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Home My WebLink AboutGreat Woods Pizza - 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:. CHRISTOS TSIANAKAS, OWNER Whose place of business is: GREAT WOODS PIZZA 428 ELM STREET PERSON(S) IN CHARGE: KATHERINE TSIANAKAS, MANAGER Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS-32 BOARD OF HEALTH lmichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY IYiI�7�1��1_\=3��9:11,� L�ti;��1•Lr_1»�[�71 (Application must be submitted at least 30 days before the ig date) 12 Establishment Name: C`j9-EA—I r v oobs Z 2_ A Establishment Address: (. 11 00 V yn 6 V'C154 01 m f-) 016 8 Establishment Mailing Address(if different): Establishment Telephone No.: - L]C—,.T(D I q Applicant Name&Title: t%-Vi'LVIYl-Q Applicant Address: 2-- Tan\) CV Vl vt_ Applicant Telephone No.: SZ)8 . ILjL VI (-+{p 24 Hour Emergency No.: Applicant E-mail: GI2U�-T /�21 1?51��17 6 LaC MH-I L. 0-0VVI Owner Name & Title (If different from applicant): Ch V131-03 I SI C r\okA as' (DLADV (2 F-- OwnerAddress 2— WoV CAVlVc tv, UQSI [elf yy) UL-zs Owner Telephone No.: V (_-)8 , Cl L( L-) - L ( (f 3� Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. A Corporation ®An Individual Name Title Address IICodV(a�,�_ 0L�ne✓ Z�Jn C(VIV-e _ IN A Partnership �_'�`JiCtV1�1lQS V�� TfJVI cjvwe Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: �Gt�'KkkAV' 1 S1 C(,,V jfD,) Address: Telephone No: 5p8.c1LILi.4ll= 24HourEmergencyNo: FAX: E-mail: VIG) M a u �� 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: 12 DAYS/HOURS: 1 Ps �)oof S Name of Person In Charge 6ertified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑® Location: Permanent Location Establishment Type ❑® Caterer $35.00 ❑® Moblie Mobile Start Date: ® Ret iV(/ Sq. Ft) ❑M Milk & Cream $10.00 Mobile End Date: cod Service u to 100 INCLUDING p ®Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 ❑id Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length Of Permit: Annual Food Service up to 201 + $300.00 ® Pushcart $50.00 # of Pushcarts: ® Residential Kitchen $100.00 IN Seasonal Seasonal Dates: Supermarkets $400 ® Retail Food $125.00 _®fernporary ®Retail Snack Food $50.00 Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: - "--"---- — Food Operations Definitions:PHF- Potentiallyhazardous food(timeAemperature controls required) Non-PHFs - non-pofenfiallyhazardous lbod(no time/lempomfum controls required) ;Check all that apply): — -- RTE- ready-foeaf foods (Ex. sandwiches, salads, muffins which needno rudherprocessing) nm Sale of Commercially Pre -Packaged Non-PHFs �, PHFCooked To Order ❑® Hot PHF Cooked and Cooled or Hot Held ® Sale of Commercially Pre -Packaged PHFs ® Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service k PHF and RTE Foods Prepared For Highly Susceptible Population Facility Reheating of Commercially Sale of Raw Animal Foods Intended rocessed Foods for Service Within 4 Hours to be Prepared by Consumer ®Vacuum Packaging /Cook Chill Customer Self -Service of Non PHF and Non- Perishable Foods Only ® Customer Self -Service Jul Use of Process indi Variance and/or HACCP Pllanan ((incicluding bare hand contact alternative, time as a public health control) ® Ice Manufactured and Packaged for Retail Sale Preparation of Non-PHFs Other Food Operations no 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 0 Offers RTE PHF in Bulk Quantities or Reconditioned Food Lbempleted bythe Board of Health mit Feeis due with application r 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. 00 nd all other applicable law. I have been instructed by the board of health on how to obtain c4es of,105-CMR 59 . I h&federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury and paid state taxes required under law. Signature of Individual or Corporate Name: Social Security Number or Federal ID: I, to my best knowledge and belief, have filed all state tax returns ►--I 9 - H M Vio W 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. Si ature 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. C:\Users\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 M www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: l'7r-ea+y OCd s vra l,4 Address: LA"1,g-) uyn City/State/Zipf) 0 Za4 a Phone #: ©I l Are you an employer? Check the appropriate box: Business Type (required): 1, ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. Restaurant/Bar/Eating Establishment 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. [No workers' comp. insurance required] S• ❑ Non-profit 3.( We are a corporation and its officers have exercised 9. ❑ Entertainment 1 v their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11. ❑ Health Care 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 #1. I am an employer that is providing workers' rompensatlon insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lic. # amm ftjC "t 015tA Expiration Date: I Z I J I 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 th�ains andpena/ties of perjury that the information provided above is true and correct Phone #: 2171 L-1 • -IN. 01 I g 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 #: www.mass.gov/dia . Ro CERTIFICATE OF LIABILITY INSURANCE DA/YYYY) 12/01/201OD1/2018 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(ies) 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 endorsements . PRODUCER PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE ROCHESTER, NY 14620 CONTACT Paychex Insurance Agency Inc MCONED. - 877-266-6850 FAX No). 585-389-7426 EMAILBESS. CertsQpaychex.com INSURER(S) AFFORDING COVERAGE NAIC if INSURED INSURER A: NorGUARD Insurance Company 31470 GREAT WOODS PIZZA CORP 428 ELM STREET INSURER B: INSURER C: WRENTHAM, MA 02070 INSURER D: INSURER E: INSURER F: 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 CONTRACTOR 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. IS LTR TYPE OF INSURANCE DD INSRMM/DD/YYYY) UBDR POLICY NUMBER POLICY EFF POLICY EXP (MM/DDNYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ��LAIMSMAOE�1DCCUR EACH OCCURRENCE $ DAMAGET -RENTED PREMISES (Ea amneence) $ $ MED EXP(Any one person) PERSONAL &ADV INJURY $ GENERALAGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY OPROIECT=LOD $ AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALLOWNED SCHEDULED AUTOS EA SCHEDULED HIREDAUTOS �AUTOSWNEO BODILY INJURY (Peraccldent) $ PROPERTY DAMAGE (Pet accident) $ UMBRELLA UAB [ OCCUR EXCESS UAB =CWMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION] WORKERS COMPENSATION AND EMPLOYERSm UMMUTY GRWC902543 12/05/2018 12/05/2019 �. WC STATU- OTH- E.L. EACH ACCIDENT $ 100,000.00 ANY PROPRIETOWPARTNERIE%ECUTNE E.L. DISEASE - EA EMPLOYEE $ 100,000.00 OFFICERIMEMBEREXCLUDED)nim)YIN (I.Lnaataryln NN) N Byea,aeattir DERcm"10N OF OPERATION% hem N/A E.L. DISEASE -POLICY LIMIT $ 500,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER CANCELLATION Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) 1988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 9 fA Q Q W Z ry W w m ƒ\ 2 ? k \ w O W U w W U V z 1� z H z w P4 w z Q F W = N O W Q V N EN (� N N Y N c 00 0 U u 0 U 0 a 4W.., 0 0 U q r w v 7 0 O Lama_ N�N0 1 P 1 Ell aaoo� n M � w M 0 'v mq� "vY y w � e V to `ti o � y