HomeMy WebLinkAboutJamie Fund 5 K 08/13/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishmeni
Type: TEMPORARY FOOD PERMIT
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:.
KIM PIRO, RACE DIRECTOR
Whose place of business is:
JAMIE FUND 5K ROAD RACE
250 EAST STREET - MANSFIELD HIGH SCHOOL
PERSON(S) IN CHARGE:
KIM PIRO, RACE DIRECTOR
Permit Expires: August 13, 2016
License Number: T-121
Food Fee: WAIVED
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
T-121
FOOD ESTABLISHMENT PERMIT APPLICATION
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1) Establishment Name JAMIE FUND 5K ROAD RACE
2 Establishment Address 250 EAST STREET - MANSFIELD HIGH SCHOOL
3) Establishment Mailing Address (if different) P.O. BOX 256
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-1409
5) Applicant Name & Title: KIM PIRO, RACE DIRECTOR
6) Applicant Address 41 MONAHAN LANE, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 339-1409 24 Hour Emergency No.: (781) 630-0463
8) Owners Name & Title KIM PIRO, RACE DIRECTOR
9) Owner Address (If different from applicant) 41 MONAHAN LANE, MANSFIELD, MA 02048
Owner's telephone number
5083391409
10) Establishment Owned BT11)
If a corporation or partnership, give name, title, and home address of officers
❑ An Association
or partner.
❑ A Corporation
Name Title Address !
❑ An Individual-----
❑ A Partnership_-
KIMPIR020@GMAIL.COM
❑ Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.
Name & Title:
KIM PIRO, RACE DIRECTOR
Address:
41 MONAHAN LANE, MANSFIELD, MA 02048
Telephone No:
(508) 339-1409 24 Hour Emergency No: (781) 630-0463
FAX:
-
E -mail:
KIMPIR020@GMAIL.COM
Alt E -Mail:
L - —
- -.
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
�14) WATER SOURCE: TOWN
15) SEWAGE DISPOSAL: TOWN
16) No. of Food Employees:
DEP Public Water Supply No: (If applicable)
1
17) DAYS/HOURS: - e" .8:00AM -12:00 PM
� I
18) Name of Person In Charge Certified in Food Protection Management:
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
❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft)
Moblie End Date: ❑ Food Service up to 100 or
Moblie Comments: up to 10' PHF display $62.50
21) Length of Permit:
❑ Annual
❑ Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Um
8:00 AM - 12:00 PM
❑ 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
❑ Milk & Cream $5.00
❑ Mobile Food & Consession $37.50
❑ Manufacture Frozen Desserts/Ice Cream
$12.50/freezer
❑ Pushcart $12.50 # of Pushcarts: 0
❑ 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/femperature 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)
❑ 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
❑ Preparation of Non-PHFs
/ Other Food Operations
Y BOTTLED WATER, GRANOLA BARS
❑ 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
and/or HACCP Plan (including bare hand
contact alternative, time as a public health—�
control)
❑ Customer Self -Service
❑ Ice Manufactured and Packaged for
Retail Sale
❑ Offers Raw Or Undercooked Food Of -I
Animal Origin II
❑ Juice Manufactured and Packaged for
Retail Sale
F1 Prepares Food/Single Meals for
Catered Events or Institutional Food Service
E] Offers RTE PHF in Bulk Quantities
❑ Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
-- -
To be completed by the Board of Health
L _ Total Permit Fee:
Payment is due with application W 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 10� CMR 590.000 an rl —othe-r-gRplicabie law. I have been instructed by the
board of health on how to obtain copigs of Y05 CMR 590.000 kd theJed al Food Code.
24) Signature of Applicant:AA
'
Pursuant to MGL Ch.62C, sec. 49A, I certi under the p
and paid state taxes required under law.
25) Social Security Number or Federal ID: 20-1994425
26) Signature of Individual or Corporate Name
of perjury that I, to my best knowledge and belief, have filed all state tax returns
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.
* Sign ture of Indiv' al or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
oQ5 -toQ - L �Jbu Qt - of
** 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: J2 IM) f
Address:AP) vn 7 ��
City/State/Zip:
Are you an employer? Check the appropriate box:
1. ❑ 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
A employees. [No workers' comp. insurance required]*
4. V We are a non-profit organization, staffed by volunteers,
with no employees. [No workers'.comp. insurance req.]
#: 502'-339 - t X07
*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 #1.
I ant 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. Lic. #.
Expiration Date:
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
ofperjury that the information provided above is trueandcorrect
Dote, (a 1 2- // 4 ,
Official use only. Do not write its 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 5. Selectmen's Office
6. Other
Contact Person:
www.mass.gov/dia
Phone
Mansfield Board of Health
W
i2 �u
Food Service Permit Fee for the following reason
Thank you,
Title
req
I co
Date U I ZI 13
request a waiver of the
April 5, 2016
The Jamie Fund
PO Box 256
Mansfield, MA 02048
Town of Mansfield
6 Park Rory, Mansfield, Massachusetts 02048
Board of Selectmen
Dear Mr. Piro:
At its meeting on March 2, 2016 the Board of Selectmen approved a Road Race Permit for The Jamie
Fund 5K, scheduled for August 13, 2016 from 7:00am — 12:00pm as referenced by the map
presented.
The Board has approved the permit subject to the following conditions:
• Organizers must follow up with Lieutenant Tracy Juda, Mansfield Police Department, to
ensure proper safety detail a minimum of two weeks in advance of this event. Lieutenant
Juda can be reached at 508-261-7301.
• Race organizers will provide a means of communication for the reporting of emergencies
throughout the race course. Mansfield Fire Department is the sole transporting agent.
Mansfield Fire can be reached at 508-261-7318.
• The Building Department recommends that any inflatable amusement devices be installed to
manufacture specifications for safety. The Building Department can be reached at
508-261-7360.
• The Board of Health requires applications for Food Vendor permits to be completed prior to
the event. The Health Department can be reached at 508-261-7366.
• Please ensure that the Raffle is properly permitted through the Town Clerk's Office. The
Clerk can be reached at 508-261-7345.
• The banner for the event has been approved for the weeks of August 1St and August Stn,
which were the closest dates available to your request. Please note that banners are hung
early Monday mornings and to be sure the banner is dropped off prior to that time.
Please remember that if there are any changes to the event to notify this office immediately. The
Board of Selectmen wishes The Jamie Fund and all its racers great success with the event. As
always, if we can be of any assistance, please contact us at 508-261-7372.
Sincerely,
Tracey Whalen
Executive Secretary, Board of Selectmen
cc: Police Chief, Ron Sellon
Fire Chief, Neal Boldrighini
Bob Blackman, Building Inspector and Zoning Enforcement Officer
Scott Leite, Board of Health
Marianne Staples, Town Clerk
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
applicantwho 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. 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
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
Form Revised 5-26-05