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Home My WebLink AboutDeco's Italian Cuisine - 12/31/20202156-®a35,2` FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD E5 I ABL16HMEN I FERMI I AI'I'LIGA I IUN (Application must be submitted at least 30 days before the planned opening date) Establishment Name Deco's Italian Cuisine (Ozcan Restaurants LLC) Establishment Address 365 N Main St, Mansfield, MA 02048 Establishment Mailing Address (if different) Establishment Telephone No 508-339-6995 Applicant Name & Title: Yucel Ozcan, Owner Applicant Address 46 Pratt St. #8, Mansfield, MA 02048 Applicant Telephone No.: 508-339-6995 24 Hour Emergency No.: 508446-4204 Applicant Email DecosPizza@gmail.com 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. X A Corporation ❑ An Individual Name Title Address Yucel Ozcan Owner 46 Pratt St. #8, Mansfield, MA 02048 Kimberly Ozcan Partner 46 Pratt St. #8, Mansfield, MA 02048 ❑ A Partnership ❑ Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Yucel Ozcan, Owner Address: 46 Pratt St. #8, Mansfield, MA 02048 Telephone No: 508-339-6995 24 Hour Emergency No: 508-4464204 FAX: none E-mail: DecosPizza@gmail.com Ait E-Mail: YucelOzcanl@gmail.com District Or Regional Supervisor (if applicable) Name & Title: none Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Public Water Supply SEWAGE DISPOSAL: Public Sewer DEP Public Water Supply No: (If applicable) No. of Food Employees: 3 DAYS/HOURS: Mon - Sat 11-10 Sun 11-9 Name of Person(s) In Charge Certified in Food Protection Management: Yucel Ozcan Name of Person(s) In Charge Certified in Allergen Awareness Training Yucel Ozcan Name of pest control company routinely inspecting the premises for evidence of pests Flynn Pest Control 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. ® Yes Does this establishment require a FOG permit? 4 If yes, please attach the FOG permit application. Length of Permit: Establishment Type: i,a-Annual Food $125.00 ❑ Mobile Food Consession [] Temporary ,,�1�6j/Retail I`AFood Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 _FOOD T TRUCKS $175.00 n Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ❑ Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ❑ Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: [X] 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) ❑ Sale of Commercially Pre -Packaged Non-PHFs n 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 ❑ 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 ❑ 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 Nan-PHFs Retail Sale ❑ 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 ith 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain.Goves of 105 CMR590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, se . 49A, I certify and paid state taxes require under law. of perjury that I, to my best knowledge and belief, have filed all state tax returns Social Security Number or Federal ID: 61-4326704��tt �}. Signature of Individual or Corporate Name: Oz cA ti k_e S-r�t.LLr''Gi [ / S /-,L 6 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. gnature of Ind v'dual or orporate Name 81-4326704 "Social Security No. (Voluntanj) or Federal Identification Number Yucel Ozcan 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\sleite\Desktop\Scou!s Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts owDepartment 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: Deco's Italian Cuisine (Ozcan Restaurants LLC) Address: 365 N Main St, City/State/Zip: Mansfield, MA 02048 Phone #: 508-339-6995 Are you an employer? Check the appropriate box: 4 PIT Business Type (required): 5. ❑ Retail 1.91 I am a employer with employees (full and/ or part-time).* 6. Restaurant/Bar/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. 8. ❑ Non-profit 3.❑ [No workers' comp. insurance required] 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 4. ❑ no employees. [No workers' comp. insurance required]* We staffed by volunteers, 11.❑ Health Care are a non-profit organization, 12.❑ Other with no employees. [No workers' comp. insurance req.] *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 is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Bene-Care Insurance Services LLC Insurer's Address: 1260 Creek St City/State/Zip: Webster, NY 14580 Policy # or Self -ins. Lic. # UB-9H330694-19-42-G Expiration Date: 11/17/20 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,,vnderthe pains and penalties of perjury that the information provided above is true and correct. 508446-4204 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 Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Deco's Italian Cuisine (Ozcan Restaurants LLC) 365 N Main St, Mansfield, MA 02048 Mailing Address: 365 N Main St, Mansfield, MA 02048 Phone/Fax Number: 508-339-6995 Email: DecosPizza@gmail.com Contact Person/Title for Grease Traps: Yucel Ozcan Name of Company scheduled to pump internal grease trap(s) monthly:' �)T .) �/ ✓/ G �� 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 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 that the information submitted in these documents is true, accurate and complete. Date Print Name Yucel Ozcan 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. Seating Capacity (per Fire Department Regulation): 24 Seating Capacity (Actual Count): 24 Normal Hours of Food Preparation/Service: Monday 11am-10pm Thursday 11am-10pm Sunday 11am-9m Tuesday 11am-10pm Friday 11am-10pm Wednesday 11am-10pm Saturday 11am-10pm 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 1 yes 3 compartment sink 1 no Handwashing sink 0 n/a Commercial Dishwasher 0 n/a Bar sink 1 no Mop Sink 0 n/a Garbage Disposal 0 n/a Ice Making Machines 2 n/a Fryolators 1 n/a Grills or Ovens 2 n/a Exhaust Hoods 0 n/a Floor drains 1 yes Other: produce sink How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): off site by private company Is dinnerware pre -rinsed before being washed? yes Yes If yes, at what station/sink? 3 compartment sink attached to GRU No E Grease Traps and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 1 Please list fixtures attached to each grease trap Grease Trap 1 3 compartment sink Grease Trap 2 produce sink Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes x No Where is the existing outdoor GRU located? Size gallons If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? yes Where is the grease storage unit located? next to dumpster How often is this grease storage unit emptied? every 4 months Newport BioDiesel Company Please list the vendor who removes the e3 TRAVELERS J�, WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: UB-9H330694-19-42-G RENEWAL OF (UB-9H330694-18-42-G) INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT 1 NCCI CO CODE: 12637 INSURED: PRODUCER: OZCAN RESTAURANTS LLC BENE-CARE INS SVCS LLC DBA DECOS ITALIAN CUISINE 1260 CREEK ST 365 N MAIN STREET WEBSTER, NY 14580 MANSFIELD, MA 02048 Insured is A LIMITED LIABILITY COMPANY. Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 11-17-19 to 11-17-20 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 500,000 Each Accident Bodily Injury by Disease: $ 500,000 policy Limit Bodily Injury by Disease: $ 500,000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY DATE OF ISSUE: 10-07-19 SD OFFICE: ALBANY N.Y. 002 PRODUCER: BENE-CARE INS SVCS LLC DCQ22 TRAVELERS Jam' ONE TOWER SQUARE HARTFORD CT 06183 CLASSIFICATION SCHEDULE: CLASSIFICATIONS CODE NO WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: UB-9H330694-19-42-G PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER $100 OF ANNUAL REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC -CODE: 5812 NAILS: 722511 ...E_1P : '!� TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 323 LOSS CONSTANT 20 PREMIUM DISCOUNT NONE 0900-20 EXPENSE CONSTANT 250 TERRORISM 8 TOTAL ESTIMATED PREMIUM 601 DEPOSIT AMOUNT DUE 601MP Minimum Premium: $ 215 EMPLOYERS LIABILITY MINIMUM: $50 DATE OF ISSUE: 10-07-19 SD OFFICE: ALBANY N.Y. 002 PRODUCER: BENS -CARE INS SVCS LLC DCQ22 COUNTERSIGNED -AGENT TRAVELERS J� WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 EXTENSION OF INFO PAGE -SCHEDULE WC 00 00 01 ( A) POLICY NUMBER: UB-9H330694-19-42-G INSURER- THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT INSURED'S NAME:OZCAN RESTAURANTS LLC PREMIUM BASIS ESTIMATED TOTAL ANNUAL CLASSIFICATION CODE LOCATION 001 FEIN 814326704 ENTITY CD 001 00 OZCAN RESTAURANTS LLC DBA DECOS ITALIAN CUISINE 365 N MAIN ST MANSFIELD , MA 02048 NAICS: 722511 RESTAURANT NOC 9079 26534.00 MA MANUAL PREMIUM $ 273 12637-MA RATES ESTIMATED PER $100 OF ANNUAL REMUNERATION PREMIUM 1.03 273 --------------------------------------------------------------------------------------- 1.00% EMPL. LIAB. INCREASED LIMITS(9807) $ 3 ADD FOR INCREASED LIMITS MINIMUM 47 TOTAL PREMIUM SUBJECT TO EXPERIENCE MOD. 323 EXPERIENCE MODIFICATION: MODIFIED PREMIUM 323 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 323 0% LOSS CONSTANT(0032) 20 EXPENSE CONSTANT(0900) 250 TERRORISM(9740) 8 TOTAL ESTIMATED PREMIUM 601 TOTAL PREMIUM 601 DEPOSIT AMOUNT DUE 601 DATE OF ISSUE:10-07-19 SD SCHEDULE NO: 1 OF 1 TRAVELERS, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 00 00 01 (A) POLICY NUMBER: UB-9H330694-19-42-G LISTING OF ENDORSEMENTS EXTENSION OF INFO PAGE We agree that the following listed endorsements form a part of this policy on its effective date. WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 00 01 A - 001 WC 00 04 14 00 - 001 WC 00 04 22 B - 001 WC 20 03 01 00 - 001 WC 20 03 02 A - 001 WC 20 03 03 D - 001 WC 20 04 05 00 - 001 WC 20 06 01 A --001 INFORMATION PAGE INFORMATION PAGE 2 EXTENSION OF INFORMATION PAGE - SCHEDULE ENDORSEMENT LISTING NOTIFICATION OF CHANGE IN OWNERSHIP ENDT TERRORISM RISK INS PROG REAUTH ACT ENDT MA LIMITS OF LIABILITY ENDORSEMENT MASSACHUSETTS - ASSESMENT CHARGE MA NOTICE TO POLICYHOLDER ENDORSEMENT MASSACHUSETTS PREMIUM DUE DATE ENDT MA CANCELLATION ENDORSEMENT DATE OF ISSUE: 10-07-19 ST ASSIGN: Page 1 of 1 w O w U w l W U V z z w z w P4 z w (M7 W a Q N O J O N N } N � Z a ° U 4 `" Q Q Pi .V C v. C p F4 � 0 A � u O N M h M w v w d � y d O. Ell X W