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HomeMy WebLinkAboutMansfield House of Pizza - 12/21/2019;/fi Commonwealth 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:. EZZAT A. ZAKHARY Whose place of business is: MANSFIELD HOUSE OF PIZZA, INC 175 NORTH MAIN STREET PERSON(S) IN CHARGE. EZZAT A. ZAKHARY, PRESIDENT Permit Expires: December 31, 2019 Food Fee: $185.00 License Number: FS -49 BOARD OF HEALTH .lblichaecHeatey, Chairman --- Milk & Cream C,P rr� N 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: f1'101 Y) $ Fi e10 140 u, O Establishment Address: 1-[5- A/0, Mttl.r S 1 ' m. r R f � Establishment Mailing Address(if different): DEC o 5I)'8 ©0 Establishment Telephone No.: 6V:9- 33G) - &L/00 4.r. Applicant Name & Title: C Z'ZQ/L )� 0G, % - �ft ) (f/-0 Applicant Address: o2q LUI,nCM5s 11.re mvlylsr end r Applicant Telephone No.: 5V:5 -3 3 9 --77 V 24 Hour Emergency No.: 60 $-o2tpC/ - L-1133 Applicant E-mail: t' Lro i-(�50 91Y)LV Owner Name & Title (If different from applicant)): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or ED An Association partner. VA Corporation Name Title Address OAnIndividual S -20 LYY) O A Partnership 19 Other legal Entity Person Directly Responsible For Daily wne , person in charge, supervisor, manager etc.) Operations Name & Title: r—Z�A J n onow- Address: V M e 0 24 Hour Emergency No: Telephone No: FAX: �p E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Y' Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) DAYS/HOURS: -7 11-10 Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Ezz�� �►����-2y Person Trained in Anti -Choking Procedures (If 25 Seats or more): a e Location: A Permanent Location Establishment Type Q Caterer $35.00 E]Moblie Mobile Start Date: Q Retail ( Sq. Ft) I'.V Milk & Cream $10.00 Mobile End Date:Iy4yIFood Service up to 100 INCLUDING Q Mobile Food Consession Mobile Comments: / V-OOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 Manufacture Frozen Dessedsllce Cream $25.00/freezer Length of Permit: Annual Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: tg Seasonal Seasonal Dates: ' '.❑�_ Supermarkets $400 Residential Kitchen $100.00 Retail Food $125,00 Q Retail Snack Food $50.00 [] Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions: PHF- Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) (Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, mums which needno furtherprocessing) E0 Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order lUg Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑�- Sale of Commercially Pre -Packaged PHFsPreparation of PHFs For Hot And �IACold Holding For Single Meal Service I] PHF and RTE Foods Prepared For Highly Susceptible Population Facility tU Delivery of Packaged PHFs Q Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially rocessed Foods for Service Within 4 Hours Q Vacuum Packaging / Cook Chill - Use of Process Requiring di Variance and/or HACCP Plan (including bare hand rt Customer Self -Service of Non PHF and Non - 0 Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) (] Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations (] 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 Q Offers RTE PHF in Bulk Quantities E] 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 E0 waived I, the undersigned, attest to the accuracy of the information provid d in this application and affirm that the food establishment operation will comply with 105 CMR 590.000 and a other applicable law. I have been instructed by the board of health on how to obtaaiir�l copies of 105 CMR 590.000 an the fede �d Code. Signature of Applicant: /'; '� Pursuant to MGL Ch,62C, sec. W!Ucertity under the peqa3f es of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: /Y1�t't5f%)t;1ei 140 03r— 0t �' ,7A )0C - Social Security Number or Federal ID: Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: MNo,-5J-1&4 14otut of iinoi ADDRESS: ),7 S --Ivo - MR)"r) 51 TELEPHONE AT LOCATION: 5-0 8 33 9 — 601) 00 FAX NUMBER: OWNER OF BUSINESS: [=r z'o 1 -e�11/-1) )04 O R/ TELEPHONE OF OWNER: 50Y ---7,39 - 7 % ikY FEDERAL ID/SS NUMBER: CL -1-3,19-1&q7 FEE: $10.00 PERMIT NUMBER: SIGNATURE: DATE: 11-�1j—I 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. 905 U4u1 e o9 - e),Z?, 1'hC, Signature of Individual or Corporate Name By: Corporate OTAVer (Mandaton� if icable) 0'-/c-�O/-/&qJ **Social Security No. (Voluntanj) 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. C1Users\s1eite\Desktop\Scott's Documents\Food Establishments. Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department oflndustrialAccidents b I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNHTTING AUTHORITY. _Applicant Information Please Print Legibly Business/Organization Name:mai rl- 61el (t1­J'D A e Or 01,7_27-Q, Address: 1*745- A10 MOh'r) 51 W P - 0,20V& Are you an employer? Check the appropriate box: 1. ❑ 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. MRestaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I1.❑ 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 is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company CIO Insurer's Address: PM C' `, r4- - City/State/Zip: 1_P� q1_k_r^ fy) T(� 49cs20 Policy# or Self -ins. Lic. #--LIE _L7. CD�_�i - Expiration Date: 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, under cthe paiins and penaltie of perfury that the information provided above is true and correct. Simiature: ,Y`V '2� Date7 Phone # 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 #: wwormass.gov/dia o � _m s N m N N J °0 0-' 00 c n 2 m T N N �a 3 n 0 3' a' a a 2 oc .+e}Srr ✓� � o D r3`;r �sidf ! a too r t= WORKERS COMPENSATION ANIn EMPLOYERS' LIAR LTY INSURANCE POLICY ---- INFORMATION ' i ACR: INSJRER: POLICY NO: GiE172629t3 NORFOLK & DEDHAM MUTUAL FIRE JNSURANCE COMPANY 222 AMES STREET RENEWAL DEDHAM, MA 02026 NCC[ Company No: 21 059 TE Account No: FEIN:. 04-3291697 ITEM 1. NAMED INSURED AND MAILING ADDgESS: AGENT NAME AND ADDRESS: MANSFIELD HOUSE OF PIZZA INC SALHANEY INSURZa,4CE AGENCY 175 N MAIN STREET 5264 WASHINGTON ST MANSFIELD, MA 02048 WEST ROXBURY, MA 02132 AGENT NO.: 20121060 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule) ITEM 2. POLICY PERIOD: From: 11/05/2018 TO: 11/05/2019 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part Gibe of the policy applies to the Workers Compensation Law of the states 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 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: SEE ENDORSEMENT WC 20 03 06-B D. This Policy includes these Endorsements and Schedules: See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: Thepremium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 215Annual Premium: $ 997 Audit Period: ANNUAL Additional/ Return Premium: Comments: Issued At: Date: 09/26/2018 Countersigned by WC 00 00 01 A Copyright 1981 National Council on Compensation Insurance INSURED COPY t!: