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HomeMy WebLinkAboutMansfield Democratic Town Com. 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 DEMOCRATIC TOWN COMMITTEE - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: m Permit Expires: ,July 10, 2018 Food Fee: License Number: FFN-13 P14e11q=1Ir BOARD OF HEALTH Michae[MCCCean, Chairman Date Received FOR BOARD OF HEALTH USE ONLY Date Inspected Approved By I Permit # Issued Mansfield Family Fun Night Food Establishment Permit Application Jul St s att c, Establishment Name: r� /cans die /c✓ < Dtmr7 ` 4mr r'own 7C Establishment Address: Establishment Mailing Address (if different): Establishment Telephone No: (,. ®. j, rr C i� Cn� C r , V ,J Applicant Name & Title: ii �w G* 6' i l: GfNi 'vh 9' j -YiM Applicant Mailing Address: I '� �a b.F. Gn n ApplicantPhone Number: Applicant Email: rChL�\I r, J C 1 C-6ey, Establishment Owned By: An association Water Source: Town A corporation Sewage disposal: Town An individual A partnership Other legal entity Days and Hours of Operation: 4PM to Midnight Location: Street Fair Establishment Type Snack Food Operations: PHF- potentially hazardous food(time/temperature controls required) (check all that apply) 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) W9 'Distribution of Commercially Pre -Packaged candy or bottled drinks ❑ Preparation and distribution of popcorn, cotton candy, open hot and cold drinks. IY Distribution of foods that are cut up and served. wcAt9oed v i Y v Other (Describe): To be completed by the Board of Health otal 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 a plicable law. I have been instructed by the board of health on how to gbtain co[idi,litspof 105,G�II�jR 5,99.000,,andy)he ffideral 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. /) )A Signature of Individual or Corporate Name: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization N Address: J .� 9 ! 1 City/State/Zip: Phone tlbrc ' 16rr', Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I 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. $. ❑ 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 J� employees. [No workers' comp. insurance required]* 11. ❑ Health Care 4. [Z We area non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 121-1 Other *Any applicant that checks box # 1 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 81. 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 (shoving 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. too hereby certify, under the pains ap11 pettaNies of pefjury that the information provided above is true and correct. Phone # 5 o 0 r / /� 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person Phone www.ni ss.gov/dia Mansfield Board of Health Waiver 2018 for Food Permit Date `Put the name of your restaurant on first line then sign the form. We, 1 ! 4 an )dH j YM OLf2T1 C fDWn (wM r& request a waiver of the Food Service Permit Fee for the following reason: Thank you, Family Fun Night 2018 Signature � Fn /�%�hl✓I�St�t�y)an ee Chime Title 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. �—Oal " "4, P/ Signature of Individual or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatonj, 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.