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Home My WebLink AboutTasty Ray's 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:. RAYMOND DEAGRELA Whose place of business is: TASTY RAY'S LLC 20 SOUTH MAIN STREET PERSON(S) IN CHARGE: RAYMOND DEAGRELA, OWNER MANAGER Permit Expires: December 31, 2016 License Number: FS -92 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH MichaeCAcCtean, 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. RAYMOND DEAGRELA having a place of business at: TASTY RAY'S LLC 20 SOUTH 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 12131/2016 unless previous to that time is suspended or revoked. Expires 1213112016 License No.: FS -92 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 FOOD ESTABLISHMENT PERMIT APPLICATION 1) Establishment Name TASTY RAY'S LLC 2) Establishment Address 20 SOUTH MAIN STREET V,41AY "1 2`016 3) Establishment Mailing Address (if different) 20 SOUTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-1839 _ I 5) Applicant Name & Title: RAYMOND DEAGRELA 6) Applicant Address 1 EAST HODGES STREET, NORTON, MA 02766 7) Applicant Telephone No.: (508) 966-7258 24 Hour Emergency No.: (508) 965-7258 RAY OND LA 8 Owners Name &-Title —_ 6 DAILEY STREET, UNIT G, ATTLEBORO, MA 02703 � 9) Owner Address (If different from applicant)} Owner's telephone number (508) 965-7258 10) Establishment Owned By: ❑ An Association V A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity -- --- ------- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc. Name & Title: (RAYMOND DEAGRELA, OWNER MANAGER 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address Address: 11 EAST HODGES STREET, NORTON, MA 02766 Telephone No: (508) 965-7258 FAX: (508) 22673860 E-mail:-- RDEAGRELAO_YAHOO.COM Ft E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: 24 Hour Emergency No: (508) 965-7258 Telephone No j 24 Hour Emergency No: - - - - - FAX: i E-mail: -- -- - -- - 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: Food Establishment Information 15) SEWAGE DISPOSAL: 16) No. of Food Employees: 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: W Permanent Location ❑ Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: i Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) 0 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) TOWN 6 RAYMOND DEAGRELA ❑ 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 23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - 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) 0 Sale of Commercially Pre Packaged Non PHFs7� PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 0 Sale of Commercially Pre -Packaged PHFs Delivery of Packaged PHFs Reheating of Commercially Processed Foods for Service Within 4 Hours 0 Customer Self -Service of Non PHF and Non - Perishable Foods Only — Preparation of Non-PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service -- --- ❑ PHF and RTE Foods Prepared For Highly --— ----- -- Susceptible Population Facility FV] 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) _ -.._- ---- �- Animal Ori in— Other Food Operations ❑Juice Manufactured and Packaged for ❑Offers Raw Or Undercooked Food Of I' Retail Sale 9 ❑ Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for __ Catered Events or Institutional Food Service ❑ Retail Sale of -Salvage, Out -Of -Date --------- or Reconditioned Food To be completed by the Board of Health — -- - Total Permit Fee: $62.50 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 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain cypies of 105 CIIV % 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: 46-0546835 26) Signature of Individual or Corporate Name: _ A�n�A 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: TASTY RAY'S LLC ADDRESS: 20 SOUTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-1839 FAX NUMBER: (508) 226-3860 OWNER OF BUSINESS: RAYMOND DEAGRELA TELEPHONE OF OWNER: (508) 965-7258 FEDERAL ID/SS NUMBER: 46-0546835 FEE: $5.00 PERMIT NUMBER: FS -92 SIGNATURE: Gil DATE: Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: CATERER 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:. RAYMOND DEAGRELA Whose place of business is: TASTY RAY'S LLC 20 SOUTH MAIN STREET PERSON(S) IN CHARGE. RAYMOND DEAGRELA, OWNER/MANAGER Permit Expires: December 31, 2016 License Number: C-4 Food Fee: $12.50 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued CC=4 FOOD ESTABLISHMENT PERMIT APPLICATION ;a lose su�imiff�a eas 3�daysTie of re fh�anned open►n—g d 1) Establishment Name TASTY RAY'S LLC 2) Establishment Address 20 SOUTH MAIN STREET 3) Establishment Mailing Address (if different) 20 SOUTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-1839 5) Applicant Name & Title: RAYMOND DEAGRELA, OWNER/MANAGER 6) Applicant Address 1 EAST HODGES STREET, NORTON, MA 2766 7) Applicant Telephone No.: (508) 965-7258 24 Hour Emergency No. 8) Owners Name & Title RAYMOND DEAGRELA 9) Owner Address (If different from applicant) 1 EAST HODGES STREET, NORTON, MA 2766 Owner's telephone number 5089657258 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. 0 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: RAYMOND DEAGRELA, OWNER/MANAGER Address: 1 EAST HODGES STREET, NORTON, MA 2766 Telephone No: (508) 965-7258 FAX: (508) 226-3860 E-mail: RDEAGRELA(a@YAHOO.COM Alt E -Mail: _ 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: i E-mail: 24 Hour Emergency No: (508) 965-7258 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: TUES-SAT 11-9 SUN 4-9 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 6 18) Name of Person In Charge Certified in Food Protection Management: RAYMOND DEAGRELA 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: 0 Permanent Location ❑ Mobile Mobile Start Date: Moblie End Date: Mobile Comments: 21) Length of Permit: W Annual ❑ Seasonal Seasonal Dates: LJ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): 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: ❑ 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-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 I, the undersigned, attest to the accuracy of the inf establishment operation will comply wAh 105 CMR board of health on how to obtain copft of 105 CM 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the and paid state taxes required under law. 25) Social Security Number or Federal ID: 46-05448', 26) Signature of Individual or Corporate Name: 0 PHFCooked To Order T� Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service n Preparation of PHFs For Hot And Cold Holding For Single Meal Service. ❑ PHF and RTE Foods Prepared For Highly ------ -- - — Susceptible Population Facility 0 Sale of Raw Animal Foods Intended -_— __— -_ _ - to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Use of Process Requiringanance � ❑ Customer Self -Service and/or HACCP Plan (including bare hand -- -- _ — - ❑ Ice Manufactured and Packaged for contact alternative, time as a public health p Retail Sale control) ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin 0 Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Offers RTE PHF in Bulk Quantities ❑ Retail Sale of Salvage, Out -Of -Date- or Reconditioned Food - - -- ro be completed by the Board of Health --' I Total Permit Fee: $12.50 Payment is due with application ❑ waived provided in this application and affirm that the food and all other applicable law. I have been instructed by the (d and the federal Food Code. 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. *f Individual Signature al or o d u Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) q 6 -od� / 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 600 Washington Street Boston, MA 02111 IV www.mass.gov/dia . Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: 1 Address: i t/VI City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. Uff I am a employer with employees (full and/ 5, ❑ Retail or part-time).* 6. [O estaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl, real estate, auto, etc,) employees working for me in any capacity, [No workers' comp. insurance required] 8. ❑Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees, [No workers' comp. insurance required]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'. comp. insurance req.] 1 12.0 Other *Any applicant that checks box t11 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 #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:: t • n Insurer's Address: P-0 A rj,y( 43 46 City/State/Zip: LY) !aa's Pix l YY14 win Y Policy # or Self -ins, Lic. # S t- 12 2 l Expiration 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, nder the pains d penalties of perjury that the information provided above is true and correct. /) Date: 'j- / � l C Cianafitra' "� 1 �A _ L M 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: Phone www,mass.gov/dia --10 A`4�>R o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/27/2016 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(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 on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C & S INSURANCE AGENCY INC. P.O. BOX 406 MANSFIELD MA 02048 CONTACT NAME: Valerie Cameron PA"/c°NN Ell): (508) 339-8991 FAA/C No): ADDRESS: Imcroce@candsins.com INSURERS AFFORDING COVERAGE NAIL # INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED TASTY RAYS LLC 20 SOUTH MAIN ST MANSFIELD MA 02048 INSURER B: INSURERC: INSURER D : INSURERE: INSURER F: rnvcDAr_Gc CERTIFICATE NIIMRFR 5RRRR REVISION NUMBER: 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 L -SR TYPEOFINSURANCE ADDL SUBR POLICYNUMBER POLICY EFF MM/DD/ POLICY EXP MWDD LIMITS 6 Park Row COMMERCIAL GENERAL LIABILITY C� Mansfield MA 02048 Daniel M. Cro ey, CPCU, Vice President — Residual Market — WCRIBMA TIA\I All ..{.4.. -4 EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS -MADE E OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ N/A GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS -COMP/OPAGG $ POLICY 1-1PRO-❑LOC JECT OTHER: AUTOMOBILE LIABILITY Ea accidentMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS 0 NON -OWNED HIRED AUTOS AUTOS N/A PROPERTY DAMAGE $ Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED RETENTION $ WORKERS COMPENSATION _ $ UI X STATUTE EERH E.L. EACH ACCIDENT $ 1 OQOOO A AND EMPLOYERS' LIABILITY Y f N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) if yes, describe under DESCRIPTION OF OPERATIONS below N/A NIA 6S62UB9F36622115 12/01/2015 1.2/01/2016 E.LDISEASE - EA FLOYEE $ 100,000 E.L. DISEASE - ViDLICY LIMIT I $ 500,000 N/A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage -Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row AUTHORIZED REPRESENTATIVE C� Mansfield MA 02048 Daniel M. Cro ey, CPCU, Vice President — Residual Market — WCRIBMA TIA\I All ..{.4.. -4 lcJ lJifif-LU I4 /iI.VRU Ii VI[1'VrVi r rvr�. nu ynw ,cac, vcu. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD L U _ _ 0 0 u x-1 0 i i u 00 O a U - b M cV = o al rq w - It 1-4 U ®° 0 U C; Z ai c v +� LLa U v CL C f� -0 o 'v o Z 0 m uj LL. U. Ln 1.4v � V, u0 W u _ o s� i 70- L to o V) a Z a m u -u in o c 0 CL fl -7, a u N wu Ln mtn Lu O ul O Q� a Z O 171 i9 p N.� ti G �Y v � h C � � J O 4 l 1 �l W 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 pen -nit 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