HomeMy WebLinkAboutLoco Sports (LL Bean Flannel 5K)- 9/22/2019OF MALTIf USF. ONLY
Approved By Permit# Issued
Community Event Food Establishment Permit Application
(Application must be submitted at feast 7 business days before the event date)
This application should only be used by otgarlizat€oris that are not food establishments but plan to
distribute non-potontially hazardous food or drinks at a local community event,
doanmonityrEvent;
Event Name:
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Event Location:
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Event time:
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1) Organization Wine- L fI G P l v t
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2) Organization Address; .... Po 6,o T-Z 3 j'rew1y Ft�iv`ke, ! i P 0 31 � � f
3) Orga rirat on Mailing Address (it different):
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a) organization Telephone No: W[� s '^ '7fv� " / -Z-0 -
61 Applicant Name & Title:_... _.._.. 4kid vt°w ��t •'Jr
7) Applicant Telephone No:, p''% .- 11
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8) AppGcanfjovmer Email address: t (Jevw9dgz mixtrl, co,44
9) person Directly Rasponsdrle ForUosft Operations; t G 7 f tit u°`LL!
Narde & Tole:
Telephone No:
t;iL17 tQr raK
Emergency Telephone 43rst
10) please give a brief description of the food arrWor drinks to be served
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1, tire on", a t to the accuracy at the information provided in this application and 1 affirm that the food
establishment operation will comply with 105 CUR 590MO and sit other applicable taw_ I have been Instructed "a board of
health on how to obtain copies f'{,) r CMR 00.000 oind the fede/ml Food Code.
11) signature of Applicant: � i tGt
V
T-AX CERTIFIC),TION FORM
I cfTffy, tarld'Cr the fNvm3ftxs (if per ury tilat 1, to my bc-.q,;, knowlr-dg v arid
bcliet have filed all State tax re-!arrvz 3-A paid aU slate tPx(,-- rypaired
tm,dtr !aw,
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EIN 272538952
'This license vVill out be issued unless this oerhfication clause is signt*j
by the applicant.
500r 506,43 SWcUfi';V noMber, ,-;Il bf, furnl&," INI to a Massachusett-,
Der,irtment of Revenue to de:emimv whether you ha vti' inn tzx filing i77r
14% --A nitro oblqgation� Ucetlskl�-, who fail to c(trrte, their 310-n-filin . Y g ,, or
dc'] it wil I be so bject to I iIcvn-,,,csUNptn-si on QrrevPcition, Th,
rcoUet v' hux!t' under thw auth'.,ni41V Or, MassacbUse-S GMer.41 LaW
Chapter 62C, se�tion 49A,
Tltr %"n tt��aaltla of :�i'irsxirt~It tf+
DvVarr7't t!tt of fft6o riol Accia£-Aa
01fice Of InvIestiv*rttrz*n t
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A2glitlat Information ftm-e print L&Xjbtv
r } 3i se= Chi n . eta a s t Rugged Races LQQ
is'sre= : 45 Bromfield Street, Ste 801, Boston, MA 02108
413,834.4501
Arr y" An emrtg3 rr7 C a, the appro0att bot. ftusmmy Type (required):
t 1q, 41 tez+ 3tu�i`ra' a a�h 70 rr^, s�� (:vit a ;r qj FFrt..i!
txmq�sie t`t�.tr k.a; 41 any,tarn-. Ti- � 3
'ale we 7u r snd its �M eas _ i Er t° mmem
Ott rt?*h�' at exznpva n TC t57�� i$s 3equr_, have ttr E] mints` ctairs
60 rra k; rye:. tN r cznnp in-' mmxc € quircal *'
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;] Esc �-�- c rrn-�*ckfit ar«�..4 s � �-ts:�xi tsy v,-:1�x^tr�, ; � i ;,
� (t £'a; �V2nt Production
LN"O sa`�€`r em' Zce"n +. a�.n`� M'7 E z. r„„'*d.} x ; four iioo
Xev ±sii°ane+ 11,W r*� #1 M'U� 4V Atx adis =+#,
f r arrs ecita r ri}s* ac#artrwi�xe�+ rs* s�rtta+trz 1n3Y3arec' far mr r#rt€rs*a�ec t�#*a+r % t�rii`& t= r'raJ`:_ brier,.
,�r� _+ National Liability & Fire insurance Company
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ea°a PO Box 113247 Stamford, CT 06911-3247
Policy # V9WC924038 02,25.2020
Attscit a It apy rt the WOrLt s` crsue ai rYt pzi�t tlecta #wra PAn ¢aiirsWmr,, (tu poUty number and t%pjr-tt" dolt).
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r p; rr a r as r rvtir a n perruta t € ea r slur t&r i:€/arrrr,4604 growded &bow
Offie.ff: &" rMdt+ DLL mw srritz r'r. 5 #x:ar tt, to ia:° + �5'rPwd b£� rr'fy Ur avama c+*'Ik fral
City or 'r n:
PrrMiVLiora-* #
Y,e<rae ?a.u3tanrita tcirtie ssnr�:
t. tsatnrd of Huth a'.. ta"Mia Tanprraamrnt 3. Cityi town C'trrk 4. Licens d a. tiekrtmtt'i O f`x e
b. Other
C.r nu'z t� 4es
Worker's Compensation and Employer's Liability Policy
National Liability & Fire Insurance Company - A Stock Co.
Policy Number V9WC033869
Renewal of V9WC924038
NCCI No. [19054]
Policy Information Page
1] Named Insured and Mailing Address
Rts,ged Races, LLC
45 Bromfield Street
sth Fm' r
Boston, MA 02108
Federal Employer's ID 00-1035$74
Risk ID Number 877938
Additional Names of Insured
Agency
V3 INSURANCE PARTNERS LLC
115 Pheasant Run
Suite 218
Newtown, PA 113940
Agency Cade: PAVTHR20
Insured is Unhited Liability Co. (LLC)
(N2) Loci Sports LLC
Locations on Policy See Extension of Information Page - Schedule of Locations
[2) Policy Period
From February 25, 2019 to February 2S, 2020, 12:01 AM, standard time at the insured's mallinca address.
[31 Coverage.
A. Workers' Compensaren insurance - Part one of this policy applles to the Workers' Compensation
Law of the following states: Connecticut, Massachusetts, New Hampshire l
8. Employer's Liability Insurance Part Two of this policy applies to work in each of the states listed
in item [31A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $1,000,000
Bodily Injury by Disease - each employer. ¢1,00b,000
Bodily Injury by Disease - policy limit r $1,000,DOID
C. Other States Insurance Part Three of this policy applies to all states, except any state listed in
item (31A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See intension of information Page - 15chedule of forms
1 [4] Premium —_
The Premium l)asls and, therefore, the premium will be determined by our Manual of Rules,
j Clasifications, Rates; arW Rating Plans. All required information Is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 23,173
Total Surcharges/Assessments $ 865.00
Total Estimated Cost A 24.018.00
INTr NA 3 v3cre 1 tatormatiun Page
MC,A ; VVAC033569
04te : 02/2612019 lyC bOt}Jo1A
MMA07
Issuing office: 100 elrst Stamford Place, P.O. Box 113247, Stamford, Cr 06911.3247 • www.nlf-lnfo.com
MansfieldBoard of
Dates 8 ! If 9
we, t'O 41O _ i`949 r
organization )
request a waiver of the Food Service Permit Fee for the following reason-
0 This is a request from a town department.
Please list the department:
We are a 501(c)(3) organization and ALL proceeds earned will go directly to the
organization.
IJ 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. u_
We are a religious organization.
Cl Other:
Thank you, � �
Si tore
i _�
Title— �—
*Please provide proof of valid 601(c)(3) status
BOH Use Only
t
_ Approved
Denied Reason:
Signature: Date: