HomeMy WebLinkAboutTrattoria Della Nonna - 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:.
KENNY M. DEFAZIO
Whose place of business is:
TRATTORIA LA CUCINI DELLA NONNA
160 NORTH MAIN STREET
PERSON(S) IN CHARGE:
KENNY DEFAZIO, OWNERICHEF
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS -80
BOARD OF HEALTH
AichaeCHeatey, Chairman
Milk & Cream
IV
FOR BOARD OF HEALTH USE ONLY Permit #Issued
i
_J
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name
Establish ment Add ress
Establishment Mailing Address (if differ)
Establishment Telephone Noor
Applicant Name & Title:
Applicant Address
Applicant Telephone No.: 24 Hour Emergency No.:
Applicant Email
Owner Name & Title (if different from applicant)
OwnerAddress
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
1 An Association partner.
1 J A Corporation Name Title Address
N! An Individual
A Partnership
Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title:
Address:
Telephone No: ILW\
24 Hour Emergency No:
FAX:
E-mail:
Alt E -Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:,
Telephone No:
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:
If more than 3 individuals are certified, complete list is on file.
Ii
Person Trained in Anti -Choking Procedures (If 25 Seats or more)
Location: Permanent Location
�.-� Establishment Type:
�,J
i J Caterer $35.00
' ! Moblie Moblie Start Date I - Retail ( Sq. Ft)
[kMilk & Cream $10.00 '.
Moblie End Date: l Food Service up to 100 INCLUDING
F-] Mobile Food Consession
Moblie Comments: FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
Length of Permit:
] Manufacture Frozen Desserts/Ice Cream
[] Food Service up to 101 -200 $250.00
$25.00/freezer
:YAnnual
Food Service up to 201 + $300.00
-.] Pushcart $50.00 # of Pushcarts:
- Seasonal
-
Residential Kitchen $100.00
Seasonal Dates: -", Supermarkets $400
'I �
_
� Retail Food $125.00
Temporary 11
[.] Retail Snack Food $50.00
Temporary Start Date:
Tobacco Products $150.00
Temporary End Date:
Temporary Time: j
Rain Date: J
Food Operations. Definitions: PHF - Potentially hazardous food (timeRemperature controls required)
Non-PHFs non -potentially hazardous food(no time/temperature controls required)
((Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no rurtherprocessing)
i
Sale of Commercially Pre -Packaged Non-PHFs
Sale of Commercially Pre -Packaged PHFs
Delivery of Packaged PHFs
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self -Service of Non PHF and Non -
Perishable Foods Only
of Non-PHFs
."HFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Self -Service
Ice Manufactured and
Retail Sale
i,..] 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 / Cook Chill
❑ Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Other Foodoil Operations ❑Juice Manufactured and Packaged for Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
F[ ]OffersR--- "—TE PHF m Bulk Quantitietie s 1 [ Prepares Food/Single Meals for
_— Catered Events or Institutional Food Service ,
I, 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 J waived
I, 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 CMR 590.000 and the federal Food Code.
Signature of Applicant: ' 6=Jif
Pursuant to MGL Ch.62C, sec. 49A, I certify
and paid stale taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name:
the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns
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.
/ iignati�re' of IxididWal or Corporate Name
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandator, 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.
R:\HmIIhVane's DocumentAPERMIT APPLICATIONWAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV www.massgov/dia
. Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name:.@
Address:��
City/State/Zip Phone #:
Are you
an employer? Check the appropriate box:
Business Type (required):
1.5
1 am a employer with 4: employees (full and/
5. [:]Retail
or part-time).*
6. Restaurant/BarBating Establishment
2. ❑
I am a sole proprietor or partnership and have no
?, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8• ❑ 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]*
I I.❑ Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
with no employees. [No workers', comp. insurance req,]
12.0 Other
*Any applicant that checks box H 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 #L
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company
Insurer's Address:
City/State/Zip:1� c `�
Policy # or Self -ins. Lic. # C i`� ��y Expiration
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,
Ido hereby certify, under the pains andpenalties ofperjury that the information provided above is true and correct
www.muss.gov/ma
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 hire,
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 a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees, However, 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 house
or on the grounds or building appurtenant thereto shall not because of such' employment be deemed to be an employer,"
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into 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 insurance company'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 cant' 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 Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should 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 regarding the 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 contact you regarding the applicant.
Please be sure to fill in the permit/license 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 (if necessary). 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. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like,to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call,
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0211 t
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Fofm Revised 5.26-05
A�CERTIFICATE OF LIABILITY INSURANCE
DAT1119120/YYYY)
11/1912!zO®
018
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
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If 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 endomement(s).
PRODUCER
CONTACT
NAME:
Automatic Data Processing Insurance Agency, Inc.
FA
PHONE a' Est); AIC No
1 Adp Boulevard
EM
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAICN
Roseland, NJ 07068
INSURERA: Travelers indemnity Company of Connecticut 25662
'\
INSURED TRATTORIA DELLA NONNA
INSURER B.
INSURERC:
DBA: TRATTORIA DELLA NONNA
INSURERD:
160 N MAIN ST
Mansfield, MA 02048
INSURERE:
INSURERF:
MED EXP (Any one person) $
COVERAGES CERTIFICATE NUMBER: 1027618 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.
INSRrypE
LTR
OF INSURANCE
INSD
WVD
POLICY NUMBER
PO C EFF
MMIDDIYYYY
POLICY E%P
MWE)E YYY
LIMITS
COMMERCIAL GENERAL LIABILITY
'\
EACH OCCURRENCE $
CLAIMS -MADE o OCCUR
PREMISES Ea occurrenceS
MED EXP (Any one person) $
PERSONAL B ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $
POLICY ❑ PHI- 0 LOC
PRODUCTS -COMP/OPAGG S
$
OTHER:
AUTOMOBILE LIABILITY
O BI sn SINGLE LIMIT S
Ea accident
BODILY INJURY (Per person) $
ANY AUTO
BODILYINJURY(Peraccitlen0 $
ALL OWNED SCHEDULED
AUTOS
AUTONIREDSAUr05
NON -OWNED
AUTOS
PROPERTY DAMAGE $
Per accldenl
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
AGGREGATE S
EXCESS LIAB
CLAIMS -MADE
DED
RETENTIONS
$
A
WORKERS COMPENSATION YIN
AND EMPLOYERS' LIABILITY
EX
ANY PROPRIETORIPARTNERIECUTVE
OFFICERIMEMBER EXCLUDED? �
(Mandatory In NH)
NIA
N
UB9J28695118
0910812018
0910812019
-
X STATUTE ER
E.L. EACH ACCIDENT $ 1,000,000
-
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
ItYyes,d y he under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT 5 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required)
CERTIFICATE HOLDER CANCELLATION
A01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registeredmarks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Manffield
ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Board of Selectmen
160 North Main St
AUTHORIZED REPRESENTATIVE
Mansfield, MA 02048
A01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registeredmarks of ACORD
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ServSafe"
CERTIFICATION
DEVIN SHENKAR
for su xossfully cwaileting the slondards sot forth for the SewSolea Food
which is accredited by Ilia American National Standards Institute (ANS
urger Certilicalion Exomindion,
for Food Protatiun (CFPI.
5110
:XAM FORM NUMBER
11/16/2020
)ATE OF EXPIRATION
xaliflmtion regWremanb.
CvAM y.rih9'Min�J I75wbJaa,Bl.d. 5a I500,06ig ,, vmis(u a Se.3hB..wnar.,
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: 0-N SHENMR
Certificate Number: 2147353
Date of Completion: sz rzm5
Date of Expiration: 12A20�
Dir abate -named pent, is hereby issued this mpv rate
far rompleling an al/ergm awareneu training program
recogniwd by the Massarbnseln Departrnetn ofAib it Health
Ds areordnnre with 105 CAM 590.009(G)(3)(a).
7his eepilinne will he valid lat, free (5)years front date ofromplelion.
bmcd By:
mna�
hlmsa<huuets Resmwant Assodation
333 Turnpike Rd, S.ht 102
Smthbomugh, NIA 01772
508-303-9905
\vxw,momernnlunrusar.org
NATIONAL l
RESTAURANT
ASSOCIATION„
800.7652122
\VWN.rt61:lUfAUt.allg
assachusetts Department of Revenue MT -1
Data Integration Bureau
CD
100 Cambridge Street 6280000
Boston, MA 02204 CERTIFICATE NUMBER
1 A
764H.
ndor herein named is registered to sell meals and all beverages pursuant to the General Laws, Chapters 62C and
his registration is effective only for the registrant at the location specified herein. Any change of name or address
s this registration null and void.
043-461-876 IDENTIFICATION
K LiiNNL H e1 DEi At 10 NUMBER
TRAT79RIA LA CUCINA 01N'0i1PIA
161,; ir0kTtl fiAIN ST 05127/1)0
ISSUE DATE
ill Ai'3s F 1`LD MA 62!1143 '
FREGI)EliICK A. LASKEY
This registration must be displayed for customers to see and is not assignable or transferable.
COMMISSIONER OF REVENUE
k (yaw A ��.
Hec.'lrqwavew-, v"� American
/ Heart
� P M _. Association.
YVONNE DEFAZIO
The above individual in successfully completed the objectives and skills evaluations
in accordance with the curriculum of the AHA Headsaver CPR AED Program. Optional
completed medulos are those NOT marked oul:
03/IMW" Intent CPR 03/2aV
Date Recommended Renewal Data
��atia I3Y(�'o American
Heart
r Association•
KENNY DEFAZIO
The above individual has successfully completed the objectives and skills evalualk ns
in accordance with the curriculum of the ANA Headsaver CPR AEO Program. Optional
completed modules are those NOT marked out:
03/I%Vly' InfmACPH 03/2646
Recommended Renewal Data
Issue Date
(" American
�
.�f_
�'� ) Heart Associatione
MELANIE TREMBLAY
The above Individual has successfully completed the objectives and skills evaluations
In accordance with the curriculum of the AHA Headsaver CPR AED Program, Optional
completed modules are those NOT marked out:
03/l�%rldifIWAED Infant CPR 03/2 E
Issue Dale Recommended Renewal Dale
FOR a 4a0 u a li D
&e an ��
0 a I to IM-) 1-i"', American
Heart
Association.
JAMES PARADISE
The above individual has successfully completed the objectives and skills evaluations
in accordance with the curriculum of the AHA Headsaver CPR PED Program. Optional
completed modules are those NOT marked out;
Child CPR AED Inlant CPR Exam
03/17/2018 03/2020
Issue Date Recommended Renewal Dale