HomeMy WebLinkAboutOur Daily Bread 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:
OUR DAILY BREAD - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
Permit Expires: JUIY 10, 2018
Food Fee:
License Number: FFN-19
WAIVED
BOARD OF HEALTH
Michae(McCean, Chairman
FOR BOARD OF HEALTH USE ONLY tj t
Date Received Date Inspected Approved By Permit # Issued
Mansfield Family Fun Night
Food Establishment Permit Application
Establishment Name:
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Establishment Address:
Establishment Mailing Address (if different):
Establishment Telephone No: V _
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Applicant Name & Title:
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Applicant Mailing Address:
Applicant Phone Number: JU v.. ' of _Z/��
Applicant Email: e, 8 Lf�1
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Establishment Owned By:
An association
A corporation
An individual
A partnership d1417,4
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Water Source: Town
Sewage disposal: Town
Days and Hours of Operation: 4PM to Midnight
Location: Street Fair
Establishment Type f bo 'r\Z
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Food Operations:
(check all that apply)
PHF- potentially hazardous food(time/temperature controls requir d)
Definitions: Non-PHFs - non- potentially hazardous food (no time/temperature controls required)
RTE- ready -to -eat foods Ex. sandwiches salads, muffins which need no furtherprocessing)
❑ 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):
I, the undersigned, attest to the ccuracy of the inform
establishment operation Will co -ply it In 1 5 CMR 59(
the board of health on how to fain )piof X5 CM
Signature of Applicant:
To be compleled by the Board of Health
otal Permit Fee: FEE WAIVED
✓ided in this application and I affirm that the food
all other applicable law. I have been instructed by
and the federal Food Code.
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:
TAX CERTIFICATION FORM
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
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"Social Security No. (Voluntary) or Federal
Identification Number
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YflyCorporate Officer Mandato j, if Applicable)
*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.
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-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Pomi Revised 5-26-05
azx The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
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Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Lel>_ibly
Business/Organization Name:
Address: 16 n.
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Phone #: 5fD L, '33 q - 04
Are you an employer? Check the appropriate box:
Business Type (required):
L ❑
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.
CIA Non-profit
[No workers' comp. insurance required]
3. ❑
We are a corporation and its officers have exercised
9.'5 Entertainment
their right of exemption per c. 152, § 1(4), and we have
10.❑ Manufacturing
employees. [No workers' comp. insurance required]*
11.0 Health Care
4�no
We are a non-profit organization, staffed by volunteers,
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with no employees. [No workers' comp. insurance req.]
12•0Other p�t�;-7a y
*Any applicant that checks box # I 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 far my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. # 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 certifW undfr 1/ne paiys onliB'eitalties of perjury that the information provided above is true and correct.
Z 3 V AJ & ZU
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
Mansfield Board of Health
Waiver 2018 for Food Permit
Date Z Z- vn, G 2o I u
*Put the name of your restaurant on first line then sign the form.
We,
Food Service Permit Fee for the following reason:
Thank you,
Family Fun Night 2018
Title
a waiver of the