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HomeMy WebLinkAboutGeno's Restaurant - 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:. JOHN J. SPIEZIO Whose place of business is: GENO'S RESTAURANT AND LOUNGE 409 NORTH MAIN STREET PERSON(S) IN CHARGE: JOHN SPIEZIO, MANAGER, OWNER Permit Expires: December31,2019 Food Fee: $175.00 License Number: FS -30 BOARD OF HEALTH MichaeC -Ceatey, Chairman Milk & Cream C0 A M 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: GEoccj Y-GSr9Uri f" Establishment Address: 4 U a 40 10 -V-A 0/1' -th 's -t Establishment Mailing Address(if different): Establishment Telephone No.: S Oe 3 3 'G- 977 ( Applicant Name & Title: t -t t'1 kol C0-1 © Applicant Address: Applicant Telephone No.: 24 Hour Emergency No.: S C-) 4 1 —3 ZZ'/ Applicant E-mail: Owner Name & Title (If different from applicant): C Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: An Association El A Corporation An Individual El A Partnership ,❑ Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address cJ i'o t �2f O �vr`{ f✓�IP� t2g.`3 Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: FAX: E-mail/ Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: 24 Hour Emergency No: 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. SII �j-4vZ� Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ Location: ❑ Permanent Location Establishment Type ❑ Caterer $35.00 ❑ Moblie Mobile Start Date: ❑ Retall ( Sq. Ft) Milk & Cream 11(1,01 Mobile End Date: food Service up to 100 INCLUDING ❑ Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 IManufacture Length of Permit: E] Food Service up to 101 -200 $250.00 Frozen Desserts/Ice Cream $25.00/1reezer Annual O --- ------- - ------1 ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: ❑ Seasonal i ❑ Supermarkets $400 F-1ResidentialKitchen $100.00 Seasonal Dates: Retail Food $125.00 ❑ Temporary Temporary Start Date: ❑ Retail Snack Food $50.00 Temporary End Date: Temporary Time: Rain Date: I - Food Operations Definitions:PHF - Potentially hazardous food(time/temperature 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 turtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order I ❑ Hot PHF Cooked and Cooled or Hot Held -o ----i -- - - -� for More Than a Single Meal Service Sale of Commercially Pre Packaged PHFs ❑ Preparation of PHFs For Hot And �_ -- ------ -- Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly E] Delivery of Packaged PHFs --. -.-. -_.-.___-_ Prepared b Processed Foods for Service Within 4 Hours P y Consumer I Vacuum Packaging /Cook Chi Susceptible Population Facility Reheating o - -ng of Commercially -- -- ❑ Sale of -Raw -Animal - Foods Intended to be Pre --- � ❑ ll ---- --- ---- ----- U Use of Process Requiring A Variance Customer Self -Service of Non PHF and Non- ❑ Customer Seif-Service and/or HACCP Plan (including bare hand Perishable Foods Only -__-- - _ - contact alternative, time as a public health __._._ _.____� ❑ Ice Manufactured and Packaged for I Preparation of Non-PHFs I Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Of RTE PHF in Bulk Quantities �❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date ---- -- --- -------- or Reconditioned Food To becompleted by the Board of Health --_-- Total Permit Fee: Payment is due with application ❑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 CM"0Y0 and thVederal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify u er the penaltie of rjury„ that I, to my bask knowledge and belief, have filed all state tax returns and paid state taxes required under law. r P/$ignature of Individual or Corporate Name: f Social Security Number or Federal ID: 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. Sig ture of Indiv' ual r Corporate Name .#, 5S U 1 4� 4r`2�F3 r., -C-0-4 *"Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) 4 It x'73 66-7l2 *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\slcite\Desktop\Scott's Documents\Food Establishments- Tetnp\TAX CERTIFICATION FORM.doc ttte uonitnonrveattu oftvlassaettusetts Department of Industrial Accidents Office of Investigations 600 Washington Street a Boston, MA 02111 www.tnass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 6'xm er 5 tges't u"Zi v, -E- Address: 1-0 � iloAt t{ M,4(" 5+ City/State/Zip: A4- 620q -f) Phone#: 506`731 f577 Are yon employer? Check the appropriate box: Business Type (required): L I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6.iETfFestaurant/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] 8• ❑ Non-profit 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp, insurance req.] 1 12.0 Other *Any applicant that checks box #1 must also fill out the section below showing their wodcers' 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 #I. I ma mt employer that is providing workers' c'oo/nipensaattiion insurance for uty employees. Below is the policy inforutation. Insurance Company Name:.7�tiTd.� .ltGgS �GG"vrCN Insurer's Address: 014 S T O try Vbi /1- City/State/Zip: Policy # or Self -ins. Lic. # tv C R 91 Cx-, 7 Expiration Date: 61-->- f ! 1 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, undeMite pains rain penalties of petfury that the information provided above is true and correct. Official rise only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # ////?/ j8 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.m,iss.gov/dia Date Prepared: 05/23/18 DIRECT BILL WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY MERCHANTS MUTUAL INSURANCE COMPANY BUFFALO, NY 14202 NCCI COMPANY NUMBER: 15652 INFORMATION PAGE POLICY NUMBER: WCA9100757 TRANSACTION TYPE: RENEWAL AGENCY/BROKER: BOYNTON INSURANCE AGENCY AGENT CODE: 84599/NER06/033 1. THE SPIEZIO ENTERPRISES INC INSURED DBA GENO'S ITALIAN RESTAURANT MAILING 407-411 N MAIN STREET ADDRESS MANSFIELD, MA 02048 RENEWAL OF NUMBER: WCA9100757 BUSINESS TYPE: CORPORATION INTERSTATE/INTRASTATE RISK ID: BOARD FILE NUMBER: FEDERAL EMPLOYER 042736676 IDENTIFICATION NUMBER: OTHER WORKPLACES NOT SHOWN ABOVE: (ADDRESS, CITY, STATE, ZIP CODE) 2. POLICY PERIOD is from 06/24/18 to 06/24/19..; 12:01 AM standard time at the insured's mailing address. 3. A. Workers' Compensation Insurance: Part One 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 our liability under Part Two are: Bodily Injury by Accident $100,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: MS IU 05 11 99 MU 06 3J 07 17 WC 00 00 00 C WC 00 04 22 B WC 20 04 04 WC 20 03 01 WC 20 06 01 A WC 20 03 02 A WC 00 00 01 A WC 20 03 03 D WC 00 04 21 C WC 20 04 01 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Rates Per Estimated Annual Classifications No. Total Estimated Annual $100 of Premium Remuneration Remuneration SEE EXTENSION OF INFORMATION PAGE MINIMUM PREMIUM $ 217 DEPOSIT PREMIUM $ 773 TOTAL ESTIMATED ANNUAL PREMIUM $ 773 Interim adjustments of premiums shall be made: ANNUAL n V / Countersigned by: l /ff�C�*U�11MM Authorized representative Date COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A INSURED COPY MERCHANTS MUTUAL INSURANCE COMPANY WORKERS' COMPENSATION EXTENSION OF INFORMATION PAGE POLICY NUMBER: WCA9100757 THE SPIEZIO ENTERPRISES INC INSURED DBA GENO'S ITALIAN RESTAURANT MAILING 407-411 N MAIN STREET MANSFIELD, MA 02048 ADDRESS MERIT RATING 9885 Premium Basis TOTAL ESTIMATED STANDARD PREMIUM 458 MASS DIA Total Estimated Rates Per Estimated Classifications Code Annual $100 of Annual TERRORISM RISK INSURANCE ACT - MA No. Remuneration Remuneration Premium LOCATION 001 MINIMUM PREMIUM 217 DEPOSIT PREMIUM 773 409 N MAIN STREET MANSFIELD, MA 02048-1945 CLERICAL OFFICE EMPLOYEES NOC 8810 37,991 .0700 27 BAR, LOUNGE OR TAVERN 9079 41,737 1.0900 455 MERIT RATING 9885 .0500- 24 - TOTAL ESTIMATED STANDARD PREMIUM 458 MASS DIA 9999 457 .0456 21 LOSS CONSTANT 0032 20 EXPENSE CONSTANT 0900 250 TERRORISM RISK INSURANCE ACT - MA 9740 .0300 24 TOTAL ESTIMATED ANNUAL PREMIUM 773 MINIMUM PREMIUM 217 DEPOSIT PREMIUM 773 COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE WC 00 00 01 A Yj +n IO r w LO me iww LJ 1 .0 .41 o U w o 44 U q