/10/2016 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 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). ,, NT CT Denise Thomas, SIR, AAI PRODUCER -- PRONE _ ac Nn). (500) 695-3957 F..S_ Gilmore Insurance Agency, Inc. c (508) 699-7511 - - - E-0AAIL 27 Elm St. ADDRESS: — P. 0. BOX 126 INSIJRER(5) AFFORDING COVERAGE NAIC # N. Attleboro MA 02761 INSURER a.Hart£Ord Accident and Indemnity 22357 INSURED INSURER B : _ 'Tang SZ, Inc INSURER 249 N Main St INSU9RD: - Mansfield MA 02048 1INSURER F-' UVCrVA"G.7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMI=NT 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. e-TnTaaT—` �—POLICY EFF_ .POLICY E7(L LIMITS TYPE OF INSURANCE COMMERCIAL GENERAL LIABILITY CLAIM&MADE [—I OCCUR GENT AGGREGATE LIMIT APPLIES PER: POLICY jECT ` LOC OTHER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NDN -OWNED HIRED AUTOS AUTOS UMBRELLA LIAR w OCCUR EXCESS LIA9 CLAIMS• DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEPfE%ECUTNE A N(A ORWECC92953 1 8/1/2015 MED EXP (Any one person) 1$ (E (Gat)— SINGLE MIT S BODILY INJURY (Per person) $ BODILY INJURY (Pera0ddent)I S PROPERTY DAMAGE S Per accident 5 DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) Jdoucette@mansfieldma.com Town of Mansfield ACORD 25 (2014(01) INS025 f9n1dh1V SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHOR12E0 REPRESENTAWF Tits Gilmore/AMKAHA ©19813-2914 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD F1 INSURER: HARTFORD ACCIDENT AND INDEMNITY COMPANY NCCI Company Number: 10448 AUDIT PERIOD: ANNUAL POLICY EFFECTIVE DATE: 08/01/15 POLICY EXPIRATION DATE: 08/01/16' Policy Number: 08 WEC CN2953 Endorsement Number: 01 HOUSING CODE: SB Effective Date: 08/01/15 Effective hour is the same as stated in the Information Page of the policy. Named Insured and Address: TANG SZ, INC 249 N MAIN ST MANSFIELD, MA 02048 FEIN Number: 042656561 PRO RATA FACTOR: 1.000 PRODUCER NAME: R S GILMORE INS AGENCY INC PRODUCER CODE: 088696 It is agreed that the policy is amended as follows: ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. IN CONSIDERATION OF AN ADDITIONAL PREMIUM OF $496 IT IS AGREED THAT: THIS ENDORSEMENT REFLECTS ADJUSTMENT IN PREMIUM BASIS DUE TO RECENT AUDIT COMPLETED FOR THIS INSURED. (A) POLICY IS AMENDED TO CHANGE PAYROLL ON CLASS 7380 FOR INSD 01 ST 20 LOC 01 (B) POLICY IS AMENDED TO CHANGE PAYROLL ON CLASS 9079 FOR INSD 01 ST 20 LOC 01 Countersigned by Form WC 99 00 06 A (1) Printed in U.S.A. Process Date: 09/08/15 -- V -VCi- Authorized Representative Page 1 (CONTINUED ON NEXT PAGE) Policy Expiration Date: 08/01/16 ® AC"R O CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 5/10/2016 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 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). R.S. Gilmore Insurance Agency, Inc. 27 Elm St. P. 0. Box 126 N. Attleboro MA 02761 CONTPRODUCER NAMDenise Thomas, CISR, AAI PHCN o Ext): (508) 699-7511 FAX (508)695-3957 AIC No E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Hartford Accident and Indemnity 22357 INSURED Tang Sz, Inc 249 N Main St Mansfield MA 02048 INSURER B: INSURERC: INSURER D: INSURER E : INSURERF: CERTIFICATE NUMBER•CL1651054328 REVISION NUMBER: COVERAGES 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 IN ADDL SUBR POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS -MADE El OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG $ POLICY ❑PRO LOC JECT $ OTHER: AUTOMOBILE LIABILITY SINGLE LIMIT COMBINED accident) BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOSNED HIRED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION.- WORKERS COMPENSATION PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 500,000 AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVEE]N E.L. DISEASE - EA EMPLOYE $ 500,000 A OFFICER/MEMBER EXCLUDED? (Mandatory In NH) / A 084Tt3CCN2953 8/1/2015 8/1/2016 E.L. DISEASE - POLICY LIMIT I $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) UtK I I Jdoucette@mansfieldma.com Town of Mansfield ACORD 25 (2014/01) INS025 1201401) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gilmore/AMKAHA ....... ...... • ��,�e� .+�,��I".1•'I A Tlll\1 All .:.. M4e. ...n n..,,.ri V IJV V -LV 1•TnVV.�V vv.., v.v.. ....... .... .�• . The ACORD name and logo are registered marks of ACORD c 0 c X U- W U c c O O U � C O m CL U 0) O m U - c O v - a) O C U N a) a) O c0 0 O(n U- z 0 g cn L a) C a) m O -0 t O a7 O (n N c O O (U z a c c � co � Q U) a) C -C Q Q U U U) U N m a) N U � L � U L 0 v r - o t u.J m �J m Eli c� z z ZI H � kn O O O 1 O J u `-� 1-1-1 r„ .ti v r 1-4 J U J r It ZI 1 O ti i Ir V L 1- e c ZI 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 is 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 i 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 cavy 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. to 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 (Le. 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 0211 I Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.govldia Form Reviscd 5-26-05