HomeMy WebLinkAboutSt. Gregory Orthodox 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:.
ST. GREGORY GREEK ORTHODOX CHURCH
Whose place of business is:
ST. GREGORY THE THEOLOGIAN (GREEK ORTHODOX CHURCH)
1007 WEST STREET
PERSON(S) IN CHARGE:
TED CHINGRIS
Permit Expires: December 31, 2019
Food Fee:
License Number: FS-68
BOARD OF HEALTH
-%1ichaeCWeaCey, Chairman
IN
VIV-17iEns
Milk & Cream
0�'-
FOR BOARD OF HEALTH USE ONLY Permit#Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name; 5�• GYf� ��-1�����o vt G�
Establishment Address: IOo-7 Wc)? AAA S� • s � � o 4 Fl
Establishment Mailing Address (If different): ��
r
O, 63x a-97 x
Establishment Telephone No: a O " �� �— �� �(' ( �� 2 2018
Applicant Name & Title:
as L.eornc'-r� si • i1 ns e�� M'�
Applicant Address:
Applicant Telephone No.: Sa$ - 63W -724 Hour Emergency No.:
Applicant Email:
Owner Name & Title (If different from applicant):
Owner Address:
Owner telephone number:
Owner small:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
0 An Association
partner.
O A Corporation
Name Title Address
Ed An Individual
--
_ -----
O ij.Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Telephone No: `o 337— 99 24 Hour Emergency No:
FAX:
Vc'�f ZZYl
E-mail: _�. G� to r S " ygg
AltE-Mail:`�fe�gf016�1� Ps,�it�1
District Or Regional Supervisor (if applicable)
Name & Title: n f
Address:
Telephone No: III 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No of Food Employees:
DAYS/HOURS:
Name of Person In Charge Certified in Food Protection Management: r CYO t h r S
If more than 3 individuals are certified, complete list is on file.
Person Trained in Anti -Choking P5Wdures (If 25 Seats or more):
Location:
�Permaneni
Fi Mobile Mobile Start
Date:
Mobile End Date:
Mobile Comments:
of Permit:
VnLength
nual
0 Seasonal
Seasonal[
N
_
0 Temporary
Temporary Start Date:
Temporary End Date:
I
Temporary Time:
Rain Date:
Location Establishment Type:
0 Retail ( Sq. Ft) $125
Q Food Service up to 100 INCLUDING
FOOD TRUCKS $176,00
l] Food Service up to 101 -200 $260.00
I] Food Service up to 201 + $300.00
I] Supermarkets $400
Nm pP.eFT
S
Caterer $35.00
0 Milk & Cream $10.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Ej Manufacture Frozen Desserisllce Cream
$25.00/freezer
Pushcart $50.00 # of Pushcarts:
EJ Residential Kitchen $100.00
E] Tobacco Products $150.00
Q Retail Snack Food $50.00
Food O erations: Definitions:PHF- Potenttallyhazardous food(timelfemperature controls required)
P Non-PHFs - non -potentially hazardous lood(no flmellemperetura controls required)
I(Check all that apply): 1 RTE-ready-to-eal foods (Ex, sandwiches, salads, muffins which need no farther processing)
0 Sale of Commercially Pre -Packaged Non-PHFs
E] Sale of Commercially Pre -Packaged PHFs
0 Delivery of Packaged PHFs
0 Reheating of Commercially
Processed Foods for Service Within 4 Hours
0 Customer Self -Service of Non PHF and Non -
Perishable Foods Only
Other Food Operations
I] PHFCooked To Order
Q Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
in! Sale of Raw Animal Foods Intended
to be Prepared by Consumer
lJ Customer Self -Service
lJ Ice Manufactured and Packaged fc
Retail Sale
E] Juice Manufactured and Packaged
Retail Sale
Offers
or Reconditioned
Out -Of -Date
Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Vacuum Packaging I Cook Chill
Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
El Offers Raw Or Undercooked Food Of
�Animal Ongin
C] Prepares Food/Single Meals for
Catered Events or Institutional Food Service
To be
Total Permit Fee:
Payment is due with application F] 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 690,000 and all other applicable law. I have been Instructed by the
board of health on how to obtain cc of 105 CMR 590,000 and the federal Food Code.
Signature of Applicant: -C o � w° ` ' '
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 to: /
Signature of Individual or Corporate Name: - 1 b� `-r'
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
trader law.
✓v
By: orporate Officer (Mandatory, if Applicable)
Signature of H1 ivid al or Corporate ame
"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.
CAUsers\sleite\Desktop\Scotts DocumentsWood Establishments- Temp\TAX CERTIFICATION PORM.doc
r The Contmollivetrltlt of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Ulf wwtv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Address: 106% W41 \\S'- I' �-
��+ v 4J v
City/State/Zip: `�r nnC i A 0zol Phone #: 5b 8 - -37
Are you an employer? Check the appropriate box:
1.1") I with _ employees (full and/
Business Type (required):
5. ❑ Retail
am a employer
or part-time).*
6. ❑ Restaurant/Bar/Eating Establishment
2. ❑ 1 am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (fuel. real estate, auto, etc.)
employees working for me in any capacity.
g. Q'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, §I(4), and we have
10.❑ Manufacturing
no employees, [No workers' comp. insurance required]*
I t.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12.0 Other
with no employees. [No workers' comp, insurance req.]
1
'Any applicant that checks box N I 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 B 1.
I aitt are employer t/tut isprovidittg Ivorkers' cotnp��ensatioiiinsurance for n:y eutp/oyees. Beloit, is tbepo/icy ittforinn/ion.
''t
Insurance Company Name:_ l�r ' t
Insurer's Address_�1�0.Y�'1L� S• S'tc7te-��. �� •{'�� YZLVS2 �� 13 Z
City/State/Zip: _ 5 t(,— W 5ja,-2Dy
"
Policy # or Self -ins. Lic. #_0 lt) ' C 53` 7>7 Expiration Date:_ _ p '
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 WORI{ ORDER and 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 ce ' y, Zn er tl % sins at l penaalltties of per7try that lite information provided above is true and correct.
c:...,.,,.,.,e, — Pr,- - l eZ- Date: / D, d 3- D' i Y-
INT,
Official use only. Do not write it) this area, to be completed by city or fawn 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
Phone
www,mass.gowma
NOTICE
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 1 (we) have provided for payment to our injured employees under the above
mentioned chapter by insuring with:
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
08 WEC CS3037 01/28/19
POLICY NUMBER EFFECTIVE DATES
655 BOSTON ROAD SUITE 1A
MERRIMACK VALLEY INS AGENCY INC BILLERICA MA 01821 (978)-667-2541
NAME OF INSURANCE AGENT ADDRESS PHONE
GREEK ORTHODOX PARISH OF 95/495 INC PO BOX 293 MANSFIELD MA 02048
EMPLOYER ADDRESS
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.
Mansfield Board of Health
Request for Fee Waiver for Food Permit
Date
We, S� �z9c M Y V Vtzb1 t U (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:.,_,
X'We are not charging a fee fof food/drink being served.
❑ We are a religious organization.
❑ Other: _
Thank you, r
Signature j
Title
*Please provide proof of valid 501(c)(3) status
BOH Use Only
Approved
Denied Reason:____
Signature: Date:
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