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Home My WebLink AboutMansfield High 5K Race 6/10/2018Commonwealth 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: 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:. DEREK ELLIS Whose place of business is: MANSFIELD HIGH SCHOOL BOOSTER 5K ROAD RACE 250 EAST STREET PERSON(S) IN CHARGE: DEREK ELLIS Permit Expires: ,June 10, 2018 Food Fee: License Number: T-7 ►1 . y BOARD OF HEALTH JIichaeCMcCCean, Chairman FOR BOARD OF HEALTH USF. ONLY Date Received Permit Fee Approved By Permit # Issued Community Event Food Establishment Permit, Application (Application must be submitted at least 7 business days before the event date) This application should only be used by organizations that are not food establishments but plan to distribute non -potentially hazardous food or drinks at a local community event. Community Event: Date(s): ko 11 ram\ Event Name: f S - � �Qy� up Event Location: m k'k\ ge�011 Event time: 1) Organization Name: 0A A SL�00\ 2) Organization Address: 3) Organization Mailing Address (if different): 4) Organization Telephone No: 5-016- �� t 5) Applicant Name & Title: be (_ 7) Applicant Telephone No: aOti3 _t 0) ApplicantlOwner Email address: D� k G (& E , S ch 9) Person Directly Responsible For Onslte Operations: Name & Title: Dem\L GAIN Address: St> leyam\ Ct 630`l Telephone No: SO —a05;' --t$ Fax: Emergency Telephone No: 30c6 _ $ 10 ) Please give a brief description of the food and/or drinks to b served: we w� AbP secv��c� 100MC uoN oTa hv"-p— chon.►}--i't bc.'t\or Ao'dLes sht3e\c r 9o�rac0.4 e , ve, 03 c Ft\o��. 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 obtain copies of 105 CMR 590,000 and the federal Food Code. 11) Signature of Applicant: "'WIFICATION FORM 1 certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes requir.. under law. Signature of Individual or Corporate Name By: Corpora!rWficer (Mandatory, rfApphc*e) 23 -T—any - Gab "Social Security No. (Voluntary) or Federal Ident�cation 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:1UstaWcitcW aktop&ott's Dwoentsfood Establishments- TempkTAX CERTIFICATION FORM.doc 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: TP')(_ Address:'aSb ek,-_xs+- `>j- t (t\Rt\7��<\� PrA (3c1q% City/State/Zip;01`\V?��tS, thq nay' Phone #:5b%-ao%-Z8 Are you an employer? Check the appropriate box: Business Type (required): I. ❑ 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 ?, ❑ Office and/or Sales (met. real estate, auto, etc.) employees working for me in any capacity, g 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]* 11.❑ Health Care 4. [� We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] 12.0 Other *Any applicant that checks box #1 must also itII 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 #l. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name:GR ,\1 Noc(c n 0 Insurer's Address: iui� h �w�,t�j Or City/State/Zip: 70_\l)(% Q fw� Policy # or Self -ins. Lic. # (yA(V P 00Cl3 JhSo Expiration Date:_ I C-N 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 e. 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 $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. nn,u^ Signature: 1� � Date: SI [ (t ce SQ3 av% Z VI Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1, Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6, Other Contact Person: Phone Mansfield Board of Health Date 5-1 ))l$ Food Service Permit Fee for the following reason Thank you, 2 Signature Title request a waiver of the �iiP`.: I'Ir�lll Jane Doucette From: Amy Donovan -Palmer Sent: Thursday, May 03, 2018 8:40 AM To: Jane Doucette Subject: FW: Scan May 2, 2018 at 1.50 PM Attachments: Scan May 2, 2018 at 1.50 PM.pdf From: Ellis, Derek [mailto:derek.ellisCalmansfieldschools.comJ Sent: Thursday, May 03, 2018 8:35 AM To: Amy Donovan -Palmer Subject: Fwd: Scan May 2, 2018 at 1.50 PM Amy Here is our application for the Booster 5k Road Race. Let me know if I need anything else. Thanks Derek Ellis ---------- Forwarded message ---------- From: Derek Ellis <derekellisgicloud.com> Date: Wed, May 2, 2018 at 2:08 PM Subject: Scan May 2, 2018 at 1.50 PM To: Derek Ellis <derek.ellisC(�mansfieldschools.com> Created with Scanner Pro Sent from my iPhone Derek Ellis This is a staff email account managed by Mansfield Public Schools. This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the sender. All students, regardless of race, color, sex, religion, national origin, limited English proficiency, sexual orientation, gender identity, disability, or housing status, have equal access to all programs including athletics and other extracurricular activities.