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HomeMy WebLinkAboutH of Cakes/Get Well Shells 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: 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: H OF CAKES & GET WELL SHELLS - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: Permit Expires: July 10, 2018 Food Fee: License Number: FFN-7 WAIVED BOARD OF HEALTH MichaeCMcCCean, Chairman (" I Date Received FOR BOARD OF HEALTH USE ONLY Date Inspected Approved By `Y 2� Permit # Issued Mansfield Family Fun Night u Food Establishment Permit Application'; MAY 3 0 2P4a8 Establishment Name: r --- ,ap_u � Establishment Address: 1[] LcwWA, Establishment Mailing Address (if different): Establishment Telephone No: �;o 3' Applicant Name & Title: i� V�V aK Applicant Mailing Address: ab� Applicant Phone Number: Applicant Email: �\��,(', Cnlo,.gV�,er�.��Le knlwit.corvt Establishment Owned By: An association c ation An individua A pa ners ip Other legal enti Water Source: Town Sewage disposal: Town Days and Hours of Operation: 4PM to Midnight Location: Street Fair Establishment Type Snack Food Operations: (Check all 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 ign sandwiches, salads, muffins which need no further processin ❑ 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. Cu Ulf �5 � 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 cI ply with 10 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to t1lb ip cgpies Of V5 CMR 590.QQ0 *and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties ciperjury that I, to my best knowledge and belief, have filed all state tax returns and paid state to es require d unde aw. 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. MahalF �iY Si tore divi u " for orporate Name W4- U-1(65 **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. Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4. Q,'We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: C 11 Vt,S Address: 'A 4- Ln u,)"1 Al a `s� City/State/Zip: MtX�nl M k OZOISPhonc t 50M 6( -'65Zj Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (met. real estate, auto, etc.) 8. 2"Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I LE] Health Care 12.❑ 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 #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. # Expiration 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. I do hereby 1�rtify, unp' the pains and penalties ofpeljury that the information provided above is true and correct. Phone #: V :50S-&6a-0)� 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.mass.gov/dia Mansfield Board of Health Waiver 2018 for Food Permit Date J / a,-+/ 10 k *Put the name of your restaurant on first line then sign the form. We, request a waiver of the Food Service Permit Fee for the following reason: Thank you, Family Fun Night 2018 ©wAe-r 6 C-Af� vom �Nes Title