HomeMy WebLinkAboutMansfield Votes 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:
MANSFIELD VOTES TABLE - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
Permit Expires: ,July 10, 2018
Food Fee:
License Number: FFN-25
WAIVED
BOARD OF HEALTH
'A4ichaeC.�IcCCean, Chairman
0 d�
FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By Permit # Issued
Mansfield Family Fun Night
Food Establishment Permit Application
Establishment Name: M�tl'tySrrGlcj YJ1-�S L�,.
Establishment Address: S3�J /i/• MM}� S,r�T:
Ari' 1 p}'(r- OM lV✓ A-1'5(
Establishment Mailing Address (If different): //��
C 2. Pw 2x\1 e VV NY"S F 4 -LN
Establishment Telephone No:
Applicant Name & Title:
Applicant Mailing Address: S zU_ hU✓,� Applicant Phone Number: J O Z �; S, t c,
Applicant Email; f1 rvs H r� o n w.1 CJ a ur , �iLtiv
Establishment Owned By:
�An assoclaJigp�
Water Source: Town
tt\ co�po�ation
Sewage disposal: Town
An individual
A partnership
Other legal entii
Days and Hours of Operation: 4PM to Midnight
Location: Street Fair
Establishment Type Snack
Food Operations:
PHF- potentially hazardous tood(time/temperature controls required)
(che k all that apply)
Definitions: Non-PHFs- non- potentially hazardous food (no UnreRemperature controls required)
RTE- read •fo�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 out up and served.
Other (Describe):
To be completed by the Board of Heallh
obit Permit Fee: FEE WAIVED
I, 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 590.000 and all other applicable law. I have been Instructed by
the board of health on how t obtain c ie of 105 CMAR 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 1, 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
1 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.
Sibmar o Tndividual or Corporate Name
/6 ZrlLl/;ol
"Social Security No. (Vol untary) ar Federal
Identification Number
By: Corporate Officer (Mandnlonj, 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.
Vie Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
rviviv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name:
Address:
S35,vo�rrarr�
ore.�� /lt.ga.ar
S`I
f�urzn�
City/State/Zip:
✓yO�SciGzD
�(� _ Phone#: SE,
Z�S,9/ t Z
Are you an employer? Check the appropriate box;
Business Type (required):
1, ❑ I am a employer with employees (full and/
5. ❑ Retail
o• part -lime).*
6. ❑ Reslaurant/BariEating Establishment
2, ❑ I am a sole proprietor or partnership and have no
7. El Office and/orSales (incl• real estate, auto, etc.)
employees working for me in any capacity,
8•
tNo workers' comp. inset once required)
on -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
o employees. [No workers' comp. insurance required]*
I ❑ Health Car
4.e
0 We area non-profit organization, staffed by volunteers,
with no employees, [No workers' comp, insurance req.]
12.0 Other
"Any upplonnt that checks box N I must also all our the sect Ion below showing (heir workers' compensation policy information.
•"If the corporate officers have exempted lhemselves, but The corporation has other employees, a workers' componsation policy is required and such ion
organization should check box N I.
I am rat employer that 1s providing rporkerv' compensation Insurance for my employees. nelmv is the policy information,
insuronce Company Name:
Insurer's
City/State/Gip:
Policy k or Self -ins. Lic.
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 MOL 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 for warded to (he Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certify, under tl oins and pentrnies of pelfury that the information provider/ above Is true and correct.
Signature:lii_ Date: 7/ `i//is
Official ase only. Do not write in thls area, to be completed by city, or town official.
City or Town:
Permit/License
Issuing Authority (circle one);
L Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office
6. Other
Contact
www,mass.gov/din
Phone
Mansfield Board of Health
Waiver 2018 for Food Permit
Date 7'1' %u
"Put the name of your restaurant on first line then sign the form.
We, 114NSFir;t'n t/ OI i�rS request a waiver of the
Food Service Permit Fee for the following reason;
Thank you,
Family Fun Night 2018
Signaturgl
Title