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Home My WebLink AboutExcel Martial Arts 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:. JOHN E. HAGMAN Whose place of business is: EXCEL MARTIAL ARTS/LEARNING CEN. FOR MARTIAL ARTS, INC. - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: JOHN E. HAGMAN Permit Expires: July 10, 2018 Food Fee: License Number: FFN-5 IrJ/_11 VA ;I DI BOARD OF HEALTH NichaeCNcCCean, 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: 1 v., Establishment Address: .., ,''"'T Establishment Mailing Address (if different): e Establishment Telephone No:�" -�//.e' Applicant Name & Title: -. y- Applicant Mailing Address: 5? Applicant Phone Number: ✓', ' ;4 Applicant Email: 'f�ae=-'oJs;G;>s.,�" Establishment Owned By: Water Source: Town Fri association •g,�'7a 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 Ec 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): I, the undersigned, attest t the ccuiecy f the establishment operation w 11 co ply Wit /105 1 the board of health on how too tai I Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, 1 certify have filed all state tax returns and paid state Signature of Individual or Corporate ra be completed by the Board ofHealth tai Permit Fee: FEE WAIVED provided in this application and I affirm that the food and all other applicable law. I have been instructed by 1.000 and the federal Food Code. of perjtjry that I, to my best knowledge and belief, 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. Signature of Individual or Corporate Name talc *"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 subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Address: Are you n employer? Check the appropriate box: 1. m 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. ❑ We are a non-profit organization, staffed by volunteers, with no emalovees. No workers' coma. insurance rea.l Phone Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.[D`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. Iam an employer that isproviding workers' comp�ensa+tion insurancefor my employees. Below is thepolicy information. Insurance Company Name: 4 j y't 'l fi 2r ` Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # 0 (j C • �&V- p Qdt H` 7 - a2,Q 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 da pst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o the A\fo�insurance coviraee verification. I do hereby ce#ify, under the pai nd penalties ofperjury 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.mass.gov/dia Mansfield Board of Health Waiver for Food Permit 1-1;16V Date s "Put the name of your restaurant on first line then sign the form. We, Food Service Permit Fee for the following reason: Thank you, r :quest a waiver of the Family Fun Night 2047 -4-14 r Title WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 26158 POLICY NO. AW6-400-7018197-2018A PRIOR NO, AWC-400-7018197-2017A ITEM 1. The Insured: Learning Center Martial Arts Inc DBA: Mailing address: 8 Indian Ridge FEIN: '""2594 Bridgewater, MA 02324 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 02/15/2018 to 02/15/2019._.12:01 a.m. standard time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA S. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ _ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy Includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per $100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTEA 120628 INTER SEE CLASS CODE SCHEDU E Minimum Premium $207 Total Estimated Annual Premium $1,414 Go--VFG-0V-1 Deposit Premium $1,461 STATE CLASS MA 9063 State Assessments/Surcharges $1,035.00 X 4.5600% $47 This policy, Including all endorsements, is hereby countersigned by ��—'� `*1 03/29/2018 Authorized Signature Date Service Office: 54 Third Avenue Burlington MA 01803 WC 00 00 01 A (7-11) Includes copyrighted materiel of the Notional Council on Compensation Insurance, used with Its permission. C L Hollis Insurance Agncy Inc 1017 Turnpike St, Unit 2-2A Canton, MA 02021 A.I.M. Mutual Insurance Insured: 7018197 Producer: 01822-001-001 Learning Center Martial Arts Inc C L Hollis Insurance Agncy Inc 8 Indian Ridge 1017 Turnpike St, Unit 2-2A Bridgewater, MA 02324 Canton, MA 02021 Insured FEIN: "'2594 Issue Date: 03/2912018 Policy Number: AWC-400-7018197-2018A Endorsement Effective Date: 02/15/2018 Policy Period: 02/15/2018 - 02/15/2019 Endorsement Number: ENDORSEMENT SCHEDULE The forms listed below are included in this policy: Form No. Form Description Applicable States Policy Effective Date AIM-1 A Dividend Classification Endorsement 02/15/2018 WC 00 00 00 C Policy Conditions 02/15/2018 WC 00 04 04 Pending Rate Change End, MA 02115/2018 WC 00 04 14 Notification of Change in Ownership 02/15/2018 WC 00 04 22 B Terrorism Risk Endorsement 02/15/2018 WC 00 04 25 Experience Rating Modication Factor Revision 02/15/2018 WC 20 03 01 MA Limits of Liability Endorsement MA 02/15/2018 WC 20 03 02 A MA Assessment Charge MA 02/15/2018 WC 20 03 03 D MA Notice to Policy Holder Endorsement MA 02/15/2018 WC 20 03 06 B MA Limited Other States Insurance Endorsement MA 02115/2018 WC 20 03 07 MA Assigned Risk Pool Eligibility Endorsement MA 02/15/2018 WC 20 04 05 MA Premium Due Date Endorsement MA 02/15/2018 WC 20 04 01 MA Pending Premium Change Endorsement MA 02115/2018 WC 20 06 01 A MA Cancellation Endorsement MA 02/15/2018 WC 20 06 04 MA Policy Definition Endorsement MA 02/15/2018 Insured EndorsementSch (04111) A.I.M. Mutual Insurance Company Insured: 7018197 Producer: 01822-001-001 Learning Center Martial Arts Inc C L Hollis Insurance Agncy Inc 8 Indian Ridge 1017 Turnpike St, Unit 2-2A Bridgewater, MA 02324 Canton, MA 02021 Insured FEIN: "-"*2594 Issue Date: 03/29/2018 Policy Number: AWC-400-7018197-2018A Endorsement Effective Date: 02/15/2018 Policy Period: 02/15/2018 - 02/15/2019 Endorsement Number: LOCATION SCHEDULE Insured Unit: 001 Workplace: 001 Business Type: Corporation Learning Center Martial Arts Inc 8 Indian Ridge Bridgewater, MA 02324 TAX ID: 202072594 Insured Unit: 001 Workplace: 003 Business Type: Corporation Learning Center Martial Arts Inc 1044 Washington Street Norwood, MA 02062 TAX ID: 202072594 Business Type: Business Type: Business Type: Business Type: Insured Insured Unit: 001 Workplace: 002 Business Type: Corporation Learning Center Martial Arts Inc 397 Oakland Street Mansfield, MA 02048 TAX ID: 202072594 Business Type: Business Type: Business Type: Business Type: Business Type: (11/11) LocatlonSch A.I.M. Mutual Insurance Company Insured: 7018197 Producer: 01822-001-001 Learning Center Martial Arts Inc C L Hollis Insurance Agncy Inc 8 Indian Ridge 1017 Turnpike St, Unit 2-2A Bridgewater, MA 02324 Canton, MA 02021 Insured FEIN: "" *'"2594 Issue Date: 03/29/2018 Policy Number: AWC-400-7018197-2018A Endorsement Effective Date: 02/15/2018 Policy Period: 02/15/2018 - 02/15/2019 Endorsement Number: CLASSIFICATION CODE SCHEDULE Policy Unit: 001 Unit State Code: MA Policy Unit Name: Learning Center Martial Arts Inc Billing Plan: Annual Classification Class Payroll Rate Estimated Description Code No. Amount Per $100 Premium EXERCISE OR HEALTH INSTITUTE & 9063 137,890 0.79 1,089 Manual Premium 1,089 Merit Modifier 0.95 (54) Standard Premium 1,035 Expense Constant 338 Terrorism Act Surcharge 41 Total Estimated Premium 1,414 DIA ASSESSMENT 4.56% 47 Total Estimated Premium & Surcharge(s) 1,461 Insured ClassCodeSch (04/11) A.I.M. Mutual Insurance Company Insured: 7018197 Producer: 01822-001-001 Learning Center Martial Arts Inc C L Hollis Insurance Agncy Inc 8 Indian Ridge 1017 Turnpike St, Unit 2-2A Bridgewater, MA 02324 Canton, MA 02021 Insured FEW: 202072594 Policy Number: AWC-400-7018197-2018A Policy Period: 02/15/2018 - 02115/2019 Issue Date: 03/29/2018 Endorsement Effective Date: 02/15/2018 Endorsement Number: INSTALLMENT SCHEDULE Units Billed to this Unit:1 Policy Unit No: 001 Billing Plan: Annual Policy Unit Name: Learning Center Martial Arts Inc Installment/ DIA Total Amount Due Date Billed Endorsement No. Assessment Annual Payment $47 $1,461 04/18/2018 Billed Insured InstallmentSch (04/11) A.I.M. Mutual Insurance Company Insured: 7018197 Producer: 01822-001-001 Learning Center Martial Arts Inc C L Hollis Insurance Agncy Inc 8 Indian Ridge 1017 Turnpike St, Unit 2-2A Bridgewater, MA 02324 Canton, MA 02021 Insured FEIN: **-***2594 Issue Date: 03/29/2018 Policy Number: AWC-400-7018197-2018A Endorsement Effective Date: 02/15/2018 Policy Period: 02/15/2018.02/15/2019 Endorsement Number: POLICY RATING SUMMARY BY STATE Massachusetts Manual Premium 1,089 Merit Modifier 0.95 (54) Standard Premium 1,035 Expense Constant 338 Terrorism Act Surcharge 41 Total Estimated Premium 1,414 DIA ASSESSMENT 4.56% 47 Total Estimated Premium & Surcharge(s) 1,461 Total Estimated Premium & Surcharge(s) $1,461 Insured RatingSum (01/12)