HomeMy WebLinkAboutGarden Club of Mansfield 5/19/2018Commonwealth 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:
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:.
GARDEN CLUB OF MANSFIELD
Whose place of business is:
GARDEN CLUB OF MANSFIELD - PLANT SALE
TOWN HALL PARKING LOT
PERSON(S) IN CHARGE:
KIM SESTAK & NANCY OLSON
Permit Expires: May 19, 2018
Food Fee:
License Number: T-8
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BOARD OF HEALTH
Michae[JAkCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date Received Permit Fee Approved By Pegrit # 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):
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Event Name:
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Event Location:
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Event time:
1) Organization Name: ;, / �
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2) Organization AddreS�r�i ('`�(`' d � � � l� i. i�, l�'�%
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3) Organization Mailing Address (if different):
4) Organization Telephone No: - -_
5) Applicant Name & Title: o
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7) Applicant Telephone No:
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8) ApplicantlOwner Email address: l
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9) Person Directly Responsible For Onsite Operations:
Name & Title:
Address
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Telephone No:
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Fax: Aj /7
Emergency Telephone No:
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10 ) Please give a brief description of the food and/or drinks to be served:
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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:
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: Corporate Officer (MandaOry, if Applicable)
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**Social Security No. (Voluntan/) 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\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department oflndusirialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organizzatio))� (ln Name: ( r`
Address: r 0 lf
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City/State/Zip:
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Are you an employer? Check the appropriate box: Business Type (required):
1. ❑ 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 7• ❑Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• on -profit
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
o employees. [No workers' comp. insurance required]* 11.0 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 #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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lie. #
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 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, under the pains andpena/ties 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
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Date �' J'v / 6"
request a waiver of the
Food Service Permit Fee for the following reason
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Thank you,
Signature
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Title