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Home My WebLink AboutMansfield Band Parents 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:. KELLEY GIAMBANCO Whose place of business is: MANSFIELD BAND PARENTS ASSOCIATION - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: KELLEY GIAMBANCO, SECRETARY Permit Expires: ,July 10, 2018 Food Fee: License Number: T-56 WAIVED BOARD OF HEALTH MichaeCwlcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received ' Date Inspected Approved By Permit # Issued Mansfield Family Fun Night Food Establishment Permit Application Establishment Name: Oct In� ' �et r ky) , (h �" Establishment Address: Establishment Mailing Address (if different): Establishment Telephone No: q Applicant Name & Title: Applicant Mailing Address: ApplicaTntt, Phone Number: QG • _�I Applicant Email: �r 1 tf• 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: 411M to Midnight Location: Street Fair Establishment Type Snack Food Operations PHF— potentially hazardous tood(tfine/tempereture controls requireqi (check all that apply) Definitions: Non-PHFs — non• potentially hazardous food (no fime/temperature controls required) RTE— ready -to -eat foods Ex. sandwiches salads, muffins which need no furtherprocessing) 41 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. El Other (Describe): W ` W )G/ wy pit v/l To be completed by the Board ofFlealtb Cr l ). b A n. and wa a0,, ., otal Permit Fee: FEE WAIVED I, the undersigned, attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will cq ply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how It tain copies of�1 5 CMR 90,000 and the federal Food Code. Signature of Applicant: 2� 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. a� �k Q1 A Signature f Ljidividual or Corporate Name t� 12 1 -`l (3 c� *"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 funiished 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 Form Revised 5-26-05