HomeMy WebLinkAboutStefano's 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:.
THOMAS BISSEN
Whose place of business is:
K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS
30 CHAUNCY STREET
PERSON(S) IN CHARGE.
THOMAS BISSEN
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS-39
BOARD OF HEALTH
NichaeCHeatey, Chairman
Milk & Cream
l�
f
FOR BOARD OF HEALTH USE ONLY Permit# Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
Establishment Name: k _ u7 ? 7Z iLGt @= - r c' • "' r2 f ' l " s "s
Establishment Address: x`= C L$ F6 •ter- `>P f y p r s_5 ii-r t4
Establishment Mailing Address(if different):
Establishment Telephone No.:'•�
Applicant Name & Title:
Applicant Address: tfiC-,q e 7, 1 -�� awe tt•i t � '�
Applicant Telephone No.: ej2> ; ``?('A-,, - - 24 Hour Emergency No.:
Applicant E-mail: .
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
1 An Association
partner.
NfA Corporation
Name Title Address,
0 An Individual
t��tr�-F� (5r'�`� =°�-- t°-�� `� '
APartnership
FO Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: .- f
Telephone No: t�—c,_ ``e , =mac°z c 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:
15
Food Establishment Information
WATER SOURCE:
EWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable)
o. of Food Employees;
rN
DAYS/HOURS:f��
Name of Person In Charge Certified in Food Protection Management
If more than 3 individuals are certified, complete list is on file.
Cam/ : {"Pf e ^-`� - R. J` �L
J '8 L F E
Person Trained in Anti -Choking Procedures (If 25 Seats or more) i t -ty :-p'
Location: N` Permanent Location
Establishment Type
Q Caterer $35.00
E] Moblie Mobile Start Date:
0 Retail (r i",OSq. Ft)
'Milk & Cream $10.00
Mobile End Date:
Food Service up to 100 INCLUDING
0 Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
Food Service up to 101 -200 $250.00
Manufacture Frozen DessertslIce Cream
$25.001freezer
Length of Permit:
y Annual
Food Service up to 201 + $300.00
Q Pushcart $50.00 # of Pushcarts:
Eg Seasonal
Seasonal Dates:
'
Q Supermarkets $400
0 Residential Kitchen $100.00
Q Retail Food $125.00
Q Retail Snack Food $50.00
E@ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations
(Check all that apply):
Definitions: PHF- Potentially hazardous food (fimerfemperature controls required)
Non-PHFs - non-potentally hazardous food(no Lima/temperature controls required)
RTE- ready -to -eat foods (Ex.. sandwiches, salads, muffins which need no 7urtherprocessing)
Q�Q Sale of Commercially Pre -Packaged Non-PHFs
[ PHFCooked To Order
Q Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
f❑--7 Sale of Commercially Pre -Packaged PHFs
Q Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
PHF and RTE Susceptible Population Facility Prepared For Highly
rp Delivery of Packaged PHFs
Q Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
Processed Foods for Service Within 4 Hours
Vacuum Packaging / Cook Chill
0,--. Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
ofMon 0 Customer Self -Service oon PHF and Non-
Perishable Foods Only
� Customer Self -Service
EP Ice Manufactured and Packaged for
Retail Sale
r4 Preparation of Non-PHFs
Other Food Operations
i] Juice Manufactured and Packaged for
Retail Sale
ii] Offers Raw Or Undercooked Food Of
Animal Origin
Offers RTE PHF in Bulk Quantities
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Dale
or Reconditioned Food
To be completed by the Board of Health
Total Permit Fee:
Payment is due with application Q waived
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comply th 105 CMR 590.000 and all other applicable law. I have been instructed by the
bt board of health on how to oa' ies of 105 CMR 5, P.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sde. 49A. I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid slate taxes required under law. r—s
Signature of Individual or Corporate Name: ritt,,
Social Security Number or Federal ID: 'As{ 4 y"G 1
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.
Signature of Individual or Corporate Name
*`Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, 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.
C:\Users\sleite\Desktop\SeotYs Doeoments\Food Establishments- Temp\TAX CERTIFICATION FORM.doo
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:
f�'D, = P1% t #a c Bp
t '
ADDRESS: �'�-=
CLF 3ii_` Jd^a Fi ?,'e Za
v"i4
TELEPHONE AT LOCATION
FAX NUMBER:
OWNER OF BUSINESS: ✓¢65 E5_.:%
TELEPHONE OF OWNER: f7C °
FEDERAL ID/SS NUMBER: gw<¢. S?-
FEE: $10.00
PERMIT NUMBER:
a
SIGNATURE:
DATE:
The Commonwealth of Massachusetts
DepartMertt of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 11�,. 71-z%Zkt�-l!�, =iAsC f�
Address:_— Clivq.s y fir- 4-1,*-J�sr tQ—_FQ1 t-r,4
City/State/Zip:rl Axj Phone #: ��PC
Are you an employer? Check the appropriate bog: Business Type (required):
Off I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. �4Restaurant/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]** 11.❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance req.] 121-1 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 bas 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 Name:/ Z W Nc-,Z-C�4-V Zw
Insurer's Address: �' ! �' �1 1 'vy C',y1YL 5 Q,
City/State/Zip: N h 6 hJ--✓i C G� a,
Policy # or Self -ins. Lie. # % C_ 37c 4 Z; 5 L. Expiration Date: 'Y `1" ��_ —% r
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 certifyyander the pains and penalties ofperjury that the information provided above is true and correct.
Phone #: 5c--z� — .3.3 �p—,=,. I6!
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
NP 92691231
20 Trafalgar Square, Suite 459
Nashua, NH 03063
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY INSURANCE POLICY
In Witness Whereof, we have caused this policy to be executed and attested, and, if
required by state law, this policy shall not be valid unless countersigned by our
authorized representative.
Stephen Unger, Secretary
Barry Dov Zyskind, President
To obtain information, please contact your agent or Technology Insurance Company, Inc.
at 877-528-7878. You may also write Technology Insurance Company, Inc. Consumer
Relations at:
800 Superior Ave E., 21 s`
Cleveland, OH 44114
NC 99 00 00 A
NP 92691231
Technology Insurance Company, Inc.
A Stock Insurance Company
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY
INSURANCE POLICY
Ncci Code: 39071
Insured:
KD ENTERPRISES, INC.
DBA: STEFANO'S PIZZA & SUB SHOP
30 CHAUNCY STREET
MANSFIELD, MA 02093-0000
Other workplaces not shown above:
None
Producer:
AmTrust North America, Inc.
c/o ZEMACK INSURANCE AGENCY
187 OAKS ROAD
FRAMINGHAM, MA 01702
WC990001B
INFORMATION PAGE
Policy Number: TWC3709886
_Individual _Partnership
X Corporation
Federal Tax ID: 043245674
Risk Id:
Renewal of: TWC3621823
2. The policy period is from 4/15/2018 to 4/15/2019`12:01 a.m. 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: Massachusetts
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:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
$1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
All states except ND, OH, WA, WY and State(s) Designated in Item 3A.
D. This policy includes these endorsements and schedules: See Extension of Information Page
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.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM
5,589
STATE ASSESSMENT
243
TOTAL ESTIMATED COST
5,832
Minimum Premium
500
Deposit Premium
801
Issue Date: 4/9/2018 Countersigned by:
Nr tlZoVl zal
NOTICE NOTICE
TO
t� - {t EMPLOYEES
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL, ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts Genera Law, Chapter 152, Sections 21, 22, 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above -mentioned chapter by
insuring with:
Technology Insurance Company, Inc.
NAME OF INSURANCE COMPANY
800 Superior Avenue East, 21st Floor, Cleveland, OH 44114
ADDRESS OF INSURANCE COMPANY
TWC3709886 4/15/2018 to 4
POLICY NUMBER EFFECTIVE DATES
187 OAKS ROAD, FRAMINGHAM,
ZEMACK INSURANCE AGENCY MA 01702 (508) 872-9999
NAME OF INSURANCE AGENT ADDRESS PHONE #
I{I) ENTERPRISES, INC.
EMPLOYER
30 CHAUNCY STREET
ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY)
MA 02093-0000
7rY
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
0;, .� �f:
Name of Recipient: n WS BMEN
Certificate Number: 2sts752
Date of Completion: 6/3/2016
Date of Expiration: �021
7be above -named person is hereby issued this certificate
for completing an allergen awareness training program
recognized by the Massachusetts Department ejPublic Health
in accordance with 105 CAM 590.009(G)(3)(a).
TVs certificate wi//be valid for five (5) years from date o% completion.
Issued Br.
NATIONAL
ova'
RESTAURANT
ASSOCIATION®
1A..h..us RertaurentAssociation
900.765.2122
333 Twnpike Road, Suite 102
�s`,Aeusunto[g
Southboxuagh,MA 01772
508-303-9905
ww,vmarcstaurantassocasg
Name of Recipient: Ui WSIUK WEN
Certificate Number: 2313624
Date of Completion: 6 O16
Date of Expitation: �21
The above -named person is hereby issued this ce.r eat,
for completing an allergen awareness tsniningprogram
recogniwd by TheMassacbuseas Department ofPvblir Heath
in accordance with 105 CMR 590009(G)(3)(a).
This certi%Irate will be valid forfrue (5) yearsliom date afrompletim
Ismed By.
NATIONAL
ASSOCIATION„
Marsaoh.0 ResmurmtAssocution
800.765.2M
333 Tumpi'se Road, Suite 102
..resCavmntnrg
Southborough,MA 01772
508-303-9905
www:taarestaurnntusoc.oaa
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