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HomeMy WebLinkAboutArnold's Worldwide (Mansfield Crossing) 12/31/2009Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: 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:. JOE DOYAN, JAMES RANJITT Whose place of business is: ARNOLD WORLDWIDE C/O MCDONALD'S 101 HUNTINGTON AVENUE PERSON(S) IN CHARGE DAN RANJITT, TOUR MANAGER Permit Expires: December 11, 2009 License Number: FS-9T Food Fee: $25.00 Milk & Cream O BOARD OF HEALTH , E 1 Dr. RSayrneri d Martin, airman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that: JOE DOYAN, JAMES RANJITT having a place of business at: ARNOLD WORLDWIDE C/O MCDONALD'S 101 HUNTINGTON AVENUE in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until December 11, 2009, unless previous to that time is suspended or revoked. Expires: December 11, 2009 License No.: FS-9T POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred Permits for December 11, 2009 Page 1 of 1 Jane Doucette From: Odenbach, Vanessa [VODENBACH@arn.com] Sent: Wednesday, December 09, 2009 11:27 AM To: Jane Doucette Subject: RE: Permits for December 11, 2009 Hi Jane, I did get your fax thank you for sending. We will be serving samples in the parking lot of the Mansfield Crossing Mall at 280 School Street, Mansfield, MA from 10AM until 8PM. We will be serving 7oz samples of McDonald's MCCafe Coffee Line (Mochas, Cappuccinos, Lattes, drip coffee and hot chocolates) I am sorry didn't fill in all the necessary information — I am sorry for any inconvenience. Thank you, Vanessa -----Original Message ----- From: Jane Doucette[mailto:Jdoucette@mansfieldma.com] Sent: Wednesday, December 09, 2009 10:37 AM To: Odenbach, Vanessa Subject: Permits for December 11, 2009 Hi Vanessa, I just faxed over your permits for December 11th. Are you going to be the only vendor? You did not put on the application what you will be serving or where the event will take place. If you could let me know as soon as possible. Thanks, Jane This email may contain confidential information and is solely for the use of the intended recipient. Any review, distribution, disclosure or other use of this information by anyone other than the intended recipient is prohibited. If you have received this communication in error, please notify the sender immediately and delete this message from your system. 12/10/2009 FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must WsUbmitted a e1�30 aays belore the planned opening date) 1)EstablishmentName: unok l WUYIAM'6� (40 MCDonaldS 2) Establishment Address tottun-mawyl 160son IRA algq 3) Establishment Mailing Address (if different) C 4) Establishment Telephone No: �Q �� S U 10 1-17- 5) Applicant Name & Title: V!, UC a AAA - Air o mt M aA a 6) Applicant Address 101 dy V\-h!M VDA aye 13(>5 01jq-1 7) Applicant Telephone No.: (in Cs^ g 1-1Z 24 Hour Emergency No.: 58 cv S 1-! O F S -1 c® I J vI 8)Owners Name &Title AdYCM(A..AU C 10C po an) 9) Owner Address (If different from applicant): 1 5 Em A- (WIT Al SA- fr"Ict (Vt 1'V►Ol, 10) Establishment Owned By: Q An Association WA Corporation OAnIndividual O A Partnership O Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 3e4 Q016kA Gd-oW(le'K Z(hrjtn Iid(K 'FGI 1011 Jul YV160 V-(Stf %Ur 011 QVl (A -OWA C.(2 L(F3 S V q t( le. tZd 81)1'iDrri 12) Person Directly Responsible For Daily Operations (owner, person in cnarge, supervisor, manager erc.) Name & Title: 'pan 0-an m -TpVr m m Q {, Address: Telephone No: I 3t3 1 N1 0 7 1 ` 24 Hour Emergency No: FAX: \ F" 6 t E-mail: V 0b (z am. GOPVI AIt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: "O hAN h� Telephone No: 1 24 Hour Emergency No: 11 FAX: £ 'd 9000'IN cool} Isli} ppli su>'W }o utao} W s Ot 6001 '£ Va Food Establishment Information 14) WATER SOURCE; MS0-(,M GYI 15) SEWAGE [16) DISPOSAL; NJA (4�nVWfA W 1 m van DEP Public Water Supply No: (Il apphcaoleCd No. Of Food Employees: . 17)DAYS/HOURS: OAtetrAVA4Z 101 11,0001 1QAYA--9PM 18) Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, corn let list is on fllq Dan ?-OA)%t (Navaph�i %IIIAMY(JR) # 5LAIA731 RfV Salk Required as of 10/12001 in accordance with 105 CMR 00.003(A) Please attach copy of certificate 19) Parson Trained in Anti-Cho(ing Procedures (If 25 Seats or more): NWIA 20) Locatiotr. 0 Permanent -000 n 22) Establishment Type Q Bakery $25 Moblie Moblie Start Date: VlC • 1111 ZoO01 ED Retail ( Sq. Ft) N Caterer $25 Mobile End Date: ��• (� ��( Q Food Service up to 100 or (2 Food Delivery $25 Moblie Comments: up to 10' PHF display $75 Food Service up to 101 -200 %Milk & Cream $2 75 Mobile Food & Consesslon $50 21) Length of Permit: [] Annual or up to 26' PHF display $100 79 Mobile Food Temporary $25 ❑ rood Service up to 201 + EJ Slnuffact re Frozen Desserts/ins Cream Q Seasonal Or 25'+ PHr display $125 Seasonal Dates; Food Service -Institution O Pushcart $25 # of Pushcarts: E] Residential Kitchen $25 19 Temporary Temporary Start Date: 121((104 ( Meals/Day)❑•F Retail Food $50 Temporary End Date: K4 11161 0 Retail Snack Food $10 TemporaryTime: 10AYM-1/f4 0 Tobacco Products No Fee Rain Date; W'A 4) Food Operations Definitions: PHF- Poten6alryhezardous/ood(6'mm4ar»pdm1wri controls required NonPHF's - non-polentially hazardous food(no dma temparafum cenfrols requited) (Check all that apply)' RTE- ready-tboat roods (Ex. sandwiches. salads, ins which need no funherprwessing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order [] 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 DElive of Packaged PHFs Cold HolOing For Single Meal Service-. 7 0 PHF and RTE Foods Prepared For Highly Susceptible Population Facility Q Sale of Raw Animal Foods Intended Reheating of Commercially to be Prepared by Consumer Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Customer Self -Service of Non PHF and Non- Customer Self-Sery Use of Process Requiring di Variance HAQCice and/or HACCP Plan (including bare hand Perishable Foods Only [Ni Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale control) Other Food Operations [F) Juice Manufactured and Packaged for Q Offers Raw Or Undercooked Food Of Retail Sale Animal Origin .. — .. Offers RTE PHF in Bulk Quantities_ '—` Prepares Food/Single Meals for _.._._....._.-.. _., _u- . OhData or Reconditioned Food To be Completed by the Board of Health Total Pennit Fee! Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with t05 CMR 590.000 and all other applicable law. I have been instructed by the board of health On how to obta;ftcopias Of 105 CM 590.000 an a federal Food Code. 24) Signature of Applicant: N QUM (nil/` Pursuant to MGL Oh,62C, sec. 49A, I certify under the penalties of perjury that 1, to my best Knowledge and belief, have flied all state tax returns and paid state taxes required under law. 26) Signal p in Number or Federal 10, m old W W We i,{ C (' O � (QU �3 reo f N(�, 26) Signature of individual or Corporate Name: 1A, , 1 Una 1 ✓8 b 'd 9000A loop ),sll} plal}suew }0 ulao) NoOl 6001 'b a0 Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1 st of each year. NAME OF BUSINESS: RT n V `N YY d w' d l ADDRESS: 'D 1 Aunt f 1q'11%► t we, Boson ma o2l 99 TELEPHONE AT LOCATION: Q 11 ' 591 •0 !1 Z FAX NUMBER: �'� . �,(� ' ,(( rot tnn-ttvanessa ockimb o, CiW�WGR,.QF BUSINESS: OF TELEPHONE OF OWNER: U1 1 •501, fli FEDERAL ID/SS NUMBER: vLA✓ 5k(P 503 FEE: $2.00 PERMIT NUMBER: SIGNATURE: V 0""�v' — DATE: 17,13101 S 'd 9000'ON 1001} Tsai} ppljsUrm }o U/a01 WV :01 6006 I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all State tax returns and paid all State taxes required under law, Aluol,i Wo4AW Ik- * Signature of Individual or Corporate Name (Mandatory) z".t"u ���o b z 1,,2126 By: Corporate Officer (Mandatory, if applicable) b y 5,- l ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the ce&rication 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 Mass. General Laws, Chapter 620, Section 49A. 9 'd 9000'IN aool} }saI} P1;1JSUrw }o uMo} WVbS Ol 6006 The Commonwealth of Massachusetts Department of1t%dustrialAccidents De-ice of Investigations U9 600 Washington Street Boston, AM 02M www.mass.gov/d'ia Workers' Compensation Insurance Affidavit: Crenelral Businesses Appheant Information Please Print Legibly Business/Organization Address: Z 01 0 ® ( 01 Are oa an employer? Check the appropriate box: I.I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole 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 c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]' 4. ❑ We are a non-profit organi2atioq staffed by volunteers, with no employees. [No workers', camp. insurance roq,] as Phone M 3 0 -3 5-1 ' 44 lBusiness Type (required): 5. © Retail 6. © Restaurant/Bar/Eating Establishment 7. XOffce and/or Sales (incl. real estate, auto, etc.) 8. [] Non-profit 9. (] Entertainment 10.F1 Manufacturing I I.❑ Health Care 12.© Other +Any applicant that checks box N I meat also All out the section bc1ow sbowing choir workers' compensation policy informavion. ""Ir the corporate ofltcm have exempted themselves, but the corporation has other employes, a workers' compensadon policy iv required and such an organisation should check box Nl. I am cot employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: insurer's City/State/Zip: Policy # or Self -ins. Lic. 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 MCYL 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 S250.00 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 oer*, under the pains and pemtWes of perjury that the information provided above is true and correct OffwW use only. Do trot write in this area, to be completed by city or town offralal City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www,mass.gowan Phone tf„ L 'd 9000'IN )001} ]S)i] plal}suelu ]o u)ao} HOb :0I 6006 0 rtliont@• 77AAr7n ENCNATS ACORDr. CERTIFICATE OF LIABILITY INSURANCE 1i 0412009 "' PRODUCER CBS Coverage Group, Inc 111 Express Street P Plainview, NY 11803 516 938-9000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Encore Nationwide, Inc 2980 Columbia Street Torrance, CA 90503 INSURER A: Arch Specialty Insurance Compan INSURER B: Tower Insurance Company of NY INSURER C: INSURER D: INSURER E: COVFRAGFS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDONW POLICY E%PIRATION DATE MM DD YYY LIMITS A GENERAL LIABILITY SPPKG0001800 05/31/2009 05/31/2010 EACH OCCURRENCE $1000000 PREMIES E,u ED $100000 COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $$ 000 CLAIMS MADE O OCCUR PERSONAL & ADV INJURY $1 OOO 000 GENERAL AGGREGATE AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG POLICY X JEOT X LOC A AUTOMOBILE LIABILITY ANYAUTO SAPAUT0001800 05/31/2009 05/3112010 COMBINED SINGLE LIMITX (Esaccident) Es2.00O.000GEN'L BODILY INJURY (Per person) ALL OWNED AUTOS SCHEDULED AUTOS X BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO $ AUTO ONLY: AGG A EXCESS I UMBRELLA LIABILITY SPUMB0001800 05/31/2009 05/31/2010 EACH OCCURRENCE $$000000 AGGREGATE $5 000 000 X OCCUR CLAIMS MADE $ $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOWPARTNER/EXECUTIVE WA919001319 WD9010007009 10116/2009 10/1612009 10/16/2010 10/16/2010 TH- X WCSTATU- OFR E.L. EACH ACCIDENT $1,000000 E.L. DISEASE - EA EMPLOYEE $1 000,000 p�FICd ERIMTMgHFR EXCLUDED? ` an story n 11 N WB9180007509 10/16/2009 10/16/2010 E.L. DISEASE. POLICY LIMIT $1 000,000 If, describe un SPECIAL PROVISIer ONS bet. WE9350003909 10/16/2009 10/16/2010 A OTHER Errors & SPPKG0001800 05/31/09 05/31/10 $1,000,000 Occurrence Omissions $2,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Evidence of Insurance Only. ***SAMPLE*** ***SAMPLE*** ***SAMPLE*** ***SAMPLE**" ***SAMPLE*** LID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30_ DAYS 'E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO: NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE ACORD 25 (2009101) 1 of 2 #S151365/M150164 - 0 TBUU-LUUB AUJNu wrcrvr« The ACORD name and logo are registered marks of ACORD JES All rights Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written," An employer is dctined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MOL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required," Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be, returned to the city or town that the application for the permit or license is being requested, not the Department of industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Solf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Off➢cials Please be sure that the affidavit is complete and printed legibly. The Departmem has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition, an applicant that must submit multiple permitnicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would Rojo thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Wvvw.mass.gov/dia Fom Revised 5-2605 8 'd 9000'ON 100 } IsIIJ p1;1Isum }o usol WyyStOl 6006 77te Conwtoxweafrh ofMamachavettr .Departfneftl ofIndustrtalAccldenis 09ke oflnmfigadons 6M WMN #gfvn Rrrd Boston, MA 02111 www.mas,�gov/die W0rkoro' Compensation InsurancC Affidavit: Gouomml Businosttes Auudea a��o formation _ Please I BusinoWOrgwiizaUox) Name: a en (o r f W %df (Irmo, Aro you on am Cbeck e i ropriate bon. 1. 7 I ma a employer with cmploym (Nil end/ or pen4dmo),' 2. [a 1 am k aola proprietor or permwrsttp and hnvo no employ= working for me in any capacity_ (No workers' comp. insurance required) 3. ❑ We are a corporation and its effia . have exereiwyl that right of wwmplom per c. 1 SZ, § 1(4), and we have no employees. [No workers' comp, msueenee required] 4. © we aro a noa-profit orAu=o04n, siaMd by voltmteen with no emnloveas. Mo workers' cc=. ismutnoe M. Phone M 1 p' U 4 Balvneps Type (repaired); 5. �J Retail b, 0 P.&=urant/B&II19ting Ettablishmat 7. tKOffioo and/or Sake (incl. real eswe, auto, etc) 8. � Nan -profit 9. � $ntertninmcnt 10.0 Manufacnnin$ 11.E Heahh Care 12 0 Od= ___-- ewny XWUMM RIM darns cox a I Mwt AU fill ad the toctton Woo thovona thee waxer:' compwetioa poky 6fanamioa: -If ra owponao oftwi lave aampw O*wA r- but the oorphutkn hu of= smployoo, awarkm• e,mpcwukm polky b mgtdr d and rvch an oraamu6ft should eheak box 01, lam an employer that is p workla'e' Gl$WY1nee Company Name: ,,d�fW9e lniuror's Address: /)/) Agm fs the pahky wormwadam ptrlioy am Self -Ins. Lick —w :I rI .I213 l q Bxplration Dale;ZG! 114 1).61 Q Atumb a copy of thn workanl compeasboos policy doclarntlon page (showing the policy nomber and expisatior date). pa;hwc tc xvuro mvcragc w repo and imdsr Section 25A of MOL o, 132 can lead to the imposition of aiminal pemidea of a fine up to T 1,500.00 and/or onuyear imprisonmtm; as well as civil penalties in the form of % STOP WORK ORDER and a fore orup to 3250.00 a day against the violator. Be advised Char a copy of this suuemont may be forwarded to the Office of Inv dons of the DIR for Insitrenoe oovera a verifiralion. I aW kertelry eatfiY�ti wndtr the pairc) and pe„radas-r'perirrY that zaeF�farnarian pnarrda)Q a6a {#/,�,rnpa and cornea. Si�natlttai � Dare' /2 7 ! Qryldat tree oily. Do tmf home In ibis area. tb be, conf4eW by clry or town gf Lla( City or Towm Permit9.:cense N iswing Authority (olrole one): 1. Beard of Haakh 3. building Dapnetawat 3, Cityrrown Clerk 4. Licensing Board S. Seleermen's oltice. d. Other c C 'c 9000'oN ;oojl ;s; } p1ai}suety }e uMoa 00V "Oi 400� .E .�;Q 120-OEICI £iT'd 666T T98 aT£ Tlol rwo,ad £SOT 68aZ FAX COVER SHEET Town of Mansfield Board of Health DATE: DECEMBER 3, 2009 TIME: 10:30 am FROM: Town of Mansfield Board of Health Six Park Row Mansfield, MA 02048 TO: VANNESSA ODENBACH FAX #: 617-587-8189 Type of Form: Phone: 508-261-7366 Fax: 508-261-7343 Number of Pages: 3 (Including this sheet) If you do not receive all of the above pages, contact the Mansfield Board of Health. MESSAGE: You will need to display the permits while the event is going on. If you have any questions you can call me at (508) 261-7366 or e-mail me idoucette(amansfieldma.com. Jane Communication Result Report ( Dec, 9. 2009 10:35AM ) * * * z 1) town of mansf ield first floor 2 Date/Time: Dec. 9. 2009 10:34AM File No. Mode Destination ---------------------------------------------- 0024 Memory TX 916175878189 Pg(s) Result -------------------------------- P. 3 OK ---------------------------------------- Reason for error E. I Hang up or line fall E.2) Busy E.3) No answer E.4) No facsimile connection E.5) Exceeded max. E—mall size FAXCOWRSHEET Town of Mangfield Roard ofHenith DATE: DECIdMDER3,3009 Mfg! 10:30om FROM: Town oflebtoefield Donrd of Health Phone: 50H-261-7366 Su Park Row Faze $00-261-7343 Mansfield, MA 02045 TO: VAPNESSAODENRACH FAX& 617-587410 Type afFonn: NmnbaroPPagu:3 �eeludlogehkAw) IPyon do not tenivc all ofthe shovepeges, eond the Mansfield DooM of Health. MESSAGE: You nill nad to dkplay the permin while Me event u going on. Ifyon hove any gvreRom you een eall me el (SUM 261-7366 oe MI.. 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