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Home My WebLink AboutOrthodox Congregational Church - 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 SERVICE 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:. ORTHODOX CONGREGATIONAL CHURCH OF MANSFIELD Whose place of business is: ORTHODOX CONGREGATIONAL CHURCH 17 WEST STREET PERSON(S) IN CHARGE: MATTHEW GEMINIANI Permit Expires: December 31, 2019 Food Fee: License Number: FS -61 WAIVED BOARD OF HEALTH Michaet'Heatey, Chairman FOR BOARD OF HEALTH USE ONLY ib FOOD ESTABLISHMENT PERMIT APPLICATI %ff� (Application must be submitted at least 30 days before the ptanne bp" ing date//) 1) Establishment Name 0 � } -- - ew'j4�4 j by _, 2) Establishment Address •�f �t _ {� f N 4 A �r� �,/� Telephone No: 3 7 & & -- - 24 Hour Emergency No: —�-- - - - - 3) Establishment Mailing Address (if different) E-mail: 4) Establishment Telephone No Alt E -Mail: 5) Applicant Name & Title: 6) Applicant Address J %C t �� a r / W� / j�/t f f z 7) Applicant Telephone No.: 24 Hour Emergency No.: 8) Owners Name & Title • G. Ci Cc�J S,r 1 e( 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers C I An Association or partner. A Corporation Name Title Address I An Individual — —---- _ --- - — [ I A Partnership -- Other_le]c al Enter_ -- ----— - --- 191 Parsnn nirPrtly Resnonsible For Dailv Operations (owner, person in charge, supervisor, manager etc.) Name & Title: ��r� / • i d Address: •�f �t _ {� f N 4 A �r� �,/� Telephone No: 3 7 & & -- - 24 Hour Emergency No: —�-- - - - - FAX: -- E-mail: rvi° t ��d :=U�nGks7--/i - Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: r 24 Hour Emergency NO: -- -- FAX: ti E-mail: - Food Establishment Information 14) WATER SOURCE: i^ti t) ,J w e ( 15) SEWAGE DISPOSAL: �- DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management:/ If more than 3 individuals are certified, complete list is on file. T Required as of 10/1/2001 in accordance with 105 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 LJ Mobile Mobile Start Date: 22) Establishment Type I] Retail ( Sq. Ft) O Caterer $25.00 Milk & Cream $10.00 Mobile End Date: Mobile Comments: Food Service up to 100 or up to 10' PHF display $125.00 Food Service up to 101 -200 ❑ Mobile Food & Consession $75.00 - Manufacture Frozen Desserts/Ice Cream $25.00/freezer r 21) Length olf Permit: Annual or up to 25' PHF display $150.00 C] Food Service up to 201 + or 25'+ PHF display $275.00 ❑ Pushcart $25.00 # of Pushcarts: ❑ Residential Kitchen $100.00 Retail Food $100.00 Seasonal - Seasonal Dates: Food Service - Institution ❑ Retail Snack Food $25.00 [j Temporary -- Temporary Start Date: ( Meals/Day) i] Tobacco Products $25.00 Temporary End Date: Temporary Time: — Rain Date: — Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHF's - non -potentially hazardous food(no timeRemperature controls required) (23) (Check all that apply): i RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non -PRFs - PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service j (] Sale of Commercially Pre -Packaged PHFs ----- --- Ll Delivery of Packaged PHFs — 71Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility -- E]Sale of Raw Animal Foods Intended to be Prepared by Consumer -----" F-1 Reheating of Commercially — j Processed Foods for Service Within 4 Hours E] Vacuum Packaging / Cook Chill j ] Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control)—_. -- --- I..I Customer Self -Service of Non PHF and Non- Perishable Foods Only �--"-- Customer Self -Service E] Ice Manufactured and Packaged for Retail Sale -- —" 0 Preparation of Non-PHFs Other Food Operations _ U Juice Manufactured and Packaged for Retail Sale ❑ Offers Raw Or Undercooked Food Of Animal Origin ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities El Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: -- Payment is due with application El waived 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 copies of 105 Cty1R. 590.000 and the federal Food Code, 24) 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. 25) Social Security Number or Federal ID: 26) 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 By: Corporate Officer (Mandatory, if Applicable) *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. R:\Health\J nes Doc=entr\PERMCr APPLICATIONMAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of ZndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 = www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERKS MG AUTHORITY. Applicant Information ( ",za cl -C sc Plea Business/Organization Name: 'la Address: . t � S 5 f` _ City/State/Zip: L Li �€ i etCt • Phone # ` Are you an employer? Check the appropriate box: 1, ❑ I am a employer with employees (full and/ or part-time).* 2.0 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 e. 152, § 1(4), and we have ,�, nno- eme req employees, [No workers' comp. insurance, 4, h,�' W e are a non-profit organization, staffed by volunteers , 0-!Wwtth no employees. [No workers' comp. insurance req.] 07'ilI %X 6 %-( Business Type (required): 5. ❑ Retail 6. F]RestaurantBar/BatingEstabiishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 1 o. ❑ Manufacturing 11. ❑ Health Care / *Any applicant that checks box#I must also fill out the section below showing theirwarkers' compensation policy information. **If the corporafe officers have exempted themselves, but the corporation bas otber employees, a workers compensation policy is required and such an organization should check box''#1. lam an employer that is providing Workers' compensation insurance for my employees. Belotp is the policy informado$. insurance Company Name:__6 , �--a k� 0 ) Insurer'sAddressj."/ /V-0 t/r S City/State/Zip: r ra. /7 Policy # or Self -ins. Lic. #- Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to svcLTa 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. Ido hereby certify r sP_ a�y(}�s and penalties ofperjury thatthe information provided above Is true and correct: 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 lure, 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 ajoint enterprise, and incfudingthe legal representatives of a deceased employer, or the receiver or w stee of an individual, partnership, association or other legal entity, employing employees, Ffewever, 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 bouse or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter I52, §25C(6) also states that "every state or local licensing agency sball withbold the issuance or renewal of a license or permit to operate a business or to constructbuildings-in the commonwealth for any applicant who has not produced acceptable evidence of compliance with tb a insurance coverage required." Additionally, MGL chapter 152, §25CO states "Neither the commonwealth nor any of its political subdivisions shall enter info 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 insurancecompany'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 Tndwtrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit sbould 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 regardingthe 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 contactyou regarding the applicant Please be sure to fill in the permitlticense 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 (ifneces'sary). 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. Wbere a home owner or citizen is obtaining a license or permit not related to any business or codrmercial venture (i,e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-N ASSAFE Fax # 617-727-7749 www.mass.gov/dia Forth Rcviscd 02-23-15 AC40`O CERTIFICATE OF, LIABILITY INSURANCE DADAVYY 1 12//03/1803/18 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 -^EPRESENTATIVEOR PRODUCER, AND THE CERTIFICATE HOLDER. ,PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. it 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 CONTACT CHURCH MUTUAL INSURANCE COMPANY PHONNo E — FAX(A C, AIC Ext: No: EMAIL ADDRESS, 3000 SCHUSTER LANE INSURERS) AFFORDING COVERAGE NAIC# PO BOX 357 MERRILL, WI 54452 INSURERA: CHURCH MUTUAL INSURANCE COMPANY 18767 _ INSURED INSURERB: INSURERC: ORTHODOX CONGREGATIONAL CHURCH 17 WEST ST - -- ----- MANSFIELD. MA 02048-2424 INSURERD: INSURERE: NSURERF: DAMAGE TO RENTED $ 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 WITH 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPEOFINSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MMIDDYYYY) POLICY EXP (MWDDIYYYY) LIMITS X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,00_0_ CIAIMSMADE uOCCUR DAMAGE TO RENTED $ MEDEXP(Any_oneperson) $ 10,000 0180100-02-173106 01/01/19 01/01/22 PERSONAL&ADV INJUR_Y____ $_ 1,000,000 AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 3,000 000 GEHL X POLICY 0 PRO- [::] LOC ECT PRODUCTS-COMPIOPAGG $ 1,000,000 ---- $ OTHER: . AUTOMOBILE LIABILITY Ea HINB [ $ BODILY INJURY (Per person) $ ANY AUTO OMED SCHEDULED AUTOSONLY AUTOS HIRED NON OVvMED AUTOSONLY AUTOS ONLY BODILY INJURY (Par accident) $ -PROPERTY DAMAGE $ (Per axiden[ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESSUAa CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN PER OTH STATUTE ER _ ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $ EL DISEASE EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) NIA E.L. DISEASE -POLICY LIMIT $ If yes, describe under DESCRIPTION OF OPERATI ONS bebw DESCRIPTION OF OPERATIONS/ LOCATIONSIVEHICLES (ACORD101, Additional Remarks Schedule. may be attached if more space is required) FOOD PERMIT CERTIFICATE HOLDER CANCELLATION TOWN OF MANSFIELD 6 PARK ROW '" INSFIELD MA 02048-2433 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDA NCE W ITH THE POLICY PROVISIONS. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD LL lV LO t Q N � LO w CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: MATTHEW GEMiNiMli Certificate Number: 2e7M49 Date of Completion: nn912016 Date of Expiration: 11/29/2021 7/ie above-namedposon is hereby issued this certxtate fa" tanpleting an allergen awareness training progmur recognized by the Massaebusetts Department ofPubli, Health in accordance with 105 OVIR 590.009(G)(3)(a). 775is mrti6tate will be valid lbr five (5) years frau Ante ofemnpletion. Issued By: NATIONAL ••I RESTAURANT ASSOCIATION, Massachuscns Reshurant Association 800.765.2122 333 Turnpike Rmd, Suite 102 wss�¢restaunntorg Southborough, MA 01772 508-303-9905 aysysem tautanussocorg Mansfield Board of Health Request for Fee Waiver for Food Permit Date le , C. a q�tSre We, � • c (restaurant! organization ) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: ❑ We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. * ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. Please list the organization: ❑ We are not charging a fee for food/drink being served. b'We are a religious organization. ❑ Other: Thank you, Signature Title *Please provide proof of valid 501(c)(3) status BOH Use Only Approved Denied Reason: Signature: Date: