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Home My WebLink AboutMansfield Elks 12/31/2018Commonwealth 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: FOOD SERVICE 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, 2018 Food Fee: License Number: FS-46 BOARD OF HEALTH Michae(McCCean, Chairman WAIVED Milk & Cream V Commonwealth of Massachusetts Town of Mansfield 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 Town of Mansfield 6 Park Row Mansfield, MA 02048 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-46 Board of Health MichaeCMcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred E FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-46 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening 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.: (617) 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 CAI An Association or partner. A Corporation Name Title Address ❑ An Individual I A Partnership 7 Other legal Entity_ - _ -_—_- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (MARK WALSH, SECRETARY Address: 140 NORTH MAIN STREET, MANSFIELD, MA 02048 Telephone No: I(508) 261-9595 24 Hour Emergency No: (817) 839.0564 FAX: E mail: IELKS2633@COMCAST.NET Alt E-Mail: i 13) District Or Regional Supervisor (if applicable) - Name & Title: Address: I -- - - Telephone No FAX: E-mail: 24 Hour Emergency No: 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: MARK WALSH If more than 3 individuals are certified, complete list is on file. Required as of 101112001 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: Moblie End Date: Moblie Comments: 21) Length of Permit: n Annual -..] Seasonal Seasonal Dates Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type LI Retail ( Sq. Ft) [] Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $25.00 Se Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Ei Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑ Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time4emperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) I Sale of Commercially Pre -Packaged Non-PHFs I_ I Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs F] 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 Preparation of PHFs For Hot And Cold Holding For Single Meal Service to be Prepared by Consumer Customer Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Ll 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 contact alternative, time as a public health ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Oriqin Offers RTE PHF in Bulk Quantitie- - Catered Events or Institutional Food Service L.I Retail Sale of Salvage, Out -Of -Date _ _ or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ❑r' 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 1fj5yCJv1g590.000 and the federal Food Code. 24) Signature of Applicant: /� L L- /! 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 December 31st 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 IDISS NUMBER: 04-2751171 FEE: $10.00 PERMIT NUMBER: FS-46 SIGNATURE: /I/) - DATE: IJl q61 % TAX CERTIFTCATIQN FORM I certify under the penalties of pe{jury that I, to my best knowledge and belief, have filed all State Tax Returns and paid all State Taxes required under law. /�lAa3F1�� ti1�S 263, /VVK WRLIP SFtAF2(X ��//l Signature of Individual or Corporate Name ]By- Corporate Officer (Mandatory, IF Applicable) Oq- Z?'S` / 17 Social Security Number (Voluntary) or Federal Identification Number** This license will not be issued uriless this 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 fling or taxi payment obligations. Licensees who fail to correct their non -firing or delinquency will be subject to license suspension or ievOcation. This request is made utidetthe authority of Massachusetts General Law Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Aecidents 1 Congress Street, smile 100 Boston, MA 02114-2017 wwnsmassgov/dio Workers' CompensaiionJmorance Artfidagft: General Businesses, TO BE.P[LED 4VI CBITIIE PERMITTING AU7lIORIT\. Aaplieant Information Please Priot Lealbly, Btisiness/Qrganization Name: IM d-.5 i r: u7 E LkS o 2 633 Address: I qQ N. IMAI/ 1 ' s-r' Are you an employer? Cheek the appropriate box, 1,9 l am a employerwith Z employees (full and/ or part-time),* 2. ❑ 1 am a sole proprietor or partnership and have no employees working forme in any rapacity. No workeW comp, insurance required] 0 We are a corporation and its officers have exercised their right of exemption per c.152, §1(4),,snd we have no employees. [No workors' comp: insurance required 4. ❑ We art a non-profit organization, staffed by volunte6n with no eravloyees, (No workers' camp. insurance req Business Type (required): 5. ❑ Retail 6. RostaurantlBar/Eating Establishment 7, ❑ Office and/or Sales (Incl. real estate, auto,'etc.) 8. SNon-profit 4. ❑ Entertainment 10.0 Manufacturing I I.0 Health Care { am an employer tlrpl is propiding workers' compensation insurance, jbrmy employee;. Below is the po7tcy injormatZon. InsutanceCompany Name lMU(LEI(S ZwD(//N ry CO2PBNy Insurer's Address: R) Roy` City(Statelzip: O X M -)D 0 / rL ? Z 90 2— �S S Poli,y W or Self -ins: Lid. Attach a: copy of the wr Pailureto secure Coyerai fine up to $1,500.00 and required under Scction 25A ofMOL c. 152 can lead to the imposition of criminal penalties of a to -year imprisonment, as well as civilpenalties: in the form ofaSTOP WQRIf 09PER end.a flne: t'the violator. Be advised hat a copy.of this statement may be -forwarded to the OlUce of Signature; Date O#Iclai use only. Do got write In this area, to be completed by city or town oriciat City or Town: Permit/License Issuing Authority (cirele one): 1. Boar'd of Health 2. Building Department 3, City/Town Clerk 4. Licensing Board 5. Selectmen's Office & Other Contact Person: Phone'#t TRAVELERS J� WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (CHUB-1K05813-.1-17) NEW-17 INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA 1 NCCI CO CODE: 13439 INSURED: PRODUCER: MANSFIELD LODGE OF ELKS 2633 ROBERT W EAMES INS 140 NORTH MAIN STREET 126 NORTH MAIN ST MANSFIELD MA 02048 P 0 BOX 289 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 11-22-17 to :11-22-18 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 S. 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: $. 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, If any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GB D. This policy Includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information Is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 12-08-17 GS ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: ROBERT W EAMES INS 73M96 000016 H �I J v ry 5� I m N N 0 0 0 h N m c 0 E o NF N i 12 B� N�cON O O Ul � U OLn N Z V 00 f? w O W V z H7� z J W z W P4 z W w S >J N > N N O N O N n Q p N N � o w 0 0 o q c�¢ N 06 QUJU3 zcg�¢ m 3 7 0 O� �• _ ug 0 M. �o y ,111101 o .N. ge „F o 0 .'•,� t7 bo e i O V ya !C l O V Mansfield Board of Health Date / ILo Ll `7 We, # 2 (23 request a waiver of the Food Service Permit Fee for the following reason OF �1$b A No'J� P2�CI7- �"R�TC-RNftt c7/�G/-�ni )ZAY]��; Thank you, Signature Sr`n ern ��l Title