HomeMy WebLinkAboutKeep Mansfield Beautiful 7/10/2018r f'J - 10
FOR BOARD OF HEALTH USE ONLY
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:
Applicant Name & Title: J�W „ /
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Applicant Mailing Address: Applicant Phone Number: Z6ct '
Applicant Email:
Establishment Owned By:
Water Source: Town
An association
• 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)
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):
To be completed by the Board of Health
Total 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 to obtain copies of 105 CMR 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 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.
n
Signature of InJividual or Corporate Name By: Corporate Officer (Mandatony, if Applicable)
"*Social Security No. (Voluntary) or Federal
Identification Number
*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 subj ect to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
The Commonwealth of Massach usetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
U1V
Boston, MA 02111
tvivrv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information q Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip:
Phone
Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ 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.
[No workers' comp. insurance required] B. ❑ Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
then right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing
4. NWemployees. [No workers' comp, insurance required]*
e are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 121-1 Other
*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 #l.
l am an employer that is providing workers' compensation insurance far my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
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.
l do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
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.mms.gov/dia
Mansfield Board of Health
Waiver 2018 for Food Permit
Date alcr (C7 LLI
*Put the name of your restaurant on first line then sign the form.
We, lrpe LP'C/l 1,10ooc,4-/I(Cl request a waiver of the
Food Service Permit Fee for the following reason:
Thank you,
Family Fun Night 2018
Signature
Title