HomeMy WebLinkAboutCapstar Radio dba Pepsi Max - 6/14/2009Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Comcast 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:.
CAPSTAR RADIO OPERATING COMPANY
Whose place of business is:
CAPSTAR RADIO OPERATING COMPANY dba PEPSI MAX @ COMCAST CENTER
885 SOUTH MAIN STREET
Permit good for., JUNE 14, 2009
License Number: MF-4T
Food Fee: $25.00
BOARD OF HEALTH
i
Dr. Raymond Martin, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
COMCAST TEMPORARY FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 48 hours prior to planned event)
1) Establishment Name: C G/Yl ca S! l -/`I V
2) Establishment Address e$S SO.4-/-h Main Sj"C•f l4anS-�)�cld 1\40 0204&�
3) Establishment Mailing Address (if different)
4) Establishment Telephone No: 568 339 .2 331
5) Applicant Name & Title: Ca nSlQv p%d10
0�7e/� �7Y1 �/ l�Ul Yt pan vl I J iJ i� P
6) Applicant Address 16 CQ b0-� kc)ad SL
a C A4 jq 62155
7) Applicant Telephone No.: -7 24
Hour Emergency No.:
8) Owners Name & Title
9) Owner Address (If different from applicant):
10) Establishment Owned By:
11) If a corporation or partnership, give name, title,
and home address of officers or partner.
/An Association
C`ap"�V W16 Qp�j'a hT C{du p
�El
P A Corporation
.J
El An Individual
a00 ECtSI rr�^�
L 2d
11 A Partnership
Ste, /�n %vvi )U i TX 7 8AU 9
11 Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: Me h L.0M014ntot17 Sa lt`
Address: l0 C SL(LtP papa
Telephone No: 78 (Q FAX:
Emergency Phone J / g , �S ��, 3-7o)4
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: FAX:
Emergency Phone
(BSI WX
Food Establishment Information
14) WATER SOURCE: tJ
15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
16) DAYS/HOURS: J Uhe. /,gym , dw9 /p -4p
17) No. of Food Employees: / U
18) Name of Person In Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate
20) Location:
22) Establishment Type
Permanent Location
dMobile Food Temporary(Snack Size
Sampling of Products,Comcast) $25
dTemporary
per day (for the event) with a cap of
$100.00
Temporary Dates:
21) LENGTH OF PERMIT:
23) Food Operations
Definitions: PHF- Potentially hazardous food (timeRemperature controls required)
(Check all that apply):
Non-PHFs - non -potentially hazardous food(no fimeAemperature controls required)
RTE - ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PFHs
❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
Preparation of PHFs For Hot And for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
Cold Holding For Single Meal Service
❑ Juice Manufactured and Packaged for
❑ Customer Self -Service Retail Sale
Reheating of Commercially Processed Foods
for Service Within 4 Hours
❑ Ice Manufactured and Packaged for
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
Retail Sale
Preparation of Non-PHFs
Other Food Operations
To be completed by the Board of Health
Total Permit Fee:
Payment is due with application
I, the undersigned, attest to the accuracy of the information provided in this application and 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.
24) Signature of Applicant: r n��.//F
Pursuant to MGL Ch.62C, sec. 49ri,.�
returns and paid state taxes required
under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax
25) Social Security Number or Federal ID: (3
26) Signature of Individual or Corporate Name:
R- r may
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 (Mandatory, if Applicable)
/3-39�?,273 Y'
*"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.
R:VicalthV=es Documents\TAX CERTIFICATION FORM.duc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name: (_g4QS rjd� ML d lO C
Address:J/) so) -
City/State/Zip:
Phone
3
PCW
mciX-
Are you an employer? Check the appropriate box:
Business Type (required):
L N
I am a employer with SQ_ employees (full and/
5. ❑ 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.
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.❑ Manufacturing
4. ❑
no employees. [No workers' comp. insurance required]*
We
11.❑Health Care
are a non-profit organization, staffed by volunteers,
6
I
with no employees. [No workers' comp. insurance req.]
12.[Z Other inn
*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 Name: /LIar" L o s A 1- c 11
Insurer's Address: l (�py M C v i S(+ _'�006
City/State/Zip:
Policy # or Self -ins. Lic. # ( w ) C `) i3 U ] ] I o 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,
ofperjury that the
Official use only. Do not write In. this area, to be completed by city or town official.
City or Town:
Permit/License
Is true and correct.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office
6. Other
Contact
www.mass.gov/dia
Phone