HomeMy WebLinkAboutMonster Energy Drink - 7/17/2009Commonwealth 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:.
HANSENS BEVERAGE COMPANY
Whose place of business is:
MONSTER ENERGY DRINK @ THE COMCAST CENTER
885 SOUTH MAIN STREET
Permit good for: JULY 17 - OCTOBER 1, 2009
License Number: MF-6T
Food Fee: $100.00
BOARD OF HEALTH
Dr. Raym artin, 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)
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1) Establishment Name:
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2) Establishment Address
ul
3) Establishment Mailing Address (if different)
4) Establishment Telephone No:
y U k — /)- 727
5) Applicant Name & Title:
6) Applicant Address
7) Applicant Telephone No.:
24 Hour Emergency No.:
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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.
L An Association
fw A Corporation
El An Individual
A Partnership
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: I 'Z 6a ^ � i , anA m- � r C 4 - . A-i / ,'4 r' -J M . L 9 , 0 Z LI7 L
Telephone No: �) FAX:
Emergency Phone
13) District Or Regional Supervisor (if applicable)
Name & Title: /V -
Address:
Telephone No: FAX:
Emergency Phone
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL:
All 1/1- tit
DEP Public Water Supply No: (If applicable)
16) DAYS/HOURS: 17) No. of Food Employees: 0—_
18) Name of Person In Charge Certified in Food Protection Management:
JZevl'" C/o(o14✓l, ) s-l- i-S--1-e7�-
Required as of 10/12001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate
20) Location:
Establishment Type
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L�mobile Food Temporary(Snack Size
Permanent Location
Sampling of Products,Comcast) $25
Tempomry
per day (for the event) with a cap of
iL7
Temporary Dates: 7/11 `%— /U/J/U
$100.00
21) LENGTH OF PERMIT:
to / o
23) Food Operations Definitions: PHF -Potentially hazardous food (timeRemperature controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous lood(no time/temperature 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 L.j Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs
Preparation of PHFs For Hot And for More Than a Single Meal Service
Cold Holding For Single Meal Service
El Reheating of Commercially Processed Foods LL Juice Manufactured and Packaged for
for Service Within 4 Hours I ❑ Customer Self -Service Retail Sale
E] Customer Self -Service of Non PHF and Non- E] Ice Manufactured and Packaged for
Perishable Foods Only Retail Sale
Preparation of Non-PHFs
Other Food Operations
F L, l / V k? 0 /2-ed'1-e d C. --i vi To be completed =application
S c't ✓Yr �r n S Total Permit Fee:
J Payment is due wi
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:
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.
25) Social Security Number or Federal ID: '�; 3 —O h 1)_6 G 1 ?�
26) Signature of Individual or Corporate Name: HQ N l Zro 5 9 w-f-+'-4 V. �J' 4 VIV
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.
4el UC,r/Ci
Signature of Individual or Corporate Name By: Corporate Officer( Mandatory, if Applicable)
3 - D 5"2-0 ( l 3
*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:\HmIthVands Documents\TAX CERTIFICATION FORM.doc
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 Legibly
Business/Organization Name: �Crv7 s era s S e t/2ti✓Ct c e Co
T
Address: S S D " ,-)t C LLC- /e # ,;Ip/
City/State/Zip:_ Go ,moo ki 6i , e p-.9d- Flo Phone #: y •S I — 73 % — 6,2 0 0
Are yoy an employer? Check the appropriate box:
Business Type (required):
L Url am a employer with employees (full and/
5. ❑ Retail
or part-time).*
2. ❑ I
6. ❑ Restaurant/Bar/Eating Establishment
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, ❑ Non-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. We are a non-profit organization, staffed by volunteers,
11.❑ Health Care
with no employees. [No workers' comp. insurance req.l
12.6j,6ther _9 ci e Co rti 17 c). c, , 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 91.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: CC I' .e `,i vn c e, n a { J h, c at ✓t �V1 SV✓ a v t r, ._� f w t Lt S
Insurer's Address: W e s AP.✓ l f��
City/State/Zip: /V , Lr/Au 64 f C %9 C2.
Policy # or Self -ins. Lic. # 7 y — 3 / Q — L, Ci' S Expiration Date: 12 • 3 /• /O
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 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains
—V � � —
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 offfchrZ
City or Town: Permit/License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Phone
www.mass.gov/dia