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Home My WebLink AboutPalagis Ice Cream 8/15/2018Commonwealth 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 FOOD PERMIT 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:. ALEX ARTEAGA Whose place of business is: PALAGIS ICE CREAM - SUMMER CONCERT SOUTH COMMON - SIX PARK ROW PERSON(S) IN CHARGE: ALEX ARTEAGA. OWNER Permit Expires: August 15, 2018 Food Fee: $25.00 License Number: T-50 BOARD OF HEALTH Michael McCCean, Chairman AUb E to £. iryi i FOR Date Received Permit Fee Approved By Permit # Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: i 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 0/ 5) Applicant/Owner Name & Title: 6) Applicant/Owner Address: J /-/,_dL k C /0A�-X 7) Applicant/Owner Telephone No: C 8) ApplicantlOwner Email address: / ��Q A� C O/y 9) Person Directly Responsible For Onsite Operations: Name & Title: i Address: Telephone No: !'� 3 , /� Fax: Emergency Telephone No: 10) Event Attending Date(s): AUG W -- Event Name: S" t/ /LI44,e C Event Location:% Event time: 11) Check one 'w' Food Truck �r C CA R,A ❑ Caterer 7 Other: 12) Solid waste disposal plan: 13) Water Source: 14) Sewage disposal plan: 15 ) Please give a brief description of the food to be served: /d G'ed l CC C Gtr v IM 16 ) Food will be prepared: Onsite for immediate consumption F, Onsite and held at proper holl cold holding temperatures ❑ Offsite and held at proper hot/ cold holding temperatures Ll Offsite, cooled and n reheated l-oon site i I Other: & 0 1 P/ `—� t� /�� 6 a p " 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: n �y Food Safety Manager: Allergen Awareness: 16) 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: 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 obtaj9 pppies of 105 CMR 590.0 and 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 taxesrequired under law. 20) Social Security Number or Federal ID: I d S 6/)Z) c d /1 21) Signature of Individual or Corporate Name: /),, •'r 2 /y.0 Y*:!!• 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. "Z �' /V ) 6/" � _2lpc Signature of Individual or Corporate Name By: Corpora Officer (Mandator, if Applicable) fi ( 6' 6)d tP// "*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. C:\Usem\s161e\Desklop\Sco1Vs Documems\Food Eslahlishmenls-Temp\TAX CERTIFICATION FORM.doe The Coinntdnivealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street y' Boston, MA 02111 wwtvanass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: ,) T �2 ,47z &9 mil% Address: 5- 5 %tj/� G 0,41 S rA-.-d City/State/zip: -J T_ , Phone #: VaZ % VA jr-d / Td Are you an employer? Check the Tpropriate box: Business Type (required): r 1, r� I am a employer with �,6 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no T ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] $• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 1 L❑ Health Care with no employees. [No workers' camp. insurance req.] 12.0 Other *Any applicant that checks box 1!I must also f II out the section below shoving their workers' compensation policy in rormalion. **If [he corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box 01. I am nn employer that is providing workers' compensation insurance for ray employees. Below is file policy information, Insurance Company Name: 7!z =0- �� c D Al /Z �e4%nz /l4l/J 414,1 /I/Ce C'd. insurer's Address: L dA ,iY � i i ( A n T F n encu > City/State/Zip: W /-//K (ti,C2®y , Vim, - // il' lj 6 Policy # or Self -ins. Lie. H_ Expiration I Attach a copy of the workers' compensation policy declaration page (showing the policy 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 tip 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, t`Iuler the pains anti penalties of perjury that the information provided above is tare and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License ¢4r- Issuing Authority (circle one): I. 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 acon Insurance Co. Policy Information Page 1 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 tire PO Box 1146 Pawtucket, RI 02862-1146 (401) 722-6010 00065 30325 T.•o..cnnH..., T.a... nc /99 NM 0 Policy Number Endorsement Effective Date Endorsement Expiration Date Account Number 0000065312 04/11/2018 04/11/2019 20497400 2 Policy Period 3 From I To Endorsement 04 11 2018 1 04/11/2019 1 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 wok in Rhode Island. The limits of our liability 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. Endorsements & Schedules: Endorsement Endorsement Endorsement Endorsement BE_00_00_01- WC and BE_00_00_01A - BE_00_00 06 - Officers and BE_00 00_40 - OFAC Trade Employers Liability Policy Cancellation Endorsement Other Exclusion Sanctions Notice and Endorsement Endorsement This is not an Invoice Insured The Beacon Mutual Insurance Company One Beacon Centre, Warwick, RI 02886-1378 1 beaconmutual.com BE_00_00_14 V9 Underwriting: 401.825.2667 1 Toll Ree: 1.888.886.4450 Page 1 of 3 MK \ § / � §} }X.2- \ \ \\ % / j Cl) \\ MK \ § I .� M-ans \\\\\ \\\{\ \ ƒ \( � ] j \ � % \ E&a6 a \ ��\ . , /