HomeMy WebLinkAboutMooyah - 12/31/2019Commonwealth 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: FOOD ESTABLISHMENT
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:.
FARID RIFAI, MARWAN ZEIDAN, ANTOIONE ZEIDAN
Whose place of business is:
MOOYAH BURGERS, FRIES AND SHAKES
321 SCHOOL STREET, SUITE 140
PERSON(S) IN CHARGE:
HEATHER BULLIO
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS-58
BOARD OF HEALTH
.MichaeCHeaCey, Chairman
Milk & Cream
V",
Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
License to Manufacture Frozen Desserts and/or Ice Cream Mix
The Board of Health in accordance with the provisions of section 65H of Chapter 94 of the General Laws,
as most recently amended, and the regulations made hereunder, hereby issues
MOOYAH BURGERS, FRIES AND SHAKES
321 SCHOOL STREET, SUITE 140
a license for the wholesale/retail manufacture of frozen desserts and ice cream mix. This
license expires December 31st of each year.
License Number: FS-58
Freezers: 1
TOTAL: $25.00
MANSFIELD BOARD OF HEALTH
MichaeCHeaCey, Chairman
V�v
. FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATIOI
(Application must be submitted at least 30 days before the planned op9Ag_datel
1) Establishment Name M 0 � u (ZG E�� An,(r 5bb4l<E5
2) Establishment Address
3ZT
3) Establishment Mailing Address (if different)
4) Establishment Telephone No
5) Applicant Name & Title:
1AQ1_n RI FA i l FAANGt-I($EE
6)ApplicantAddress QIVeg St. S.• EP5ToN_4__MA• 6�3�5_
7) Applicant Telephone No.: 24 Hour Emergency No.: 508- dqq- 111g,
8) Owners Name & Title FAet D t�I FAC M&.(�Jn/Ar t Ze'tDAM, A^iTO/NE 2 raopal l F(IANt%N15EE51 ..
9) Owner Address (If different from applicant)
Owner's telephone number 5�94aw-711f9
417-_g3J5-L/ 5°I T 1-$l- 1/0- 7Jf5
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
0Association
Corporation
Name Title Address
0 An Individual
MAgWk l 2,t90An1 1•RANc4tse�-_ 3YI RiAiH bl. 14QAt"rTUF,14A-
ANTul�6 2t: t 4gnt 11 31 c�Ln cul.onry 1WIn:t#Ywh,
A Partnership
Other legal Entity
nfr' V SO- on(r1
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
91184
14.
{. o04-
Name & Title:
x+ + 14e fL '%9 u 1. U 0
--
Address:
-
_-9 9 GoriNG LL _/9'V'c'. �990(;IC.TtPrl iHA ,
n 23 o a�
Telephone No:
y _ _ Of 24 Hour Emergency No:
97t-1 _ A6- j - O$3 R
FAX:
E-mail:
TLC9 ClLot.7a C.o nl�
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Uizk EKlSToN "q• 0oMS
Telephone No:
24 Hour Emergency No: ,50 _
FAX:
E-mail:
I ' _ 6�I FA'0-T KAI t_ Cor1'1
Food Establishment Information
14) WATER SOURCE:
15) SEWAGE DISPOSAL:
16) No. of Food Employees; O
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS: Sv
of f�P. 4 fr K — t o
Pt 1
18) Name of Person In Charge Certified in Food Protection Management: Hfr�T►Fc2
y3uLL to
If more than 3 individuals are certified, complete
list is on file.
Required as of 101112001 in accordance with 106 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: Permanent Location
22) Establishment Type
$35.00
f€7 Mobile Mobile Start Date:
0 Retail ( I f 00 Sq. Ft)
,Q,/Caterer
p� Milk & Cream $10.00
Mobile End Date:
PrFood Service up to 100 INCLUDING
Mobile Food Consession
Moblie Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
Food Service up to 101 -200 $250.00
Ea Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
21) Length Of Permit:
1
tR Annual a t7
� Food Service up to 201 + $300.00
Supermarkets $400
E Pushcart $50.00 # of Pushcarts:
r-1 Residential Kitchen $100.00
Retail Food $125.00
� Retail Snack Food $50.00
Tobacco Products $150.00
—
i3 Seasonal
Seasonal Dates:
L1 Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions:PHF- Potentially hazardous food thmalemperature controls required)
Nan-PHFs - non -potentially hazardous food(no time/temperature controls required)
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
F�J Sale of Commercially Pre -Packaged Non-PHFs
9�7tFCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
-: Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
0 PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Fol Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
sterner Self -Service
Q Reheating of Commercially
Processed Foods for Service Within 4 Hours
iU Customer Self -Service of Non PHF and Non-
0
Perishable Foods Only
Vacuum Packaging / Cook Chill
Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
.-, Ice Manufactured and Packaged for
Retail Sale
P3 Preparation of Non-PHFs
Other Food Operations
:-., Juice Manufactured and Packaged for
Retail Sale
Q Offers Raw Or Undercooked Food Of
A irrfal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
completed by the Board of Health
Fobcl, PermitFee:
ment is due with application 0 waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comgty-wi(Iy195�CMfj 590.000 and all other applicable law. I have been instructed by the
board of health on how to o6ta' co of 1 CMR 590.000 and the federal Food Code.
24) Signature of Applicant: ,• t ' '4"� ' z�
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:
26) Signature of Individual or Corporate Name:VG-
TAX CERTIFICATION FORM
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.
22g' Godz) t',oY 5; ruc. FaUc� gt,FP- i
Signature of Individual or Corporate Name By: Corporate Officer (Mandatmij, if Applicable)
�I - `/Rol6V0
**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.
C:\Usem\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industridl Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: m o Y A� 'fHP_o' Go o v u 5 l IN C.
Address: �j A I SOA&o L 'Sk
City/State/Zip:
Phone #: So 8- a 9 `l - l l ff
Aveyr an employer? Check the appropriate box:
Business Type (required):
1. LI
1 am a employer with employees (full and/
5. ❑Retail
6. �estaurant/Bar/Eating Establishment
or part-time).*
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.
$• ❑ Non-profit
[No workers' comp. insurance required]
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]**
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 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 #l.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Tj C NAQTFoRn
Insurer's Address: 3 (p o c WI 5 C-Mlkt-1 PoL.V D
City/State/Zip: 5H-tj AnlI�Nty iy W5I
Policy # or Self -ins. Lie. # Z 6 cue 4 A c_ O Z .i L Expiration Date: O/- 0 b - o10,2O
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 cer j frdetir thepains andpena/ties ofperjury that the information provided above is true and correct.
Offlcial 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
NOTICE
TO
EMPLOYEES
NOTICE
TO
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 — http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give
you notice that I (we) have provided for payment to our injured employees under the above
mentioned chapter by insuring with:
76 WEG ACOZSL
The Hartford Accident and Indemnity Insurance Company
NAME OF INSURANCE COMPANY
One Park Place 300 South State St 7th Floor Syracuse NY 13202
ADDRESS OF INSURANCE COMPANY
1 ADP BLVD M/S 625
ROSELAND NJ 070E
The Three Good Guys Inc 4 RIVER ST SOUTH EASTON MA 02375-1286
EMPLOYER ADDRESS
9
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment
to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the
Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The
employee may select his or her own physician. The reasonable cost of the services provided by the treating
physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related
injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for
such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 D Printed in U.S.A.
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To: All Concerned Parties
From: Cindy Rice, RS
Eastern Food Safety
Re: ServSafe Food Manager Course /Exam confirmation
Date: 12/3/2018
This is to verify that Heather Bullio and Marwan Zeidan, of Mooyah, have
completed the ServSafe Food Manager Certification Course and Exam on
December 3, 2018 in Braintree, MA.
ServSafe results and certificates are available in 10-14 business days from
the exam date.
Thank you.
Cindy A. Rice, RS, CPFS, MSPH
Eastern Food Safety 70 Christina Drive. Braintree, MA 02184 781-356-1467
www.eastemfoodsafety.com cindy@eastemfoodsafety.com
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
Mansfield, MA 02048
'l'o the Board of Health at the Town of Mansfield. -
In accordance with the provisions of section 6511 gf'Chapier 94 of the General Laws, as most recently cnnended, and
the regulations invade thereunder, the undersigned hereby applies,for a lleense,for a 11!HOLGSAI.[JRL"PAIL
manufacture offi-ozen desserts and ice twain ndy and submits the following information:
Full name of applicant:
2. Business address 2
3, If applicant is an individva/: Full name:
Residence:
3a. If'applicam is a partnership, fall name and residence ofall partners:
36. /f applicant is a corporation: State of incorporation: --TN L 7iiA�F - tro (Dy<
Date of incorporation:
],u// name and address of: Principal office: F"Fq(�t D g! %a f
President � i �q i :, y QI vER 14. 5a EA O N - tik 0 23 5S' —
''Dvasurcr: ply-tVINC 7611)F).N ; 31 OLIO) ea9(ioNy WAN
Clerk: MR(LWAal Zee 3A6): 3yJ fM)9 / s 6P-Al"' 7'.ei;
4. Location of Plants:
5. Names of brands and trade or corporation name, of any, under which the products are to be sold:
6. Number and capacity offs eezers and fees: I Fee: ($25.00 per fieezei) $ #Type!
7. Is the mix purchased? 16 5 If so, fr oin whom purchased? S �s a
S. Is the mix pasteurized? y �j
9. Nuinher ofgallons of frozen desserts and/or ice cream nux to be .sold in Massachusetts during the licensing
period dl A
70. Nunrber o/ gatlons o,ffi ozen desserts and/or ice cream nux sold in ,Lassachusetts during the previous licensing period IA
II. Is the plant constructed and equipped as provided in the, regulations? 6A/
12. Is the wales supply public or rut? v
13. Have you received a copy of the regulations? 65
1 hereby certify that the frozen desserts and/or ice cream m>I sell in MassachuseKs will be manufactured in compliance with all law of
the Commonivealth f Alas saschuseus pertaining thereunder and all rules and regulations promulgated by the Massachusetts
Depanun t'f ubll Health made thereunder and will be manufactured under sanitary condltions. I attest that the information stated
In thl , ppll tl s true ccurate under the pains and penalties ofper fury.
Can ny owner/officer's signature) (DATE)
re5I'd < t,� Ma✓sFl�x�
(Title) (City or Town)
r�
Bank #
Pkt#