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HomeMy WebLinkAboutOrganic Valley/Cropp Coop - 9/20/2008TOWN OF MANSFIELD, BOARD OF HEALTH SIX PARK ROW, MANSFIELD, MA 02048 PERMIT TO OPERATE A MOBILE FOOD TEMP ESTABLISHMENT 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: ORGANIC VALLEY/CROPP COOPERATIVE Whose Place of Business is: ORGANIC VALLEY/CROPP COOPERATIVE @ THE COMCAST CENTER Permit expires September 20, 2008 License Number. MF-309T Food Fee: $25.00 Milk & Cream: NO BOARD OF HEALTH Dr. Raymond Martin, Chairmari The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization N Address: City/State/Zip: h (0 : hone #C9 O`a ' (oc).S — a (o OJ— Are you an employer? Check the appropriate box: Business Type (required): k.0 4-ana-a employer with q M employees (full and/ S. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ElI 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. $• ❑ 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 I 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.] 12J�I(ther ]ilQf r.ZC.,Qa CA � r- *Any applicant that checks box #I 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' Insurance Company Name: o.Y e.� Insurer's insurance for my employees. Below is the policy information. City/State/Zip: 1't+_ UAAU `l Policy# or Self -ins. Lie. # T 9w 6 "rnact (110 `� 5— t a09 � , � — , _ ei CJ Expiration Date: e Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). -a� k(oo']I 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 cerito, under the paafnf and penalties 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 OF Date Received Date Inspected Approved By Permit # Issued ,3o i FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: - VDJ 2) Establishment Address: ©np- Qc O — C" 3) Establishment Mailing Address (if different) 4) Establishment Telephone No: 0 6) Applicant Name & Title: udli `T'U 6) Applicant Address: C , 6 / Z " f% ,5 / - 8 0 9 3 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned By: T0.0 MC_CS ❑ An Association ❑ A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. 191 Persnn nirwctly Rasnnnsihle Fnr Daily Oneratinns(Owner- Berson in charge. SUBervisor. Manaaer. etc.) Name & Title: - _ O Address: VD--Z Telephone No: CQQ (QutS---SjbUa _ F-(OOS-a(DQ0 Emergency Telephone No: 13) District Or Regional Supervisor if applicable) Name & Title: Address: Telephone No: Fax: BLANK FOOD PERMIT APPLICATION ^COOPERATIVE REGIONS OF ORGANIC PRODUCER POOLS SUMMARY OF INSURANCE WORKERS COMPENSATION & EMPLOYERS LIABILITY -ALL OTHER STATES (EXCEPT WI) Carrier: Travelers Casualty and Surety Company Broker: Marsh USA Inc. Policy Number: YACRUB-2929M07-1-08 Policy Term: May 1, 2008 to May 1, 2009 Covered States: CA CO FL IL IN KY MA ME MN MT NY OR PA TX VA VT Other States: All states except ND, OH, WA, W V, WI, WY and the Covered States listed above Limits of Liability: Workers Compensation Statutory Employers Liability Bodily Injury by Accident —Each Accident $1,000,000 Bodily Injury by Disease — Policy Limit $1,000,000 Bodily Injury by Disease — Each Employee $1,000,000 Stop Gap Liability — WA only Bodily Injury by Accident — Each Accident $1,000,000 Bodily Injury by Disease —Policy Limit $1,000,000 (At Policy Inception): Employers Liability Coverage - WA only WC 00 03 03 C Notification of Change in Ownership WC 00 04 14 00 Domestic Terrorism, Earthquakes, and Catastrophic Industrial Accidents Premium WC 00 04 21 B Foreign Terrorism Premium WC 00 04 22 00 Terrorism Premium WC 99 0120 00 Various State Statutory Endorsements Page 1 of 2 7/11/2008 MARSH This document is only a synopsis of coverage and intended for use as a reference. The actual policy contains exclusions and/or limitations not summarized herein. The actual policy should be consuUed for fill coverage terms and conditions, including any endorsements that maybe issued after the policy inception. Dept: Board of Health To the Departmental Officer making the Payment: Recent of for the period G� E7_i7_CF.I Collections as ersch 1� f iQwt4 OF MA7t;fIELP - LIVE <3 P o this date, filed in office RISC. CASH ® a $ .rate ,' Time rfy,r o; i ,. Oc. 1� Trea T 7-1"7 Card 4. ORGANIC VALLEY Clem re;i y Paid By ORGANIC VALLEY _a n