HomeMy WebLinkAboutField of Honor 7/10/2018FOR BOARD OF HEALTH USE ONLY rr,N 2.
Date Received Date Inspected Approved By Permit # Issued
Mansfield Family Fun Night
Food Establishment Permit Application
Establishment Name: VL 11
Establishment Address:-�:.,t^%�r�
Establishment Mailing Address (if different):
Establishment Telephone No: 3 3
Applicant Name & Title:
Applicant Mailing Address:'10
(v
`ter
p I ant Phone Number:
Applicant Email: CL."ri(
t J� P-",
Establishment Owned By:
An association
�
Water Source: Town 1 i^ \ `4q5
• A corporation
Sewage disposal: Town
• An individual
• A partnership
Other legal entity
Days and Hours of Operation: 4PM to Midnight
Location: Street Fair -
n
Establishment Type >" V
Snack f U (.�Z '
Food Operations:
IPHF- ptitentially hazardous food(time/temperatu a con equired)
(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
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 comp)"ikh 105 CM 590.000 and all other applicable law. I have been instructed by
the board of health on how to obtain copies of 10 CMR 590."00 and the.[,;deral 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.
i
Signature of Individual or Corporate Name: Q�"-\, IS
t�
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.
:e Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Ident Ration 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 subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
IZX The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insulrance 4ffidavit: Gent
Business/Organization
Address
City/State/Zip:
�� L
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. ❑ 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.
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
employees. [No workers' comp. insurance required]*
11.0 Health Care
We are a non-profit organization, staffed by volunteers,
4.�o
12.❑ Other
with no employees. [No workers' comp. insurance req.]
*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 # I.
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. Lic. #
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 certify der the pains and
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
Phone
www.mms.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.
� i -7e '
We, '�-� -`7 / �/ lc) W dA� request a waiver of the
Food Service Permit Fee for the following reason:
Family Fun Night 2018
Thank you, &I /'
Signature
Title