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HomeMy WebLinkAboutKona Ice 5/1/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. DAVE SOUZA Whose place of business is: KONA ICE CUMBERLAND R.I., INC. - FRESHMAN FUNDRAISER MANSFIELD HIGH SCHOOL - EAST STREET PERSON(S) IN CHARGE: DAVE SOUZA, VICE PRESIDENT Permit Expires: May 01, 2018 Food Fee: License Number: T-5 WAIVED BOARD OF HEALTH Michae[McCtean, Chairman Commonwealth 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:. DAVE SOUZA Whose place of business is: KONA ICE CUMBERLAND R.I., INC. - FRESHMAN FUNDRAISER MANSFIELD HIGH SCHOOL - EAST STREET PERSON(S) IN CHARGE: DAVE SOUZA, VICE PRESIDENT Permit Expires: May 08, 2018 Food Fee: License Number: T-5 LUTI-Al LIFA 41 BOARD OF HEALTH Michael wMcCCean, Chairman 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: AnoG' •m i " `—'km 1 [ l Date(s): G r t� r Event Name:• [, " . ,.--,,07..: i Y , / Event Location: J� C: , S "i , Event time: L, 1) Organization Name: 2" - 2) Organization Address: G L- ) i� <" 3) Organization Mailing Address (if different)` ��"1 - - 6 _Y _� VIC \ry L 4) Organization Telephone No: �.� C� _. (,{ (� r'> ,,., (- (- •'� 5) Applicant Name & Title: _ \ � ; ,1 11 7) Applicant Telephone No: "1' -. L.L A qd , 8) Applicant/Owner Email address: ' I c 9) Person Directly Responsible For Onsite Operations: C` , Name & Title: - ) Sri e, ; - Address: C1L.) X Telephone No: (`- Q,7, r Fax: Emergency Telephone No: G L1 (r' r"1 � _ 2) 7uu 10 ) Please give a brief description of the food and/or drinks to be served: _ aL 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 CUR 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 Meral Food Code. 11) Signature of Applicant: 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 lndividual or Corporate Name By: Corporate C Ccer (M ,ndaloni , if Applicable) LJ **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:\Users\sleltc\Desktop\Scott's Documents\Food Establishments-TempUAX CERTIFICATION FORM.doc ,ueparmrenr of inauscriat ficciaenis Office of lit vestigations 600 Washington Street Boston, MA 02111 Ulf Wlvw.ntass.gov1dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeibly Business/Organization Address: ql+" ) �AA- Le City/State/Zip Cttl I jj�--(i i Phone #: Are von an employer? Check the appropriate box: Business Type (required): 1. Ej" I am a employer with employees (fill and/ 5_ (Z, 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 (met. real estate, auto, etc.) employees working for me in any capacity. S. ❑ 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 1 ❑Health Care 4. El We are a non-profitnteers organization, staffed by volu, with no employees. iNo workers' comp. insurance req.] 12.❑ `Any applicant that checks box HI must also fit out the section below showing their workers' compensation policy information. m+if the corporate officers have exempted themselves, but the corporation has other employees, aworkers' compensation policy is rewired and such an organization should check box k I. I am an employer t/rat is providing }vrkers' conipensatiarr insrtrmrce fo-r�my employees. Below is the policy information. Insurance Company ^�Name: ``� ,--I(�L j 7 �`Sl�}j'kq _<.s�t�({ Insurer's Address: / City/State/Zip: Policy # or Self ins. Lie. # �'� �ft tf t7 l r�t? Expiration Date: 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 a 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. Ido hereby certify, under the pants and penalties of perjury that the information provider/ 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 are): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #c wwwa acs.gov/dia Mansfield Board of Health Waiver 2018 for Food Permit Date (i- -�(� `Put the name of your restaurant on first line then sign the form. We, µ4-�,w-_-Cyr Co 7mb�' od '�—L —roc, request a waiver of the Food Service Permit Fee for the following reason: Thank you, Signature Title Jane Doucette From: Amy Donovan -Palmer Sent: Thursday, April 26, 2018 7:49 AM To: Jane Doucette Subject: FW: Permits Attachments: Mansfield Waiver.pdf; Mansfield FoodEstPermit.pdf; MansfieldTaxtCertForm.pdf; Mansfield Worker'sComp.pdf Can you process this permit application? The frozen ice truck has been approved by the police. Thanks! Amy From: David Souza [maiIto: dsouza(d)kona-ice.com] Sent: Wednesday, April 25, 2018 7:39 PM To: Amy Donovan -Palmer Subject: Permits Hi Amy, I have attached the permit application. Please let me know if you need any more information. Thank you, Dave & Cheryl Souza Kona Ice Cumberland RI, Inc. 401-450-9483 Workersvumlierisation And Employers Liability Insnrance Policy Coverage Is Provided In: Liberty Ohio Security Insurance Company Mutual. INSURANCE NCCI Co. No. 19291 Workers Compensation and Employers Liability Insurance Policy Information Page WC 00 00 01 A Policy Number: (XWS (19) 5611 65 661 Prior Policy Number: �XWS (18) 5611 65 66 ITEM 1: The Insured & Mailing Address Agent Mailing Address & Phone No. KONA ICE CUMBERLAND RI (859) 356-3126 30 BROOKDALE ST NORTHERN KENTUCKY INSURANCE CUMBERLAND, RI 02864 AGENCY INC PO BOX 357 HEBRON, KY 41048-0357 _Individual _Partnership X Cornoration or Other workplaces not shown above: FEIN:455177834 NAICS.722320 ITEM 2 The policy period Is from 05/19/2018 to 05/19/2019 12:01 am StandardTimeat the insured'smailingaddress. ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: RI B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $1,000,000 each accident Bodily Injury by Disease $1,000,000 policy limit Bodily Injury by Disease $1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: See Extension of Information Page 0. This policy includes these endorsements and schedules: See Policy Forms and Endorsements Summary ITEM 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 Code Premium Basis - Total Bate per Estimated No. Estimated Annual $100 of Annual Remuneration Remuneration Premium See Extension of Information Page(s) Total Estimated Annual Premium $1, 024.00 Total Surcharges and Assessments $49.00 Minimum Premium $900.00 RI Total Estimated Cost $1, 073.00 If indicated below, interim adjustments of premiums shall be made. Deposit Premium $1, 073.00 Countersigned by: Issue Date To report a claim, call your Agent or 1-800-362-0000 WC000001 A(WC 3010E) © 1987 National Council on Compensation Insurance, Inc. 56116566 POLSVCS 550 AGENT COPY 006360 PAGE 7 OF 24