The URL can be used to link to this page

Home My WebLink AboutBristol Liquors 12/31/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Permit to Operate a Snack Establishment Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. MIGUEL SANCHEZ BOARD OF HEALTH Whose place of business is: BRISTOL LIQUORS 670 EAST STREET License Number: S-20 Permit Expires: December 31, 2016 Food Fee: $25.00 Milk & Cream ❑ Michae(MCCCean, Chairman Permit or the Sale of Tobacco Products Violation of REGULATION AFFECTING SMOKING AND THE SALE, VENDING, AND DISTRIBUTION OF TOBACCO may result in fines, suspension or revocation of this permit. Whose place of business is: BRISTOL LIQUORS 670 EAST STREET BOARD OF HEALTH License Number: S-20 Permit Expires: December 31, 2016 MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued S-20 FOOD ESTABLISHMENT PERMIT APPLICATION - (Vp—pfication must -be submitteu aueasi-3o-days byre the planned opening dateT I1) Establishment Name BRISTOL LIQUORS 2) Establishment Address 670 EAST STREET 3) Establishment Mailing Address (if different) 670 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-3782 5) Applicant Name & Title: MIGUEL SANCHEZ, OWNER 6) Applicant Address 75 THURBER AVENUE, BROCKTON, MA 02301 7) Applicant Telephone No.: (761) 405-1016 8) Owners Name & Title 24 Hour Emergency No. MIGUEL SANCHEZ (781) 405-1016 9) Owner Address (If different from applicant)- - - - - - 75 THURBER AVENUE BROCKTON MA 02301 Owner's telephone number 7814051016 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. V A Corporation Name Title Address 9L- -� ❑ An Individual - �inf" -- ❑ A Partnership ,a✓)r If� ❑ Other legal Entity - -- -- - -- - - - _O ' 0/ _! 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MIGUEL SANCHEZ, OWNER Address: 75 THURBER AVENUE, BROCKTON, MA 02301 Telephone No: (781) 405-1016 24 Hour Emergency No: 1781) 408-1016 FA' - E -mail. MIGUEL.A.SANCHEZ(a_ME.COM Alt E -Mail: $( MIGSAN(aDMSN.COM 13) District Or Regional Supervisor (if applicable) j Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: SEPTIC DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: MON-THUR 8AM-10PM FRI-SAT 8AM-11PM SUN 12PM-6PM 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 (❑ Moblie Moblie Start Date: I Moblie End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary j 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) ❑ 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/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature 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 I -- ' ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held --- -- - - - ❑ Sale of Commercially Pre -Packaged PHFs + ---- --- --- for More Than a Single Meal Service ❑ Preparation of PHFs For Hot And -_ - _ -- --- -_ -____ -- - -- -- — -- - ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly - - --- --- -. ---- -- - -- Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended - - - ❑ Reheating of Commercially to be Prepared by Consumer i ❑ Vacuum Packaging ! Cook Chill Processed Foods for Service Within 4 Hours -- -- - - - ❑ Use of Process Requiring A Variance ❑ of Non PHF and Non-- ❑ Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only _ _ r� -- _ { U Ice Manufactured and Packaged ror contact alternative, time as a public health control) ❑ Preparation of Non-PHFs - -- — Retail Sale - - _ { Other Food Operations Packaged forr ❑Juice Manufactured and Packaged ❑ 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: $12.50 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 59,V.000 and all other qpplicable law. I have been instructed by the board of health on how to obtain copies of 105 CMF$90.000jand the fecyral Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec .49A,(ertify under the penalties and paid state taxes required under law. 25) Social Security Number or Federal ID: 47-3510984 26) Signature of Individual or Corporate Name: F rjury 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 PERMIT NUMBER: S-20 Application for the Sale of Tobacco Products I hereby make application for a permit to sell tobacco products in compliance with the Board of Health Regulation Affecting Smoking and the Sale, Vending and Distribution of Tobacco. This permit expires on June 1st of each year. Violation of this Regulation may result in fines, suspension or revocation of this permit. NAME OF BUSINESS: BRISTOL LIQUOURS LOCATION OF SALE OF TOBACCO PRODUCTS: 670 EAST STREET, MANSFIELD, MA 02048 TELEPHONE AT LOCATION: (508) 339-37-82 OWNER OF BUSINESS: MIGUEL SANCHEZ ADDRESS OF OWNER: 75 THURBER AVENUE, BROCKTON, MA 02301 TELEPHONE OF OWNER: (781) 405-1016 FAX NUMBER: If a corporation or partnership, give name, title, and home address of officers or partner. JODAMI LIQUORS, INC. 75 THRUBER AVENUE, BROCKTON, MA 02301 * Provide a copy of current Department of Revenue CT -3T Retail Excise Unit License. FEE: $12.50 CT -3T NUMBER: FEDERAL ID/SS NUMBER: 47-3510984 SIGNATURE: DATE: oEQAR*MFtir Form CT -3T 08716 a o„ Massachusetts Department of Revenue 2014-2016 m Cigarette Excise Unit Retailer License for Sale of Cigarette's and Cigars and Smoking Tobacco. a - D01i This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by law. Application Number: 68356 License Number: Date of Issue: Federal Identification or Social security Number: 473-51-0984 08716 09/09/2015 Mailing address for license: Retail sale location (if different than mailing address) JODAMI LIQUORS INC BRISTOL LIQUORS 670 EAST ST 670 EAST ST MANSFIELD, MA 02048 I MANSFIELD, MA 02048 Massachusetts Department of Revenue- ST -1 Customer Service Bureau PO Box 7010 Boston, MA 02204 The vendor herein named is registered to sell tangible personal property at retail or for resale, pursuant to the General Laws, Chapters 62C, 64H and 641. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST -1 can be issued. JODAMI LIQUORS INC 670 EAST ST MANSFIELD MA 02048 IDENTIFICATION NUMBER 473-510-984 ISSUE DATE 07/01/15 This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE l i i� 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. * Senatuile of Individual or Corporate Name (Mandatory) --� 6(-< el /� L' B : C rporate fFicer (Mandatory, if applicabl 7 - i 09E-� ** 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: Y i C, 1 Address: �,,� 70 6fi'_/i I 67 . _ l/ City/State/Zip:LfHjI �U /U& ( t_ Are Vu 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 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 #: 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 # 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#1. 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. 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 DIA for insurance coverage verification. I do hereby certify, uW der the pa' s a penalties f 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 ® A� o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 5/27!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 Association Benefits Insurance Agency CONTACT NAME: PHONE I A/C No Ext q+C No E-MAIL ADDRESS: 299 Ballardvale St, Suite 1 Wilmington, MA 01887 INSURERS) AFFORDING COVERAGE NAIC # INSURERA: MA Retail Merchants WC Group Inc. EACH OCCURRENCE $ INSURED INSURER B: INSURER C : Jodami Liquors Inc INSURER D d/b/a Bristol Liquors 670 East Street PRODUCTS - COMP/OP AGG $ Mansfield, MA 02048 INSURER E: INSURER F: ern/GRnr_ES CERTIFICATE NUMBER' 00001 REVISION NUMBER: 00001 v 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 DDL INSR SUBR WVD POLICY NUMBER POLICY EFF MWDD+YYY POLICY EXP MM+DDIYYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR EACH OCCURRENCE $ —DAMAGE —TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOSAUTOS EO MBI & SINGLE LIMIT BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ _ DED RETENTION $ $ AOFFICER/MEMBER WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A 014005033803116 1/01/2016 110112017 X WC STATUS OTH- TORY LIMITS I I E E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEd $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) UtKIIFIUAIt 11VL.IJCK Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 6 Park Row THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mansfield, MA 02048 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �Q kV'I`Jt$0-LU I U AL+VKL/ L.U111-JKA IMV. N11119 11 LJ I UbUIVUU. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Client#: 317784 RRlQTni I Ini CERTIFICATE OF LIABILITY 1 DATE (MM/DD/YYY1f) 1i/(MMIOD 5 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). PRODUCERA HUB Intl New England (ABIA) 299 Ballardvale Street Wilmington, MA 01887 NPHo E — - (TON Eel : 978 657-5100 ac No : 978-988-0038 ADDRESS: INSURERI#S) AFFORDING COVERAGE NAIC 978 657-5100 INSURERA: Preferred Mutual Insurance Comp INSURED Bristol Liquors INSURER B : INSURER C: Jodamt Liquors, Inc DBA INSURER D: 670 East St INSURER E: Mansfield, MA 02048 INSURER F 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. jp TYPE OF INSURANCE ADD )NSA SUB WVD POLICY NUMBER PQLICY EFF LADI POIJOEXP M/D L1MTrS A GENERALuaBiUTY BOP0100723958 7/01/2015 07/01/2016 s2,0001000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR pEAApCMMH,0ECCURppRENCE PREM ES EaLNTLU e $ MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY s2,000,000 GENERAL AGGREGATE $4 000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY WT El LOC PRODUCTS -COMP/OPAGG $4000000 Lig. Lieb. $$2M/$4M AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a acdderd) ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOSBODILY HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per parson) $ INJURY (Per accident) $ PROPERTYDAMAGE fPer accident $ $ UMBRELLA LIAB CESS UAB OCCUR CLAIMB-MADEAGGREGATED EACH OCCURRENCE $ ffRETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F $ WC STATU- OTH- / N / A EL EACH ACCIDENT $ (Mandatory in NH) if yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYEE $ EL DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101. Additional Remarks Schedule, if more space Is required) Town of Mansfield 6 Park Row Mansfield, MA 02048 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 m1988-2010 ACORD CORPORATION. All rights reserved. Autinu is tcu♦ Ulu*) 1 of 1 1 ne AL KLi name and logo are registered marks of ACORD #S1495904/M1495903 NID001 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 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-MASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05