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HomeMy WebLinkAboutDeco's Italian Cuisine - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. YUCEL OZCAN, OWNER Whose place of business is: DECO'S ITALIAN CUISINE 365 NORTH MAIN STREET PERSON(S) IN CHARGE: YUCEL OZCAN, OWNER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-17 BOARD OF HEALTH MichaeCHeaCey, Chairman Milk & Cream a 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: Deco's Italian Cuisine Establishment Address: 365 N. Main St, Mansfield, MA 020 LL Establishment Mailing Address(if different): Establishment Telephone No.: 508-339-6995 Applicant Name & Title: Yucel Ozcan, Owner Applicant Address: 46 Pratt St. #8, Mansfield, MA 02048 Applicant Telephone No.: 508-4464204 24 Hour Emergency No.: 508-4464204 Applicant E-mail: decospizza@gmail.com 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 An Association partner. * A Corporation El An Individual Name Title Address Yucel Ozcan Principal Officer 46 Pratt St. #8, Mansfield, MA 02048 El A Partnership El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Yucel Ozcan, Owner Address: 46 Pratt St. #8, Mansfield, MA 02048 Telephone No: 508-446-4204 24 Hour Emergency No: 5084464204 FAX: E-mail: decospizza@gmail.com 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: No. of Food Employees: 2 DEP Public Water Supply No: (If applicable) DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. yucEL_ Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ Yucel ozcan Location: ❑X Permanent Location Establishment Type Caterer $35.00 ❑Moblie Mobile Start Date: X� Retail ( 1200 Sq. Ft) © Milk & Cream $10.00 Moblie End Date: Food Service up to 100 INCLUDING ❑ Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 o Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: [?q Annual ❑ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 # of Pushcarts: ---- El Seasonal Seasonal Dates: Supermarkets $400 ❑Residential Kitchen $100.00 ®Retail Food $125.00 Retail Snack Food $50.00 El Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions:PHF - Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs X PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held 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 Susceptible Population Facility Delivery of Packaged PHFs ❑ 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 ❑ Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) El Customer Self -Service of Non PHF and Non- Perishable Foods Only ❑ Customer Self -Service 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 Offers ATE PHF in Bulk Quantities 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 waived 1, 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 obtai0 cglpies of & CMR490.000 and,(tle federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, se�,A9A, I certify under thh olenalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required nder law. �J yy Qp r, /� /� ` �r Signature of Individual or Corporate Name: o'Lt & RG5%A u Am T5 ULC . Social Security Number or Federal ID: 81-4326704 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. O,Z Cg IJ 1e'c"7e57 au,,'_a4t.� 11C Signature of Individual or Corporate Name 9/- `/3z & 70 Social Security Number (Voluntary) or Federal Identification Number" This license will not be issued unless this Certification clause is signed by the applicant. ,able) "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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ow 600 Washington Street Boston, MA 02111 www.mass govldia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:, 365 N. Main St Deco's Italian Cuisine City/State/Zip: Mansfield, MA 02048 Phone #: 508-446-4204 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 the 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]* 11.❑ 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 kl 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 H 1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's Travelers One Tower Square City/State/Zip: Hartford, CT 06183 Policy # or Self -ins. Lic. # UB-9H330694-18-42-G Expiration Date: 11-18-2019 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 the pains and penalties of perjury that the information provided above is true and correct. 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 Phone www.mass.gov/dia TRAVELERS J� WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: UB-9H330694-18-42-G RENEWAL OF (UB-9H330694-17-42-G) INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT NCCI CO CODE: 12637 1. INSURED: PRODUCER: OZCAN RESTAURANTS LLC BENE CARE AGENCY LLC DBA DECOS ITALIAN CUISINE 1260 CREEK ST 365 N MAIN STREET WEBSTER, NY 14580 MANSFIELD, MA 02048 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 11-17-18 to 11-17-13_ 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 state(s) 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: $ 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: AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SO TN TX UT VA VT WI WV D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY DATE OFISSUE: 10-05-18 SO OFFICE: ALBANY N.Y. 002 PRODUCER: BENE CARE AGENCY LLC DCQ22 I Z Q N O J W `U} i _ 5 w O w U w *--4 hil w U z *M,4 z w z w P4 3 d Q N y O N p N m m ..I a 440 o o U 140 kn o z� U Q Q „ d a x` fiAl �� vo M O Z y 'l O ti �