HomeMy WebLinkAboutMansfield Elks 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:.
MANSFIELD LODGE OF ELKS
Whose place of business is:
MANSFIELD LODGE OF ELKS #2633
140 NORTH MAIN STREET
PERSON(S) IN CHARGE:
MARK WALSH, SECRETARY
Permit Expires: December 31, 2016
License Number: FS -42
Food Fee: WAIVED
Milk & Cream W
BOARD OF HEALTH
Michae(NcCtean, 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:
MANSFIELD LODGE OF ELKS
having a place of business at:
MANSFIELD LODGE OF ELKS #2633
140 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 -42
Scott Leite, Health ,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-42IL
FOOD ESTABLISHMENT PERMIT APPLICATION
– — y p g T -- ,
icaf�on mu-s� �s�iffe�Teast�0-mss byre fhe manned o enm date ,
1) Establishment Name MANSFIELD LODGE OF ELKS #2633
2) Establishment Address 140 NORTH MAIN STREET
3) Establishment Mailing Address (if different) 140 NORTH MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 261-9595
5) Applicant Name & Title: MARK WALSH, SECRETARY
6) Applicant Address 140 NORTH MAIN STREET, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 261-9595 24 Hour Emergency No.:
317) 839-0564
8) Owners Name & Title MANSFIELD LODGE OF ELKS
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
V An Association or partner.
❑ A Corporation Name Title Address
❑ An Individual
❑ A Partnership
❑ Other legal Entity --- — - -
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.
Name & Title: IMARK WALSH, SECRETARY
Address:
Telephone No
FAX:
E-mail:
Alt E -Mail:
40 NORTH MAIN STREET, MANSFIELD, MA 02048
508) 261-9595 24 Hour Emergency No: (617) 839-056.
ELKS2633(aD-COMCAST. NET
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: i 24 Hour Emergency No:
_ E-mail:
FAX:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: SEWER
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:
17) DAYS/HOURS: BY EVENT
18) Name of Person In Charge Certified in Food Protection Management:
If more than 3 individuals are certified, complete list is on file. MA fLk W ALS}
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: W 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:
W Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
❑ 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:
❑ 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)
❑ Sale of Commercially Pre -Packaged Non -PRFs
❑ Sale of Commercially Pre -Packaged PHFs
❑ Delivery of Packaged PHFs
Q 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
❑ 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
- --- — --I
E] Offers RTE PHF in Bulk QuantitiesCatered
� Prepares Food/Single Meals for
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:
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 CMR1590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain copies of 5 MMP 590.000 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: 04-2751171'
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: MANSFIELD LODGE OF ELKS #2633
ADDRESS: 140 NORTH MAIN STREET
TELEPHONE AT LOCATION: (508) 261-9595
FAX NUMBER:
OWNER OF BUSINESS:
TELEPHONE OF OWNER:
MANSFIELD LODGE OF ELKS
FEDERAL ID/SS NUMBER: 04-2751171
FEE: $5.00
PERMIT NUMBER: FS -42
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.
—V//
* Signature of Individual or
Corporate Name (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
c) LI - Z7S`" 11 -71
** Social Security Number (Voluntary) or
Federal'ldentification 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: X633
Address: /40 ,N. /-MM S-t-
City/State/Zip: A 0201 :S'69- Z 1
� li � Phone #:
Are you an employer? Check the appropriate box:
1.9 I am a employer with Z 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.]
Business Type (required):
5. [] Retail
6, ❑ Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8, ANon-profit
9. ❑ Entertainment
10, ❑ Manufacturing
U. , ❑ Health Care
12.❑ Other
*Any applicant that checks box t/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 #Il.
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:
Policy # or Self -ins, Lie. # 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 DIA for insurance coverage verification.
I do hereby certify, undep tjlp pirins and penalties of perjury that the information provided above is true and correct
Phone #• G i " �3 U SJ�/
Official use only. Do not write in 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
www,mass.gov/dia
Phone
F AW
TRAVELERS
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6HUB-OG1 0309-2-16)
RENEWAL OF (6HUB-OG10309-2-15)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
NCCI CO CODE: 13439
1.
INSURED: PRODUCER:
MANSFIELD LODGE OF ELKS 2633 ROBERT W EAMES INS AGCY
140 NORTH MAIN STREET 126 NORTH MAIN ST
MANSFIELD MA 02048 MANSFIELD MA 02048
Insured is ASSOCIATION, LABOR UNION, RELIGIOUS ORG.
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 06-16-1 6 to 06-16-17 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-11-16 WC
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: ROBERT W EAMES INS AGCY
2922M
ST ASSIGN: MA
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Mansfield Board of Health Date OS 2-7 /
We, ELKS` V 2-6� � request a waiver of the
Food Service Permit Fee for the following reason
IJD,J - rAor-pj' OR6A J jZAn6�
Thank you,
Signature
Title
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 burn 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