HomeMy WebLinkAboutVFW Post 3264 7/10/2018Commonwealth 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: STREET FAIR -FAMILY FUN NIGHT
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:.
Whose place of business is:
PHILLIPS - WELCH VFW POST 3264 - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
Permit Expires: ,July 10, 2018
Food Fee:
License Number: FFN-20
BOARD OF HEALTH
NichaeC cCCean, Chairman
_--� 5
FOR BOARD OF HEALTH USE ONLf
Date Received Date Inspected Approved By , ,*__ __ Permit#
Mansfield Family Fun Night
Food Establishment Permit Application
Establishment Name:
1ti
i s. J - t V7-
Establishment Address: ear
Establishment Mailing Address (if different):
Establishment Telephone No:
Applicant Name & Title:
Applicant Mailing Address:,h/3 — Applicant Phone Number:
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Email:
Applicant
4�G
If
Establishment Owned By:
Water Source: Town
• An association
• A corporation
Sewage disposal: Town
• An individual
• A partnership
Other le al entit
Days and Hours of Operation: 4PM to Midnight
Location: Street Fair
Establishment Type Snack
Food Operations:
PHF- potentially hazardous food(lime/temperature controls required)
that apply)
Definitions: Non-PHFs - non -potentially hazardous food (no Hme/temperature controls required)
(check all
RTE- read -to-eat foods Ex. sandwiches salads muffins which need no further processin
Distribution of Commercially Pre -Packaged candy or bottled drinks
Preparation and distribution of popcorn, cotton candy, open hot and cold drinks.
❑ Distribution of foods that are cut up and served.
Other (Describe):
To be compleled by the Board of Health
otnl Permit Fee: FEE WAIVED
1, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food
establishment operation will comply with 105 CMR 5 0.000 and all other applicable law. I have been instructed by
the board of health on how to obtain copies of R 590.000 and the federal Food Code.
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.
Signature of Individual or Corporate Name:
CN The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
low www.muss.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
City/State/Zip:
r
hone #:
Are you an employer? Check the appropriate box:
Business Type (required): '
1, ❑
I am a employer with employees (full and/
5. ❑ Retail
or part-time).*
6. ❑ Restaurant/Bar//Eating Establishment
2. ❑
1 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.
8• ;q Non-profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its gfficers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have
10.0 Manufacturing
4.
no employees. [No workers' comp. insurance required]**
We are a non-profit organization, staffed by volunteers,
1 1 ❑Health Care
with no employees. No workers' comp. insurance reg.j
12.0 Other
*Any applicant that checks box NI must also fill out the section below showing their workers' compensation policy information.
**I f 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 N I.
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, Lie.
Expiration
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 tip 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 ce�rtijy/under the pain g a d penalties of perjury that the information provided above is true and correct.
Signature: <2/ Date:01��
SL
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1, Board of Health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Phone
www.mass.gov/dia
TAX CERTIFICATION FORM
I certify under the penalties of perjury that I, to my best knowledge and
belief, hove filed all state tax returns and paid all state taxes required
under law.
S' nature of individ I or o orate Name By: Corporate Officer (Mandator , i%Applicable)
0y-6L5V7,e!T:
"Social Security No. (Voluntary) or Federal
Identification Number
*This license will not be issued unless 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 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 Massachusetts General Law
Chapter 62C, section 49A.
Mansfield Board of Health
Waiver 2018 for Food Permit
Date
*Put the name of your restaurant on first line then sign the form.
We, i-'111- L.i /%� V,Ckd /�s o ti request a waiver of the
Food Service Permit Fee for the following reason:
Thank you,
Family Fun Night 2018
Si nature �—
Title