HomeMy WebLinkAboutMansfield Pop Warner Football 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 POP WARNER FOOTBALL
Whose place of business is:
MANSFIELD POP WARNER FOOTBALL @ MEMORIAL PARK
250 EAST STREET
PERSON(S) IN CHARGE:
GLENDA SMITH, CONCESSIONS MANAGER
Permit Expires: December 31, 2016
License Number: FS -43
Food Fee: WAIVED
Milk & Cream W
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.
MANSFIELD POP WARNER FOOTBALL
having a place of business at.
Town of Mansfield
6 Park Row
Mansfield, MA 02048
MANSFIELD POP WARNER FOOTBALL @ MEMORIAL PARK
250 EAST 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 12/3112016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -43
Scott Leite, HeaCth .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 -43
FOOD ESTABLISHMENT PERMIT APPLICATION
i pp
mustUe sub
rj�itted'at least 3U days -before 1he planned oPening date)
1) Establishment Name MANSFIELD POP WARNER FOOTBALL @ MEMORIAL PARK
2) Establishment Address 250 EAST STREET
3) Establishment Mailing Address (if different) P.O. BOX 92
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 562-0739
5) Applicant Name & Title: REGGIE THEVENOT, PRESIDENT
6) Applicant Address 3 DUSTIN COURT, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 562-0739 24 Hour Emergency No.
8) Owners Name & Title
(508) 245-9974 (508) 339-5412
MANSFIELD POP WARNER FOOTBALL
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
El An Association I or partner.
V A Corporation Name Title Address
[I An Individual
1:1 A Partnership
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.-----------------
)__
Name & Title: iGLENDA SMITH, CONCESSIONS MANAGER
MARTHA'S WAY MANSFIELD, MA 02048
(508) 245-9974 (508) 33,9-5412
No'h nn ns 117RI 1 189-9269 24 Hour Emergency No:
eepo
FAX:
E-mail:
GLENDA.SMITHftCOMCAST.NET
Alt E -Mail:
IMANSFIELDPOPWARNER(cD-G-MAIL.CO-M
13) District Or Regional Supervisor (if applicable)
Name &Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: SEPTIC
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 6-8
17) DAYS/HOURS: SAT & SUN 7 AM -9 PM
18) Name of Person In Charge Certified in Food Protection Management: GLENDA SMITH
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
i
certificate
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:
0 Annual
❑ Seasonal
Seasonal Dates:
� Temporary
Temporary Start Date:
jTemporary End 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)
❑ Caterer $12.50
0 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
Temporary Time:
Rain Date:
Definitions:
nnfoods t
23) Food Operations N Hpiallrsps r
I(Check all that apply). RTE --adyto'e 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
F,/1 PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
❑ Customer Self -Service
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
❑ Ice Manufactured and Packaged for
- -- --- - g control
Preparation of Non-PHFs Retail Sale --- -- -
Juice Manufactured and Packa ed for{
Other Food Operations ❑ F-1 offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
---- -- ❑ 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 To be completed by the Board of Health
I
_-- -_-- -_ - % 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 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtail copies of 105 CMF 590.040 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 ��')-7n7n
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 POP WARNER FOOTBALL @ MEMORIAL PARK
ADDRESS: 250 EAST STREET
TELEPHONE AT LOCATION: (508) 562-0739
FAX NUMBER:
OWNER OF BUSINESS: MANSFIELD POP WARNER FOOTBALL
TELEPHONE OF OWNER:
FEDERAL ID/SS NUMBER: 04-322-7070
FEE: $5.00
PERMIT NUMBER: FS -43
SIGNATURE: `
DATE: 6, A-3 " 111p
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.
t
* ignature o ndividual or
Corporate Name (Mandatory)
r
By: Cor ate Officer
(Mandatory, if applicable)
69? -- `Z-Z-� -b')C)
** 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 62.C, 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; Q h S�e Id '442 KXY V tilt? V
Address: I�'' U ZQ'K 6) Z
City/State/Zip:_ Y1Spy Vic[ M& C�Z _L,,4 Phone #: I 8"� ;) C) Z -
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
4,�no employees. [No workers' comp. insurance required]*
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. %Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11,❑ Health Care
12.❑ Other
*Any applicant that checks box # I 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 employees. Below is the policy information.
Insurance Company
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 cgtify, under the pans and penalties of perjury that the information provided above is true and correct
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 Person
www,mass,gov/dia
Phone
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF REVENUE
PO BOX 7010
BOSTON, MA 02204
4030
0
MANSFIELD POP WARNER INC
PO BOX 92
MANSFIELD MA 02048-0092
L\
Notice
�A�7, pig
Notice Date: 09/11/15
Taxpayer ID Number: 043 227 070
Dear Taxpayer,
Below please find your Certificate of Exemption (Form ST -2). Please cut along the dotted line
and display at your place of business.
Sincerely,
Massachusetts Dept. of Revenue
__Massachusetts_ _
Form ST -2 Department of
kl-
Certificate of Exemption
Revenue
Certification is hereby made that the organization herein is an exempt purchaser under General Laws, Chapter 64H, section 6(d) or (e). All
purchases of tangible personal property by this organization are exempt from taxation under said chapter to the extent that such property is
used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or any
unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation. Willful misuse of this
Certification of Exemption is subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines.
MANSFIELD POP WARNER INC
PO BOX 92
MANSFIELD M.A. 020.18
EXEMPTION NUMBER
043 227 070
ISSUE DATE
09/01/15
CERTIFICATE EXPIRES ON
09/01/25
NOT ASSIGNABLE 012 TRANSFERABLE CONINHSSIONER of REVENUE
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Mansfield Board of Health Date • �3 -
We, Aja jjj, f�,Pj2,J2 0 rilei" 'G'O Hgg l / request a waiver of the
Food Service Permit Fee for the following reason
due are na�_pro A, I
Thank you,
Title
ature
Information and Instructions
Massachusetts General Lawn 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. 'Acre 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 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