HomeMy WebLinkAboutMansfield Police Assoc. 7/10/2018FOR BOARD OF HEALTH USE ONLY
Date Received Date Inspected Approved By
Mansfield Family Fun Night
Food Establishment Permit Application
Permit# Issued
Establishment Name: cM
l,l
Establishment Address: �u
Establishment Mailing Address (if different):
Establishment Telephone No: _ �� D
Applicant Name & Title:/- , vti why'r'— "7� �,�-. �. ✓''Z
Applicant Mailing Address: C-. Applicant Phone Number:
Applicant Email: �.'� yL �Er�y.(j, i {.l !!�%} - C`b r"1
Establishment Owned By:
•An association
• A corporation
• An individual
• A partnership
Other legal entity
Water Source: Town
Sewage disposal: Town
Days and Hours of Operation: 4PM to Midnight
Location: Street Fair
Establishment Type Snack
Food Operations:
(Check al/ that apply)
PHF- potentially hazardous food(time/temperature controls required)
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 accuracy
establishment operation will comply with
the board of health on hoyOJb obtain cppi
Signature of
To be completed by the Board of Health
otal Permit Fee: FEE WAIVED
xmation provided in this application and I affirm that the food
5-M000 and all other applicable law. I have been instructed by
CMR 590.000 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.
vns
Signature of Individual or Corporate Name
**Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
u,p
600 Washington Street
Boston, MA 02111
wrvw.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information ++� Please Print Legibly
Business/Organization Name: b np JJO-cc,
Address:
City/State/Zip: Phone #:
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. ❑ RestaurantBar/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• ❑Non-profit
[No workers' comp, insurance required]
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,
12.0 Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box 91 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 41.
l 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, 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 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.
l do hereblirtify, a i er the fins atl4enattles of perjury that the information provided above/isltrue and correct.
--)1(�I/L3
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.masxgovldia
Mansfield Board of Health
Waiver 2018 for Food Permit
Date /�-a
"Put the name of your restaurant on first line then sign the form.
We �/JJ 4�t �d pol r' :-e' Ar5 a' request a waiver of the
Food Service Permit Fee for the following reason:
Family Fun Night 2018
Thank you,
Sidnature
Title