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HomeMy WebLinkAboutDoll E. Daze 10/6/2018Commonwealth 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:. FELICIA WALKER Whose place of business is: DOLL E. DAZE PROJECT AND MUSEUM DBA NATIONAL BLACK DOLL MUSEUM ABOLITION DAY CELEBRATION SOUTH COMMON PERSON(S) IN CHARGE: FELICIA WALKER & GWENDOLYN STINSON Permit Expires: October O6, 2018 Food Fee: License Number: T-24 BOARD OF HEALTH Michaet'McCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date Received Permit Fee Approved By Permit # Issued Temporary Food Establishment Permit Application (Application must be submitted at least 7 business days before the planned opening date) 1) Establishment Name: 0 .E U4ZC: r0 ?(;.r e-r, d yvuAel. h t✓ v 6iq xl`1&0 2) Establishment Address: 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 7 C% 5) Applicant/Owner Name & Title: �(✓L Z '� , k'C 6)Appllcant/Owner Address: t...�'14. U3 7) Applicant/Owner Telephone No: ._7 $ 0 --' 8) Applicant/Owner Email address: FlN L _ J t/ C O 19 71 9) Person Directly Responsible For Onsito Operations: f6 L Z Cam- 'VU FAUQ,K• Name & Title: <•- i�pd��lk-e�- Address: /�i✓L f 1"� (`�'�1-/�-� 'd. t (e 02OLt,� Telephone No: / 7(-( q —7d.6 Fax: JCS I (� Emergency Telephone NO: 10) Event Attending , Date(s): Event Name: ���+.1 �ti( C01�/ Event Location: CC' Vv-\ Utz S i A111-^ r 6-51-� Event time; 1 P, 11) Check one Food Truck J caterer Other: D-1-"A-tc .rT 12,,) ppSolid waste disposal plan: � f�` C)Ar,e' S G"'t �0vtg�✓ 13) Water Sourco: C (M4 V`-e 14W O,I- � L(^'t"v'CL, l 14) Sewage disposal plan: Co ncpr e 5t+l C LA"mac. � 1 15) Please give a brief description of the food to be served: ' U'p /-�-- L IZ j'�o 4 (z-�-Q ✓' lC C k Cw v'i o 3�C� , jLic6 f dotc S. (�ii+lCe O (p z d5 CprK�Si cR�/cic 01 Olty)tac., Ae(elea GA7�a�LniO />tt,v"ts9 pte (�PCf:e�l Wl�}w�-e✓tr�e(;QS. (���ZW sitCe S. Food Protection Questionnaire for Catered Events d /�6e,ie bk zf Date of Fvent: Ci—a �J -� � Event Time: I //,- Location of Fvent: List all foods that you will be chilling, holding, cooking, and/or re heating at the event location: On ice/Refrigerated Cooking Reheating vtl GL.i cKe n P zzi� Food Manager Certification Person Trained On Site? Allergen Awareness Menu Label Present? Y r1I'Nn n Yes I .l No List all Potentially Hazardous Food (PHF) and the individual intended temperature required: List the required temperature for each food as it leaves your preparation site: How will the PHF be kept at or below 4179 How will the MIT be kept at or above 140°F? Time of PHF? Setup Served Removed List all equipment that will be supplied for an event, including but not limited to food thermometers, cleaning wipes, utensils, non latex gloves, heating utensils, ice etc. �ylur�S UL)�LP6or ocs , v� `�c��S �eciram\�cA C 16 ) Food will be prepared: TodOnslte for Immediate consumption Onslte and held at proper hot/ cold holding temperatures r i Offsite and held at proper hot/ cold holding temperatures I t /Offsile, cooled and reheated on site Other: � C' 41'c" D ir> r104-S &-ZzA C �-i�t�y Sa cf,4 t,c)✓.k -(v f 17) If PHF is being served, please list the person who has completed the following trainings and attach appropriate certificates: P i Food Safety Manager: G VV AI Allergen Awareness: 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: I, the undersigned, attest to the accuracy of the information provided in this appllcation and I affirm that the food establishment operation will comply 105 CMR 590.000 and all other applicable law. I have been Instructed by the board of health on how to 0 o les of 1p5,CppR 5 O.00D and the federal Food Code. 19) Signature of Applicant; G/ 1lJJ Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, 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: 420— Sq a -, 219 % 21) Signature of Individual or Corporate Name: b D 1 I C (:)�ze, oez 0 I eJ V. 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. L DAZC: Signature of Individual or Corporate Name l'y: Corporate Officer (Mandatory, if Applicable) ,Q0-SRR-,597l- "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:\Usen\sleile\Deskmp\Scotl's Ducuments\Food Eslablishmen(s-'remp\TAX CERTIFICATION FORMAac The Conintonnaealth of Massachusetts Department of Industrial Accidents Office of lit vestigations 600 Washington Street 3' Boston, MA 02111 www.niass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant information Please Print Legibly Business/Organization Name:{ / 0 1) C DA 7,C n/Dj Address:. gy l� br`�C ilA(�L vt 8 � City/State/Zip: fVK;iSl—fie � All t4 0'2 ®LJ�Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ 1 am a employer with 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. [No workers' comp, insurance required] 8• UNon-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 no employees. [No workers' comp, insurance required]* 4.54 We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp, insurance rcq.J 12.❑ Other *Any applicant that checks box NI must also rill ant the section below showing the!r 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 NI. t am air employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company insurer's City/State/Zip: Policy b or Self -ins, Lic, 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 thePIA for insurance coverage verification. / do hereby cw7.1jorder the pains arrtd penalties of per jury that the information provided above is Eire and correct. Official use only, Do not write in this area, to be completed by city or• town ofrcial. 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 Phone www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE 09/27/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in firm of suCh wndw.ewma„u�l PRODUCER ACE INSURANCE SERVICES INC i75 WARREN AVE 3ROCKTON, MA 02301 INSURED DOLL E DAZE PROJECT, NATIONAL BLACK DOLL MUSEUM /DBA 288 NORTH MAIN STREET MANSFIELD, MA 02048 COVERAGES eco.lmrATE _ __...._... _ .-,,.....�. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN KEVISION NUMBER: ISSUED TO THE INSURED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR NAMED ABOVE FOR THE POLICY PERIOD OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - ALL THE TERMS. INSR - - LTR TYPE OFINSURANCE OBL SUBR----"'-TOLICY EFF -POLICY EXP- POUCYNUMBER rdMIpDIYYYY MMIDUMYY . GENERAL LIABILITY LIMITS X COLGENERAL COMMERCIAL GENERAIABILITY �` IEACHOCOURRENCF .DDO 000 j DAMFG �TOlEL'F1TE0 �$ 1 -- PREMISESIE oxu wj $10,0 000 A . CLAIMS MADE L�� OCCUR ---- MED C%P (Any one on ) 5 5,000 NPP8479014 10/05/2018 10/05/2019--- I -- "- PERSONAL B AOV INJURY IS1,000000 _ �— -- ------ EN'L AGGRCGATE LIMITAPPLIES PER I GCNERAL AGGREGATE s 2.000.000 /X POLICY PRO- I PRODUCTS COMPIOPAGG SINCUVDED _. ____ __ JE .T TOG -_..._ S AUTOMOBILE LIABILITY COMBINED SINGLE LIMB j._.- ANJ AUTO 'ALL OWNED ( 9CHEDULEO 'AUTos AUTos HIRED AUTOS {I� NON -OWNED `_ AUTOS N/A Eanwden�_„ BODILY INJURY (Per person) BODILY INJURY (Par awdenB PERd 1N,\GE- 5 $ _...._ $ I PR YID I UMBRELLA LIAR OCCUR `y j�� EAC410CCURREHCE $ E%GEES LIAR CLAIMSMADE 'T�-' N/A i - s AGGREGATE — _.- $ - DEO RETENTIONS S COMPENSATION AND EMPLOYERS' YERS' LIABILITY ANDEMPLOYERS'LIABILITY YIN WC STATIC- CHIT ?ORYLI ITS,I- €R_ ANYPROPRIETO EAC,UDERIEXECUNVE ❑jNIA� N/A EL. EACH ACCIDENT --- $ (MnOftai,yIBERE%CiVOED> 11,,ds.aa�nder ELOISEASE - EAEIAPLOYE s riI014 OF OprIGNONR E L DISEASE -POLICY HNrT S hF—NIA R f�X�1GAt4���8��I W608?5AM1M u�I�� gR�a�,�i� �i��� ��I�ii°�i'd�° rF� � ` Yii�C�u. AND VENT ON 10106/2018 IN THE TOWN OF MANSFIELD. PAINTING, THERE IS ALSO AN OUTSIDE cPRTIG1c ATC .n. r .. TOWN OF MANSFIELD I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 PARK ROW ACCORDANCE WITH THE POLICY PROVISIONS. MANSFIELD, MA 02048 AUTHORIZED REPRESENTATIVE ) IIJOSE JORGE / s /n P 198B-201 A ORD`CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered Marks of A ORDi/1' Clear All N Q ti w O 4 I 2: z W-4 u � 0 PM � /. k 051810:15a Felicia Walker 5089156127 p.1 Mansfield Board of Health Request for Fee Waiver for Food Permit Date �ol,� 6 . A2L '0 eG�`c�n —Qeu A � restaurant/ organization) We, 0 4 G�otjl bK 144'3�ory request a waiver of the Food Service Permit Fee for the following reason: (! This is a request from a town department. Please list the department: We are a Sol (c)(3) organization and ALL proceeds earned will go directly to the organization. ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. . Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, 7ignature /Q{�2yC� �1 fj✓1S-� �✓ Title 'Please provide proof of valid 501(c)(3) status BOH Use Only i Approved Denied Reason: Signature: Date: BOX 2509 Cl f.")AZE' PROJECI-I'll AlID M` MEBRA DR-I'l,"T 0') D4 6 App 1 i (: a T, ',-� � R 2 9 q S la z a �j e 'L is L-d CO apolication Y p p i a ip F-r� t-. a r, u s we ba"! C, X r Q m e 6 e r 9 D )L ( C 0 (lo,,le, ("On �Clr ib-u, 1, �r section ,ctible under 9eC7Li-0Fl deductibli 3 h e 113 e, resolv, an "T �rd.` nc X NP V, "i '�V- S-) youz- PE!x-M,-koaxllc Inzi, iCi on de au-e h D j)UblJ-C char7 Lie-0, --ha, c.he beadil-1q, 'D da t (D PUC s e, 7i iUM5_�.;i? oa:qfam.