HomeMy WebLinkAboutClassic Pizza - 12/31/2020�) FOR BOARD OF HEALTH USE ONLY Permit# Issued, 1ok
FOOD ESTABLISHMENT PERMIT APPLICATION "I".-,/,y
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name L -
Establishment Address
Establishment Mailing Address (if different)
Establishment Telephone No [z; j
Applicant Name & Title:
AApplicant Telephone
licant Te er hone No — H y Applicant p �_ our Emergency No..
%-
Applicant Email (- r `fit-
\` \�3\
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
El An Association
partner.
1-1 A Corporation
Name Title Address
An Individual
VA Partnership
0' Other legal Entity
Person Directly Responsible For Daily.Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:,
Address: r
Telephone No — 1` 24 Hour Emergency Noj L ,� —0-W 1r�
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address: /
Telephone No: J f / 24 Hour Emergency No:
FAX:
E-mail:
f/
Food Establishment Information
WATER SOURCE: _r,
SEWAGE DISPOSAL: (o £,,,,
DEP Public Water Supppgly No:
(If applicable)
No. of Food Employees:
DAYS/HOURS: \\ vk�= \----- —
Name of Person(s) In 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_El_
n
If there is seating for 25 peo,Ple or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. LJ Yes
Does this establishment require a FOG permit?0 _ If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
etail Food $125.00 Mobile Food Consession
tFodServiceupto100
E] Temporary
INCLUDING NO PHF PREPARED ON SITE $100.00
Temporary Start Dale:
DD TRUCKS $176.00 Manufacture Frozen Desserts/Ice Cream
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
E] Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts:
Temporary Time:
0 Supermarkets $400 0 Residential Kitchen $100.00
Rain Date:
[] Milk &Cream $10.00 Caterer $35.00
Food Operations: Definitions: PHF-Potentially hazardous food (timeRemperature controls required)
(Check all that apply): Non-PHFs-non-potentially hazardous foodino time/temperature controls required)
RTE - ready -to -eat foods (Ex sandwiches, salads, muffins which need no further processing)
a Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order N(Hot PHF Cooked and Cooled or Hot Held
Sale of Commercially Pre -Packaged PHFs jE/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 Susceptible Population Facility
Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer Self -Service
0 Customer Self -Service of Non PHF and Non- contact alternative, time as a public health
Perishable Foods Only Ice Manufactured and Packaged for control)
Preparation of Non-PHFs Retail Sale 0 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
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply y,Mh 105 CMIj„590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain c s of 105 R 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, h}pve filed all state tax returns
and paid state taxes required under law. /'
Social Security Number or Federal ID: V .� - `- \"i '^,�.�5. t i-_..n-.1 if,/�/j�
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
"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.
C:\Users\slehe\Desktop\ScoLVs Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
UlfBoston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization
Aru an employer? Check the appropriate box:
LM 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 organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.]
Business Type (required):
5. ❑ Retail
6. ERestaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I LE] Health Care
12.❑ Other
*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 isprorviding workers' conipensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. # \\ ,' 7( > 9 Expiration Date: 1 l
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
and penalties ofperjmy that the information providea�above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
www.mass.gov/dia
NOV-13-2019(WED) 16:15 Tinos Insurance/Tinos Travel (FOX)508 880 504d
P.0011002
C . CERTIFICATELIABILITY INSU ANC I DATB(MM, Y,
11 - 1 3 -2012018
PRODUCER - 4-%8Tjj THIS CFRTIFIrATF IR IRCIIFn AA A MAT Q nw 1MVn0UA"nM
C J MURPHY INSURANCE
22 FRUIT St - BOX 3
TAUNTON. MA 02780
MR K CLASSIC, ILC
c/o CLASSIC PIZZA
242 CHAUNCY St
MANSFIELD, MA 02048
COVERAGES
INSURERS AFFORDING COVERAGE
NAIC #
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANOING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDEO 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT YO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSA
OD am
TYPE OE INSURANCE
pODOY NUMBER
POLIO f'ECTI
nAQT&OENERALLIAMUTY
POLICY EXPIRATION
LIMITS
EACHOCCURRENCE
5
MEDEXP(Ansana arean
5m
COMMERCIAL GENERAL LIABILITY$I��e_L
CLAIMS MADE ❑ OCCUR
5
PERSONALAAOVINJURY
$
GENERALAGOREOATE
S
GEN'LAGGREGATE LIMITAPPIJES PER;
PRODUCTS-COMPIOPAGG
$
POLICY Fj PRO- 0 LOC
AUTOMOMLELIASILRY
ANYAUTO
COMBINEOSINGLEUMIT
(FFpgodenl)
S
BGGILYINJIIRY
(Ferpereon)
5
ALLOWNEOAUTOS
SCHEOULEDAUTOS
BODILYINJURY
(PeremI&M)
S
HIREDAUTO6
NON•OWNEDAUT08
PROPERTYDAMAGE
(Pereacldeni)
S
0ARAOEUA8ILITY
AUTO ONLY -EA ACCIDENT
6
OTHERTHAN EAACC
$
ANYAUTO
S
AUTOONLY: AGO
EXCESSIUMBRELLA LIABILITY
OCCUR CLAIMS MADE
EACHOCCURRENCE
S
ABOREGATE
6
_..
DEDUCTIELE
�—
RETENTION 8
WORNENSCOMPENSATION ANO
EMPLOYERG'UABILITY
ANY PROPRIETORIPARTNEREXBCU'RVE
WCC.50.0..50Z7764
8-25—Z9
8�25�20
CETATt} OTW
EL,FACHACCIDENT
OO,OD
EL. DISEASE- EA EMPLOY
$
OPPISERIME1,18ER EXCLUDED?
Ityeadeeulbe under
SPECIAL PROASIONSElIAW
EL DISEASE, POLICY LIMI
SOD,OO
OTHER
PRSCRIPTION OP OPBRATIONO I LOCATIONS J VEHICLES IEXCLUSION$ADDEO BY ENDOR$EMENTIOPECIAL PROVIBIONS
RESTAURANT
PIZZA PARLOR - No DELIVERY
TOWN of MANSFIELD
8 PARK Rd
MANSFIELD, MA 02048
SHOULD ANY OF THE ABOVE 090CRIDED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENOEAVOR TO MAIL — DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURS TO DO 80 SHALL
IMPOSE NO OBLIGATION OR LIABWTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
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 defined 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."
MGL 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, MGL 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. Self -insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department 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 permit/license 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 burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Deparfrment'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
Form Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name:__
Mailing Add
Phone/Fax
Contact Person/Title for Grease Tra
CD
s,
Name of Company scheduled to pump internal grease trap(s) monthly: v, ,0� 't�
Name of Company scheduled to pump external grease trap quarterl } �L&
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
container
($50 `
`
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 th_4t the inforrotion submitted in these documents is true, accurate and complete.
Signed �`� Date \�
Print
Customer INFO
~\
Name
Address
\
City, ���p��
�
[
|i |[���[�[�k/[lF�keo
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POBOX 1l44,MAR8iEH64[\MAO1945 ^
GREASE TRAP SERVICE TICKET
`
SERV|CEDATE:|/
SITE INFO
Name:
Address:
City, STZip:
Contact:
Phone Phone
************************************++****************************************
TRAP CONDITIONS:
Joe firbluing
/
� GOOD /
/
'
-
DEPTH iUINCHES:
(��\
DEPTH iDINCHES: ( / )
NEEDS REPLACEMENT
SETTLED SOLIDS DEPTH inINCHES:
GALLONS �°��- /�Pk8/—~ \ ---�rR�PK8 --FAC RE
��--'GPM '- �
'
***********************+******************************************************
TRAP CLEANING:
'
�
SCRAPE SIDES ( I-)
REMOVE BAFFLES ( )/
SCRAPE BAFFLES
CLEAR INLET ( )''
�/�
/
CLEAR OUTLET
REPLACE BAFFLES( )
^/
PROPER FLOW: TEST( /\
RUST /K4ED\ (HEAVY)
-
SECURE LID /)^'
LEAKS /Y ) /j LOG COMPLETE
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N[lTES: \
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CUSTOMER SIGNATURE / DATE
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. f
Seating Capacity (per Fire Department
Regulation): �
Seating Capacity (Actual Count):
Normal Hours of Food Preparation/Service:
Monday �( >
Thursday
Sunday --
Tuesday Vi� - - \u
Friday f\0 -`V.._:
Wednesday ` '° Au
Saturday
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
sI
3 compartment sink
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
01
Ice Making Machines
Fryolators
`4
V/
Grills or Ovens
Of
Exhaust Hoods
Floor drains
other:
vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed?
If yes, at what station/sink?
Yes
No
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
c"T
Please list fixtures attached to each grease trap
Grease Trap 1
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? f (}
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 fr
Where is the grease storage unit located?
How often is this grease storage unit emp
Please list the vendor who removes the w
NOV-13-2019(WED) 16:15 Tinos Insurance/Tinos Travel (FAX)508 880 5044 P.002/002
ACOR CERTIFICATE OF LIABILITY INSURANCE 11-1M, -201Y,
11 -1 a-zole
PRODUCER - - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
TINO'$INgUpANGEINC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
3S TR INSURANCE
AGENCY, SE HOLDER, THIS CERTIFICATE DOE$ NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
TAUN'iON, MA 0275D
INSURERS AFFORDING COVERAGE NAIL#
INSURED INRURERA: M AP F R E - Commerce ins
MR K CLASSIC, ILC INSURERB:
CIO CLASSIC PIZZA INSURERB
242 CHAUNCY Si INSURERD:
MANSFIELD, MA 02048 NSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED RY 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,
INBE
A
PO4CY NUMBER
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5-11.2019
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WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTKIVEXECUTIVE
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OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES IEXCLUSIONSADDED BY ENOORBEMENTI SPECIAL PROVIBIONS
" RESTAURANT
PIZZA PARLOR = No DELIVERY
TOWN of MANSFIELD
6 PARK Rd
MANSFIELD, MA 0204E
SHOVLO ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORETHS ESPIRATION
DATE THEkEOP, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ DAYS WRRYEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUY FAILURE TO 00 90 SHALL
IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
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