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Home My WebLink AboutStefano's Pizza & Sub Shop - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) z Establishment Name e ='� CI ,. .> , < '> / r ) Establishment Address " Establishment Mailing Address (if different) Establishment Telephone No > C, r=, - 77, Applicant Name & Title: Applicant Address -;' i#t'rt Applicant Telephone No.:Emergency 24 Hour No.: 5 `'-4 _ J'& -' a Applicant Email Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ❑ An Association partner. MA Corporation Name Title Address 11 An Individual 3 r'y 4? e <: L g = ❑ A Partnership ❑ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: i yrcri s;- eX^`iLa i✓trl Mrd <'ar` Telephone No: 24 Hour Emergency No:� e' FAX: E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: /t Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) No. of Food Employees: y.._v✓ DAYS/HOURS: Name offP''ersotn(s) InJ Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. Ff-'Yes Does this establishment require a FOG permit? F If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [P�nnual etail Food $125.00 .g. ❑ Mobile Food Consession ❑ Temporary M Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream ❑ Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: Food Service u to 201 + $300.00 ❑ p ❑Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 E] Residential Kitchen $100.00 Rain Date: LI ,.,�./ Milk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions: PHF - Potentially hazardous food(timeAemperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous lood(no gma/temperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ,. �' [q Sale of Commercially Pre -Packaged Non-PHFs LU PHFCooked To Order 10 H t 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 ❑ Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially Susceptible Population Facility to be Prepared by Consumer Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- E] Customer Self -Service contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) E]Retail Sale p Preparation of Non-PHFs ❑Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑ Vacuum Packaging /Cook Chill ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for ❑ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 1, 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 odes of 105 CMR 590.000 and the federal Food Code. 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. Social Security Number or Federal ID: Signature of Individual or Corporate Name:'`I 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 ,_,._j xi.7 cf c-;%.? 19 "*Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *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. The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations Of 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢ibly Business/Organization Name: f�- °: Address: City/State/Zip: iris `v "'/ c-, a -iA kl Phone #: 1 '. _ 43 ,t b /// Are you an employer? Check the appropriate box: Business Type (required): L [TI am a employer with " employees (full and/ 5. ❑ Retail or part-time).* 6. bi estaurantBar/Eating Establishment 2. ❑ I 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 30 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]* 11.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box #1 most 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: i" -f t" 1 f [ l _'` , 0 �_, . Insurer's Address: °' i `l• 7-h I 0 6 4—` —LF City/State/Zip: 9`J ?. 7v g l 1 t >,, -j Policy # or Self -ins. Lic. # /1, `1 (' ^ -1-< : - I,'5�, r 3 � " ;--I `j 4 Expiration Date: :t - /c-= - 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, under the pains and penalties ofperjury that the information provided above is true and correct Phone #:> Official use only. Do not write in this area, to be completed by city or town official. City or Town: 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 Av� OF LIABILITY INSURANCE DATE " 2"0""'CERTIFICATE 0182,9`o THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(fes) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 00343-001AMIINer1EECT Branch 343-1 pX : (508)872-9999 No.: M. AIC. Aby Zemack EMAI ADD SS: 187 Oaks Road Framingham, MA 01702 EACH OCCURRENCE $ INSURERIS) AFFORDING CO GE NAICS INSURER A . A.I.M. Mutual Insurance Company 33758 INSURED ED ENTERPRISES INC INSURERS: GENERAL AGGREGATE S STEFANOS PIZZA & SUB SHOP INSURER C' INSURER , 30 CHAUNCY ST Mansfield, MA 02048 INSURER E: LIABILITY ANYAUTO ALL ED SCHEDULED HIREDAUTOSH NON010.NED AUTOS COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CONTRACT OR OTHER DOCUMENT HATH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I�TFt TYPE OF INSURANCE INSR VIVD POLICY NUMBER IWDV EXP LIMITS GENERAL LIABILITY COMMERCIAL GENERALLIABILNY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGETO RENTED $ PREMISES Fa occurrence MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE S EN'LAGGREGATE LIMIT APPLIES PER: oucv Ecr oc PRODUCTS -COMPIOPAGG $ AUTOMOBILE AUTOMOBILE LIABILITY ANYAUTO ALL ED SCHEDULED HIREDAUTOSH NON010.NED AUTOS I -----------EE- COMBINEDSING Ea accident $ BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) S PROPERTYDAMAGE Per accident $ $ UMBRELLALUAB EXCESSLIAB OCCUR CLAIMSMADE ---- EACH OCCURRENCE $ AGGREGATE $ $ $ A yVyI��pp1IDLLEEEppOS5 fr..T�EERNNETEppNT�IIONLN ANDEMPLO�ERS'LIABILITY Y AOt ERREMM66 F:(ECUTIVE� (Mandatory in NH UDED'� N DWIIMONOFOPERARONshelow NIA AWC-400-7038139-2019A 4118/2019 4/1812020 L�rr��CC �{{ X TORYLIMRS OER ELEACHACCIDENT $ 100000.00 E.L. DISEASE - EA EMPLOYEE $ 100000.00 E.L. DISEASE -POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS LOCATIONS i VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mare space B required) Proof of Coverage Worker's Compensation Coverage Applies to Massachusetts Employees Only KD Enterprises Inc Stefanos Pizza & Sub Shop 30 Chauncy Street Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: i�-- r= g-- E , 1 ' ' % " /�"J'" Address: j '1 l 5 t"—t wry qtr f V'A0 --f t Mailing Address: 4 Phone/Fax Number: — ' —Lie Email: J tft.-e 4� t :> 'rc.,t, f 0 L C'c;.- Contact Person/Title for Grease Traps: /?' ,--z, �5 �s Name of Company scheduled to pump internal grease trap(s) monthly: P+ jo— I ✓»` ` Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges hat the information submitted in these documents is true, accurate and complete. Date /e' -._. r -__� c Print Name Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? � c `"i r Q)�c e a L= ' i r krl s, -t How often is this grease storage unit emptied? 45 j Please list the vendor who removes the waste: tc. r?<,a�etrc fa r 7-1 Please list fixtures attached to each grease trap Grease Trap l »t t+044 -,R Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? Where is the grease storage unit located? � c `"i r Q)�c e a L= ' i r krl s, -t How often is this grease storage unit emptied? 45 j Please list the vendor who removes the waste: tc. r?<,a�etrc fa r 7-1 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. t Seating Capacity (per Fire Department Regulation): tt c! Seating Capacity (Actual Count): t Normal Hours of Food Preparation/Service: Monday 1 + Tuesday !r — r Wednesday Thursday (! — Friday /s — L Saturday r i Sunday Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU l J^ry 3compartment sink t Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal ( Ice Making Machines j Fryolators Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? P' 'pj Yes No If yes, at what station/sink? PATRIOT/SERVICES, INC. Your Grease Trap Pro & Drain Specialist P.O. Box 294 Bridgewater, MA 02324 LIKE (508) 697-9565 1 (800) 449-4480 (508) 759-0979 us ON www.PatriotServicesMa.com Date of Service 9/ is - Customer S Customer Name ST C Invoice # L11 `J 7 S y Address CityZip Job Address (if different than customer) DESCRIPTION OF WORK Apt. # I hereby authorize the right. I certify Signature Terms: PO # to perform the above described services and I agree to pay the I am duly authorized to order and approve the work requested. Cash �i� 7, Bill OuD This is to acknowledge completion of the above described work which has been done to my complete satisfaction. Customer Name Customer E -Mail Address PARTS_ LABOR OTHER TAX indicated to TOTAL DISCOUNT. TOTAL DUE Date y CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: TMw.us m—N Certificate Number: 2313752 9 Date of Completion: ss o15 Date of Expiration: The above-named person is hereby issued this certifrrate ftr rompleting an allergen awareness training program recognized by the Mmiribuseus Department ofAiblit Health in attordance with 105 CMR 590.009(G)(3)(a). This rerti6iate will be validforfrue (5) years from date o(coripletimv t=.n.a Br. _.- Iwacd By: "AP®_p�� NATIONAL - l_ ASSOCA IONS M.whu.mResti nt Aswciation 800.765.2122 333 Turnpike Road, Suite 102 Southbomugh,MA 01772 wwrastaurant.otg 508-303-9905 recognized by the Massachusetts Department ofArblir Heath wsvw.maresreuranteawc.otg CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: usarrtsuK-mwm Certificate Number: 23imm Date of Completion: 5n zols Date of Expiration: sm2ozl _.- Iwacd By: Be above-named person is hereby issued this rerti crate - l_ Jar completing. an allergen awareness trainingprogram NATIONAL RESTAURANT 1 recognized by the Massachusetts Department ofArblir Heath °�^^. SSO ACIATION, in accordance with 105 CMR 590.009(G)(3)(a). Masmchuwm RcstamantAss iation 800.7652122 333 Turnpike Road, Suite 102 m ..te.mure tors 71iis rerti rate will he valid r 5 ears rom date fa fm' fra () y f ofromDletion. Southboo gh,MA 01772 b .\ \� } . e .� - !2 [ �� ° { ( 2 .� { < \ § i � . d«{ « ƒ « <: � z � « � ° y� \� � . \� � \ 1 :11 j ao m Iff- 3 i9 3 � O a R 3 Q 0' D w T ^� 5 a 1�. Oil 70 1�. W % ■ |