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HomeMy WebLinkAboutFresh Catch 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: CATERER 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:. WILLIAM F. SARRO Whose place of business is: THE FRESH CATCH, INC. 30 CHAUNCY STREET PERSON(S) IN CHARGE: WILLIAM F. SARRO, MANAGER Permit Expires: December 31, 2016 License Number: C-6 Food Fee: $12.50 Milk & Cream BOARD OF HEALTH michaeCAcCCean, 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. WILLIAM F. SARRO having a place of business at: THE FRESH CATCH, INC. 30 CHAUNCY 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 12131/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: C-6 Scott Leite, Heaah ,Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Date received: 1) Establishment Name FOR BOARD OF HEAL (H 08E ONLY Date Inspected: Approved By: Permit # Issued C-6 FOOD ESTABLISHMENT PERMIT APPLICATION ;bion mus�be subm►e e oreff lanneclopening� THE FRESH CATCH, INC. 2) Establishment Address 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 34 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5187 5) Applicant Name & Title: WILLIAM F. SARRO, PRESIDENT 6) Applicant Address 453 TURNPIKE STREET, UNIT 2, SOUTH EASTON, MA 02375 7) Applicant Telephone No.: (508) 404-4603 24 Flour Emergency No.: 508-404-6680 508.339-1427 508-339-6204 8) Owners Name & Title WILLIAM F. SARRO 9) Owner Address (If different from applicant) 453 TURNPIKE STREET, SOUTH EASTON, MA 02375 Owner's telephone number (508) 404-6680 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. * A Corporation Name Title Address ' El VLA/N k t OU fi Z An Individual Wj(li� — � 5 - - - N ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) ----------- Name & Title:_1WILLIAM F. SARRO, MANAGER Address: TURNPIKE STREET, UNIT 2 SOUT EASTON, MA 02375 Telephone No: (508) 404-6680 24 Hour Emergency NO: 508-404-6680 508-339-1427 508-339-6204 FAX: (508)339-3941_____ E-mail: billjr(djreshcatchinc.com Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No:.. FAX: T UNIT 1, NORTON„ 24 Hour Emergency No: (5 _ pFBG{ BqF B6{ nn rr u�w OM E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: _26- 17) DAYS/HOURS: MON-TOES-WED 8 AM -8 PM THURS 8 AM -9 PM FRI-SAT 8AM-9:30 PM SUN 8 AM -5 PM 18) Name of Person In Charge Certified in Food Protection Management: JOSEPH C. MATRULLO JESSICA If more than 3 individuals are certified, complete list is on file. BOUCHARD Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of ANTONIO BONILLA certificate HENRY ESPINOZA -_ 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: W Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑ Food Service up to 100 or 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) W Caterer $12.50 n Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ 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 23) Food Operations ( Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - 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) V Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only - 0 Preparation of Non-PHFs Other Food Operations ❑ PHFCooked To Order I0 Hot PHF Cooked and Cooled or Hot Held - ---- - -- - -- for More Than a Single Meal Service ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑PHF and RTE Foods Prepared For Highly - ---- --- - - Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance ❑ Customer Self -Service and/or HACCP Plan (including bare hand E] Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale _ -control) ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities or Reconditioned Food T be completed by the Board of Health -- - - - -- - !, Total Permit Fee: $12.50 Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this pa Food tiCode.and affirm that •g y p pp at 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 590.000 a t 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under thenalties 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: 04-2745150 ,-1.M`' 26) Signature of Individual or Corporate Name: a r fi 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: THE FRESH CATCH, INC. ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-5187 FAX NUMBER: OWNER OF BUSINESS: (508) 339-3941 WILLIAM F. SARRO TELEPHONE OF OWNER: (508) 404-6680 FEDERAL ID/SS NUMBER: 04-2745150 FEE: $5.00 PERMIT NUMBER: C-6 SIGNATURE:°_ DATE: Commonwealth 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:. WILLIAM F. SARRO Whose place of business is: THE FRESH CATCH, INC. 30 CHAUNCY STREET PERSON(S) IN CHARGE: WILLIAM F. SARRO, MANAGER Permit Expires: December 31, 2016 License Number: FS -66 Food Fee: $75.00 Milk & Cream V BOARD OF HEALTH MichaeCMcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that: WILLIAM F. SARRO having a place of business at: THE FRESH CATCH, INC. 30 CHAUNCY STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 -66 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 -66 FOOD ESTABLISHMENT PERMIT APPLICATION - (pp7►ca-on must -be- subm-5d of Teast-30 days -before fie plannecFopening dater 1) Establishment Name THE FRESH CATCH, INC. 2) Establishment Address 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) P.O. BOX 34 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5187 5) Applicant Name & Title: WILLIAM F. SARRO, PRESIDENT 6) Applicant Address 453 TURNPIKE STREET, UNIT 2, SOUTH EASTON, MA 02375 7) Applicant Telephone No.: (508) 404-6680 24 Hour Emergency No.: (508) 404-6680 (508) 339-1427 (508) 339-6204 8) Owners Name & Title WILLIAM F. SARRO 9) Owner Address (If different from applicant) 453 TURNPIKE STREET, SOUTH EASTON, MA 02375 { Owner's telephone number (508) 404-6680 - 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. D A Corporation Name Title Address ❑ An Individual )��)GM �--ji�i-'�� 4�� rurlt�;lh UA) -f Z �i� Anis 4335 ❑ A Partnership -_ ❑ Other legal Entity j 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IWILLIAM F. SARRO, MANAGER Address: 453 TURNPIKE STREET, UNIT 2 S. EASTON, MA 02375 Telephone No: r(608) 339-5187 24 Hour Emergency No: (508) 404-6680 (508) 339-1427 — -- - - --- - - (508) 339-6204 FAX: 1(508) 339-3941 1 E-mail BILLJRC@_FRESHCATACHINC.COM I Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title:"�;^.�R D17CS�L{1:�A��iiiES Address: ZI,UNIT 1, NORTON, Telephone No: (508) 294 -SM 24 Hour Emergency No: t -- . — — - -- FAX: (608 1 -mail: 14) WATER SOURCE: TOWN r Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 50 17) DAYS/HOURS: MON-TU-WED 8 AM -8 PM THURS 8 AM -9 PM FRI-SAT 8 AM -9:30 PM SUN 8 AM -5 PM 18) Name of Person In Charge Certified in Food Protection Management: ANTONIO BONILLA JESSICA L. If more than 3 individuals are certified, complete list is on file. BOUCHARD Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of JOSEPH MATRULLLO certificate HENRY ESPINOZA 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): 20) Location: 0 Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑d Retail ( 5,000 Sq. Ft) ❑ Food Service up to 100 or up to 10' PHF display $62.50 d❑ 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) ❑ Caterer $12.50 d❑ Milk & Cream $5.00 ❑ Mobile Food & Consession $37.50 ❑ 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 23 Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) 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) 0 Sale of Commercially Pre -Packaged Non-PHFs n Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non - Perishable Foods Only ❑ Preparation of Non-PHFs Other Food Operations F./I PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held -- for More Than a Single Meal Service ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly —--- - - Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended - - -__ - -_- -- to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill — -- - - - ❑ Use of Process Requiring A Variance ❑ Customer Self -Service and/or HACCP Plan (including bare hand ❑ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale __ control)-- ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities - --- - Retail Sale of Salvage, Out -Of -Date Retail ❑ 9 or Reconditioned Food - - =-J i— _Y To be completed b the Board of Health - — - - - Total Permit Fee: $75.00 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 1%CMR 590.000 a d.the federal Food Code. .. 24) Signature of Applicant: - Pursuant to MGL Ch.62C, sec. 49A, I certify under th ep and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-2745150 26) Signature of Individual or Corporate Name: nalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 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: THE FRESH CATCH, INC. ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-5187 FAX NUMBER: (508) 339-3941 OWNER OF BUSINESS: WILLIAM F. SARRO TELEPHONE OF OWNER: (508) 404-6680 FEDERAL ID/SS NUMBER: 04-2745150 FEE: $5.00 PERMIT NUMBER: FS -66 { SIGNATURE:° 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 IndividuaKor Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** 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: Ae Address: 30 Pt- City Are you an employer? Check the appropriate box: 1. LJ I am a employer with <50 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.] Phone #: clt0 (-_c% Cyl F� Business Type (required): 5, [t'Retail 6. [aRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc,) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing I LFJ Health Care 12.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. **lf 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 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: /ClZi ``A1 % / f Policy # or Self -ins. Lie. # �f7� y 7�1 ?� 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 DTA for insurance coverage verification. I do hereby certify, under the pains andpenal#es pfperjuty that the information provided above is true and correct. "V_ & S� Jr -,3351 ' 547 Official use only. Do not write in this area, to he 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 5. Selectmen's Office 6. Other Contact Person: www,mass.gov/dia Phone #: ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 4/8/2016 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). PRODUCER C.L. HOLLIS INSURANCE 27 Glen St Unit 8 Stoughton MA 02072 CONTACT MELANIE KEEFE NAME: PHOC.NENo, (781)344-8578 A/CNo:(781)341-0129 E-MAIL ADDRESS: MELANIE@insurehollis.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Sentinel Insurance Co Limited 11000 INSURED THE FRESH CATCH, INC & THE FRESH CATCH II INC THE FRESH CATCH V INC 30 CHAUNCY ST MANSFIELD MA 02048 INSURERB:The Hartford 11000 INSURERCkia Retail Merchants/Cove Risk INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:CL1622203052 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 ADD SUBR POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR OBSBAIL3302 DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 $ MED EXP (Any one person) $ 5,000 /28/2016 /28/2017 &ADV INJURY $ 2,000,000 -PERSONAL GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY M PRO X LOC LIQUOR LIABILITY $ 1,000,000 AUTOMOBILE LIABILITY MBINED COSINGLE LIMIT Ea accident 1 000 000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNEDSCHEDULED AUTOS X AUTOS 08UECAA8551 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ X NON -OWNED HIRED AUTOS X AUTOS /28/2016 /28/2017 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE f.E DT1 RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / NCRY ANY OFFICER/MEIMBEOR EXCLUDED? ECUTIVE (Mandatory In NH) N /A 014005031479116 1/1/2016 1/1/2017 X I WC STATU- OTH- LIMITS E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) RE: LOCATION: 30 CHAUNCY ST MANSFIELD, MA 02048 CERTIFICATE HOLDER CANCFI I ATION baudette5O@hotmail.com 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 MANSFIELD, MA Melanie Keefe/MFK AGUKU 25 (ZU9U/U5) INRn95 tsmnn�i m ©1988-2010 ACORD CORPORATION. All rights reserved. Th. Arf1Rn noma —A Innn ora ranictararl morlrc of Af`f1Rn L. Je 5:= A k0l LA. ?m 0 4vN 10 15 y U M 1:$'IFIV��, 0 Igg gmp I(A x w L. Je 5:= A k0l LA. ?m 4vN 10 15 y M 1:$'IFIV��, CL Igg gmp I(A L. Je 5:= A 10 I(A m z C] -4 t 6 .J U. n Au 1 tp (0 + •- P g z r " Q O z Z '«� ~ _ � Q a . ro 'cc7Trgq x�, x (1 w w d 0 � 0 O o U N d W a w a a a a 1 tp (0 + •- P g N '«� z m ro 'cc7Trgq � 2 o U N d � N O N � a`0uj, w a a 1 tp (0 + •- C: \� 4-+ o a� E X w Z a E t O O M m D (B m co V Q C: \� o X w Z O t u M m D (B m co V Q b LO b�4 N L M oO �C U0)0 -- Oi V co M VVU rC a u 0 M icg0 CV), mo LL- N q jo Z N t u M m i m co V Q b LO N L M oO �C -- Oi V VVU rC a u dU N icg0 CV), mo . in C N N q UAD Q tNI U 0000 i I (y + AN [ 1� aF ry Cqo—Ito N t5'j ,p v 00 O M Y..+E jam �' (� Cv t�. 4 C�0 in lIt I 'I w r� 0 I I tu ,r E N� Batu 4N u C nom, e .�,���.. ► < , �'Aly su G d� y io 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 -MASSA -FE Fax # 617-727-7749 www.mass,gov/dia Form Revised 5-26-05