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HomeMy WebLinkAboutSake Steakhouse 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:. GUANG K. SHI Whose place of business is: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE 280 SCHOOL STREET PERSON(S) IN CHARGE: MICHELLE LI, MANAGER Permit Expires: December 31, 2016 License Number: FS -83 Food Fee: $80.00 Milk & Cream BOARD OF HEALTH NichaeCvicCCean, 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: GUANG K. SHI having a place of business at: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE 280 SCHOOL 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 12131/2016 License No.: FS -83 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 -83 FOOD ESTABLISHMENT PERMIT APPLICATION 1) Establishment Name SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE {( 2) Establishment Address 280 SCHOOL STREET 3) Establishment Mailing Address (If different) 280 SCHOOL STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-2388 5) Applicant Name & Title: GUANG K. SHI, PRESIDENT 6) Applicant Address 141 ARMSTONG AVENUE, METHUEN, MA 7) Applicant Telephone No.: (646) 410-6228 24 Hour Emergency No.: (646) 410-6228 8) Owners Name & Title GUANG K. SHI 9) Owner Address (If different from applicant) 141 ARMSTRONG AVENUE, METHUEN, MA Owner's telephone number (646) 410-6228 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. W A Corporation Name Title Address Li FM11 IIIUIVIUUCII ❑ A Partnership ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: MICHELLE LI, MANAGER Address: 111 EAST MAIN STREET, APT RIGHT, NORTON, MA Telephone No: '(646)410-6228 24 Hour Emergency No: (646) 410-6226 FAX: (508) 337-2328 - _{ E-mail: MICHELLELI662(cD-YAHOO.COM r At E -Mall: ___ T 13) District Or Regional Supervisor (if applicable) ---------- Name & Title: Address: Telephone No: 24 Hour Emergency No: � FAX: 1 (508) 337-2328 E-mail: SAKESTEAKHOUSE_MA@HOTMAIL.COM 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 1 16) No. of Food Employees: 4 �17) DAYS/HOURS: MON-SAT 11:00 AM -1:00 AM SUN 12:00 NOON - 1:00 AM 18) Name of Person In Charge Certified in Food Protection Management: GUANG K. SHI 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: ❑d 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: F -/I Annual ❑ Seasonal i 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) XIANG WEI ZHUO ❑ 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 ❑ 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 PRFs For Hot And ___— ------ - __ . Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ----- -- --- - - Susceptible Population Facility p- p y F] Sale of Raw Animal Foods Intended _ __ - to be Prepared by Consumer I ❑ 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 ea � p Retail Sale --.- control -- ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin - - - - ❑ Offers RTE PHF in Bulk Quantities --_ - Prepares Food/Single Meals for Catered Events or Institutional Food Service -D—R- tail S eale of Salvage, Out Of -Date--- or Reconditioned Food - - - I To be completed by the Board of Health 1 L - - - -- 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 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: 4pf - Y Vtr 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: 27-2378335 ��� 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: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE ADDRESS: 280 SCHOOL STREET TELEPHONE AT LOCATION: (508) 337-2388 FAX NUMBER: (508) 337-2328 OWNER OF BUSINESS: GUANG K. SHI TELEPHONE OF OWNER: (646) 410-6228 FEDERAL ID/SS NUMBER: 27-2378335 FEE: $5.00 PERMIT NUMBER: FS -83 SIGNATURE: 1W 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 Individual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) 'z 7 2 � 7(R-3:?? . ** 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 IF 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information / r j Please Print Legibly Business/Organization Name: Address: ZisV SC City/State/Zip: Are you an employer? Check the appropriate box: 1. © I am a employer with Z'1 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 #: *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 prov(dingrworkers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: NUI 2%W 1jUV_ ffl: Insurer's Address: ) 14 V INs4," 911,,eee' f r y City/State/Zip: 02 � Wel //�� � Policy # or Self -ins, Lic. # el 0#723 7 / ��� 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 pains and penalties of perjury that the information provided above is true and correct Sig_rtature• Date: Phone # 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 #: Apr 2716 02:26p 15083372328 15083372328 p.2 From -Loretta Lee PaxlD: Page 2 of 4 Date:4/1212016 11: 18 AM Page 2 or 4 SASTE-1 OP ID: LL ,acoRo- CERTIFICATE OF LIABILITY INSURANCE �----� OATEIMM Da�1212o1 2016V) s 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsementis). PRODUCER Richard Soo HOD insurance 1148 Washington St, Suite 1 Boston, MA 02118.2108 CONTACT AMG: PHONE FA Arc rro E :617-33"168 Arc No: 617 38-1148 E -MAL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC INSURERA: Public Service Mutual EACH OCCURRENCE $_ INSURED Sake Steakhouse, Inc. --- Sake Steakhouse,_ ................... _280 School 'St: ._._... .. ..... _ ... .._..- INSURERS: _ INSURER C: _. .. . INSURER 0:. -.- .rlansfIeld-.eiA 02045._... ... ..... .__..._. ...... — -- INSURER E : PRODUCTS. COIAPIOP AGG 4 INSURER F, --rin ViFROr:FS CPRTIPICGTP NIIMRPR• RPVISIAN NIIMA;:P_ TH.S IS TO CERTIFY'HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDriION 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSD POLICY NUMBER ErF MMIDDYYYY MWDDI ICY EXP LIMBS COMMERCIAL GENERAL LIABILITY CLAIMS -MACE � OCCUR EACH OCCURRENCE $_ PREt/1SES Ea occurrence S MED EXP (Any one person) S PERSONAL & ADV INJURY $ GENT AGGREGATE LIMIT APPLIES P@7?: POLICY PRO- JECT LOC OTHER' GENERAL AGGREGATE t PRODUCTS. COIAPIOP AGG 4 $ AUTOMOBILE LIABILITY ANY A.UTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HREDAUTOS AUTOS COMBINED SINGLE LMrT S Ea acadenl BODILY INJURY (Pet person) 5 BODILY INJURY (Peracddenl) Y PROPERTY DAMAGE Peraccidenl $ f UMBRELLA L' .8 EXCESS LIAR CC( CLAIMS -MADE EACH OCCURRENCE I AGGREGATE $ CEO RETENTION S S A WORKERS COMPENSATION AI�D EMPLOYERS' LIABILITY .ANYPROPRIETORIPARTNERIEJ�CUTIVE YIN OFFICEMAEMBER EXCLUDED? (MandatoryinNH) V yes, describe under CES-CRI°TION OF OPERATIONS below N I A C 042871 06101/2015 09/01/2016 X H H- IT TE EP. E.L.EACH ACCIDENT S 1,000,00 E.L. DISEASE - EA EMPLOYEE S 1,000,00 E.L. (DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS rLOCATIONSIVEMCLES(ACORD 101, Additional Remarks Schedule, maybe attached if more space N required) Asian Rest Loc: 280 Schoold St. Mansfield, MA D2M MANSFI1 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo ars registered marks of ACORD Public, Service Insurance Company One Park Avenue New York, NY 10016-5807 WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY EXTENSION OF INFORMATION PAGE ITEM #4 NCCI Company No: 16152 Prior Policy Number: WC 042871 14 RENEWAL Policy Number: WC 042871 15 1. Named Insured and Mailing Address: Sake Steakhouse, Inc. dba Sake Steakhouse 280 School St Mansfield, MA 02048-1840 2. The policy period is from 6/1/2015 to 6/1/2016 4. Premium Massachusetts Classifications Restaurant NOC Total Manual Premium Premium for Increased Limits Part Two Balance to Minimum for Increased Limits Rate Deviation of 5.0% Total Premium Subject to Rating Merit Rating of 1.00 Total Modified Premium Policy Balance to Minimum Total Estimated Standard Premium Expense Constant Charge Terrorism Risk Insurance Extension Act 0.03 Total Estimated Premium Massachussetts Assessment of 5.8% Producer and Mailing Address: Richard Soo Hoo Insurance Agency, Inc. 1148 Washington Street Boston, MA 02118 Tel. (617) 338-8168 12:01 A.M. Standard Time at your mailing address shown above. Premium Basis Rate Per Estimated Loc. Code Total Estimated $100 of Annual St. No. No. Annual Remuneration Remuneration Premium MA 1 9079 $222,027 1.15 $2,553 $2,553 (9812) $49 (9848) $26 (9037) ($128) $2,500 $0 $2,500 (0990) $0 $2,500 (0900) $338 $67 $2,905 $148 THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY. Edition 10/97 Page 2 of 5 Copyright, 1987 National Council on Compensation Insurance ichard Soo Hoo Insurance Agency, Inc. INSURED COPY Public Service Insurance Company -- _ One Park Avenue New York, NY 10016-5807 WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY INFORMATION PAGE NCCI Company No:16152 Prior Policy Number: WC 042871 14 1 RENEWAL Policy Number: WC 042871 15 1. Named Insured and Mailing Address: Sake Steakhouse, Inc. dba Sake Steakhouse 280 School St Mansfield, MA 02048-1840 The Insured: Corporation Other workplaces not shown above: Named Insured: Sake Steakhouse, Inc. 2. The policy period is from 6/1/2015 to 6/1/2016 Producer and Mailing Address: Richard Soo Hoo Insurance Agency, Inc. 1148 Washington Street Boston, MA 02118 Tel. (617) 338-8168 12:01 A.M. Standard Time at your mailing address shown above. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here: Massachusetts 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 $ 10, 00.000 each accident Bodily Injury by Disease $ 1 0. 00.000 policy limit Bodily Injury by Disease $ 1.000.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes the following endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rate Per Estimated Loc. Code Total Estimated $100 of Annual Classifications St. No. No. Annual Remuneration Remuneration Premium See Extension of Information Page $2,715 Loss Constant: $0 Expense Constant Charge: $338 Minimum Premium $ 219 Deposit Premium $ 3,053 Total Estimated Annual Premium: $3,053 Premium Adjustment Period: Annually Servicing Office: New England Branch Countersigned 6/3/2015 at New York, N.Y. by Authorized Representative THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY. Edition 10/97 Copyright, 1987 National Council on Compensation Insurance Page 1 of 5 Richard Soo Hoo Insurance Agency, Inc. INSURED COPY 0 LL '-t? U o � R � 0 N G1 e -i 01 LL - c m o O Z w a O O Cn :.L —� LL -a, a LL y -ca � C X _ - tiF v 3 co 15 -23 � - C Y L)UL) .- c • � N � o o Q o o N N U N U O W ' 'y lA U w rs � Q 0 W t U V! W O O r- � U L 3 n 0 ti 3 L•d 99L 16L9£09 asnoy �BeJS ewnN dLZ:90 96 £Z AV i z u O m z m a. Lu "- Q LL. O N N j $ G Ln w a ti 3 L•d 99L 16L9£09 asnoy �BeJS ewnN dLZ:90 96 £Z AV W r— Z O 0 N a \ Z M m - S_ X w C) 0 M W ED 2716 02:26p .e s 15083372328 15083372328 p.1 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: GUANcsHi Certificate Number: 2305760 Date of Completion: 4r27t2016 Date of Expiration: 4r27121121 Thr above -warned person is hereby issued this eertXrate for Completing au allergen awareness tridningprosraan rerognixed by the Alassaebuseus DLparrment of Pnblic Healtb in arrordanre w,'tb 105 CAIR 590.009(CJ(3)(a). 7liis rertii irate will be valid forfive (5) yeart f rzm Mate ofeampl •tion. I3sued Sr i mIM! 1blassachuserts Res ua .t Association 333 Turnpike Road, Suht 102 Southborough, MA 01772 508-303-9705 —A%v mam rav n n tvssoc. o rg 1 Egg NATIONAL i RESTAURANT ASSOCIATION,; 800.7652122 sww.rataurant.org 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