HomeMy WebLinkAboutPalagis Ice Cream 6/28/2018Commonwealth 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: TEMPORARY MOBILE FOOD
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:.
ALEJANDRO ARTEAGA, PRESIDENT
Whose place of business is:
PALAGIS ICE CREAM CO. @ MEMORIAL PARK
100 HOPE STREET
PERSON(S) IN CHARGE:
ALEJANDRO (ALEX) ARTEAGA
Permit Expires: June 28, 2018
Food Fee: $25.00
License Number: T-27
BOARD OF HEALTH
Michae[McCCean, Chairman
FOR BOARD OF HEALTH USE ONLY `" d
Date Received Permit Fee Approved By Permit # Issued
I
Temporary Food Establishment Permit Application
(Application must be submitted at least 7 business days before the planned opening date)
1) Establishment Name: ` C
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2) Establishment Address:
3) Establishment Mailing Address (if different):
4) Establishment Telephone No:
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5) Applicant/Owner Name &Title:
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6) Applicant/Owner Address:
7) Applicant/Owner Telephone No:
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8) Applicant/Owner Email address:
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9) Person Directly Responsible For Onsite Operations: Lam. • 2 A' e
Name & Title:
Address:
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Telephone No:
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Emergency Telephone No:
10) Event Attending
Date(s):
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Event Name:
Event Location:
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Event time:
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11) Check one
'L,/ Food Truck
❑ Caterer
7 Other: Z Ce l /-CIA-*
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12) Solid waste disposal plan:
13) Water Source:
14) Sewage disposal plan:
15 ) Please give a brief description of the food to be served: ` 1,24 c 2-
�C'tA/dG2L�°P%
16 ) Food will be prepared:
Onsite for immediate consumption
I Onsite and held at proper hot/ cold holding temperatures
Offsite and held at proper hot/ cold holding temperatures
J Offsite, cooled and reheated on site
17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate
certificates:
!ice Food Safety Manager:
Allergen Awareness 4� �j-T—oa !fin y ,�✓�. �%r �„
18) For caterers: City/Town where food establishment permit is held. Please attach a copy of the caterer's permit:
For food trucks, please list additional communities where a food permit is held and attach copies of the permits:
1, 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_CM&590;900and the federal Food Code.
19) 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.
20) Social Security Number or Federal ID:
21) 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.
Signature of Individual or Corporate Name By: Cor rate Officer (Mandatory, i/Applifable)
D 5- 0 5-d d �'//
"*Social Security No. (Voluntary) or Federal
Ideuti fcatio uunller-
*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.
C:\Usen\slcile\Desklop\Scolrs Domimems\Food Esiublishmcnfs-Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
s` Boston, MA 02111
tvivw.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: ,4 f ,/,/ 6;1 i 2 0 6A
Address: 5_5 _ 13,4ifaH ,f . /.
City/State/Zip: &z.,, /v e: �i, �—i Phone #:
Are you you an employer? Check the appropriate box:
Business Type (required):
1. E 1 am a employer with j employees (full and/
5. [Retail
or part-time).*
6. ❑ Restaurant/Bar/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,
$• ❑ 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
no employees. [No workers' comp, insurance required]*
l 1.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.]
12.❑ Other
*Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information.
**Ir 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.
I aot an employer that is providing /ivorlters' corrtpeetsatioa instn•attee for my employees. Below is the policy infortnatioa.
Insurance Company Name: afe%l C 0,,v 4 4 6 ZZ4 //I/ Y y Mlel C-,, r t7 1
Insurer's Address: Q/ (Z- 6ey/y C env
City/State/Zip:
F16;
,
Policy # or Self -ins. Lic. # 0 tf 0 � 0 C S `fi /2 Expiration Date: Z/R // —%
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, raider the pains and penalties ofpetyury that the information provided above is true and correct.
e
Official use only. Do not write is this area, to be completed by city or town official
City or Town:
Permit/License
�sM
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
www.mass.gov/dia
Phone
Teacon
Policy Information Page
ii
Account Holder: Palagis 2000 Inc Agent Name:
Address: Palagi's Ice Cream Agent Address:
55 Bacon Street
Pawtucket, RI 02860-4537
Phone:
Agent Number:
NCCI Carrier Code:
Named Insured: Palagis 2000 Inc Dec Type: Amended Group Affiliation:
Endorsement Reason
Endorsed to Audit Figures
Date: June 22, 2018
Policy Number: 0000065312
Chatterton Insurance Inc
PO Box 1146
Pawtucket, RI 02862-1146
(401) 722-6010
00065
30325
Policy Number
Endorsement Effective
•naaanuaaau Mate:
Endot cement Expiration Date
VO 4L 4ultf
$560,000
Date
BODILY INJURY BY DISEASE
Account Number
0000065312
04/11/2018
04Z11/2019
20497400
2
Policy Period
3
From To
04/11/2018 04/11/2019 12.01 a m standard time at address of named insured
A. Workers' Compensation Insurance: Part one applies to the Workers' Compensation law of Rhode Island.
B. Employers' Liability Insurance: Part two applies to work in Rhode Island. The limits of our liability are:
BODILY INJURY BYACCIDENT
$100,000
EACH ACCIDENT
BODILY INJURY BY DISEASE
$560,000
POLICY LIMIT
BODILY INJURY BY DISEASE
$100,000
EACH EMPLOYEE
C. Endorsements & Schedules:
Endorsement
Endorsement
Endorsement
Endorsement
BE00 00 01- WC and
BE 00_00_01A -
BE_00_00 06 - Officers and
BE_0000 40 - OFAC Trade
Employers Liability Policy
Cancellation Endorsement
Other Exclusion
Sanctions Notice and
Endorsement
Endorsement
This is not an invoice
The Beacon Mutual Insurance Company Insured
One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com
Underwriting: 401.825.2667 1 Toll Free: 1.888.886.4450
BE_00 00 14 V9
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