HomeMy WebLinkAboutCape Cod Chip Co. - 5/30/2009Commonwealth 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:.
THE CAPE COD CHIP COMPANY
Whose place of business is:
THE CAPE COD CHIP COMPANY @ COMCAST CENTER
885 SOUTH MAIN STREET
Permit good for: 5/30/2009
License Number: MF-3T
Food Fee: $25.00
BOARD OF HEALTH
Dr. RFi
ymo d 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: -me
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2) Establishment Address 885 MAINSTKE6T MANSFIELD MA 0 -6
3) Establishment Mailing Address (if different)
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4) Establishment Telephone No: ;.7vvpu
5) Applicant Name & Title: ^,r 1V1. tE O'DONNEU-j SALES MICTG•
6) Applicant AddressGMMG� 55MQ12121SS�y QL1/A gQg-rQtlt MA Q2iL5
7) Applicant Telephone No.:�1 7_ Qnz / _zOO 24 Hour Emergency No.: ��2
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A��r10^^ cic lQ COA- "I
8) Owners Name & Title -THE ewe
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9) Owner Address (If different from applicant):1QO j3gCGDC xj 4y N1W 0zW 1
10) Establishment Owned By:
11) If a corporation or partnership, give name, title,
and home address of officers or partner.
El An Association
A Corporation
O An Individual
O A Partnership
0 Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: I AEOI VALN/ F02D,_DIRECTd2CiF MARKETIM&
Address: 1160 BREED'S WL.L RLI. INANNIS. MA o2(ool
Emergency Phone
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
Emergency Phone
FAX:
Food Establishment Information
14) WATER SOURCE: " j'OWN
15) SEWAGE DISPOSAL: -TOWN
DEP Public Water Supply No: (If applicable)
16) DAYS/HOURS: 518019009
17) No. of Food Employees:
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: CoMCAST CGnER
22) Establishment Type
Permanent Location
Mobile Food Temporary(Snack Size
Sampling of Products,Comcast) $25
Temporary
per day (for the event) with a cap of
$100.00
Temporary Dates: 5'�t,J�,G lJv9
21) LENGTH OF PERMIT:
I W-1
23) Food Operations
Definitions: PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply):
Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
RTE - ready -to -eat foods (Ex. Sandwiches, salads, muffins which need no furtherprocessing)
0 Sale of Commercially Pre -Packaged Non-PHFs
IJ PHFCooked To Order EJ Hot PHF Cooked and Cooled or Hot Held
El 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
E] Juice Manufactured and Packaged for
Reheating of Commercially Processed Foods
for Service Within 4 Hours
I] Customer Self -Service Retail Sale
Ice Manufactured and Packaged for
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
Retail Sale
To be completed by the Board of Health
Preparation of Non-PHFs
Other Food Operations
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.
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24) Signature of Applicant: �(ze L��i/iQ L 6
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns and paid state taxes required under law, I'
25) Social Security Number or Federal ID: O'7 -3!51 P I Z_
26) Signature of Individual or Corporate Name:
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)
ON-3311HIZ
*"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:\HwIthVanes Doeummts\TAX CERTIFICATION FORM.doo
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office Of Investigations
6001Washington Street
Boston, MA 02111
wwrp mass gopli is
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: �u" z
Address: E"(,: -C
Are you an employer? Cheek the appropriate box:
1. ErI am a employer with employees (tali and/
orpart-time).+'
2. ❑ I man solo proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. Insurance required]
3. ❑ We are a corporation and Its officers have exercised
their right of exemption per a 152, §1(4), and we have
no employees. [No workers' comp, insurance required]"
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance real
Phone#: C�k%U---jf`.
Business Type (required):
5. ❑ Retail
6. ❑ Restaumnt/Bar/Pefing Establishment
7. ❑ Office and/or Sales (hie]. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10. [] Manufacturing
11.❑ Health Care
12.❑ Other
-nny appueant mat 01'ecks box #1 must also fill out the section below showing their workers' compensation policy inibrmatlon.
"*If the corporate officers have exempted themselves, but the curpomtion has other employees, a workers' compensation policy Is requited and such on
otgalilzation should check box #1.
1 am an employer deaf is providing workers' compensation lnsurance for my employees, .Below is the policy inforniallon:
Insurance Comuanv Name: ?_t t, i r 1-. 11, w , — �,._ t _ r -
Insuror's Address: ?k o
city/state/zip:__ 'F-ter, Oti 1 P, C3-,,' —_
Pelicy # or Self -ins. Lie. # ( j Expiration Date,ri
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
pailure to secure coverage as required under Section 25A of MOL 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
www.muss,gov/dia
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEE
The Commonwealth of
Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we)
have provided for payment to our injured employees under the above -mentioned chapter by insuring
with:
ZURICH AMERICAN INSURANCE CO.
NAME OF INSURANCE COMPANY
P.O. BOX 55217 BOSTON MA 02205
ADDRESS OF INSURANCE COMPANY
WC 2939036-05 08/01/08 TO08/01/09
POLICY NUMBER EFFECTIVE DATES
WACHOVIA INSURANCE SERVICES 6100 FAIRVIEW RD. CHARLOTTE NC 704 553-6036
NAME OF INSURANCE AGENT ADDRESS PHONE #
LANCE, INC 8600 SOUTH BOULEVARD CHARLOTTE NC 28273
EMPLOYER ADDRESS
MEDICAL TREATMENT
The above named insurer Is required in cases of personal injuries arising out of and in the course of employment
to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the
Worker's Compensation Act. A copy of the First Report of Injury must be given to the Injured employee. The
employee may select his or her own physician. The reasonable cost of the services provided by the treating
physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related
injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such
attention at the
t I a� p
TO BE POSTED BY EMPLOYER
WC 7506g (2-02) UNIFORM