HomeMy WebLinkAboutCousin'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:.
FRANK MYLONAS
Whose place of business is:
COUSIN'S PIZZA & SUBS, INC.
660 EAST STREET
PERSON(S) IN CHARGE:
FRANK MYLONAS
Permit Expires: December 31, 2019
Food Fee: $175.00
License Number: FS-13
BOARD OF HEALTH
AichaeCHealey, Chairman
Milk & Cream
L
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'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: Cousiv I Z Z Q
Establishment Address: W (W srwe MO
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Establishment Mailing Address(if different):
3
Establishment Telephone No.: Q M b
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BY: -
Applicant Name & Title: �(qk 10� �l WI I
Mil UX�
Applicant Address:��� �����
Applicant Telephone No.: (/, p� / 6 24 Hour Emergency No.:
0 1�UQ(I
f ��
Applicant E-mail: cdufw I l 6 AO� ' n r/
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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
El An Association
partner.
XA Corporation
Name Title
Address
El An Individual
El A Partnership
El Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: / Mt
o //v pp{�Address: J q(a 6W (out MA (] 1W
Telephone Nb: ( I d 1 24 Hour Emergency No:
l9 o D L
FAX: ✓1J� a
E-mail: C����rplAlOW V0(l0dW_
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
PIN
WATER SOURCE: W
i, Il I /1
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.
Person Trained in Anti -Choking Procedures (if 25 Seats or more): 0
Location: Permanent Location
Establishment Type
0 C erer $35.00
❑Mobile Mobile Start Date:
j "'I( Sq. Ft)
ilk &Cream $10.00
Mobile End Dale:
L—y'/Food Service u to 100 INCLUDING
P
Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
Food Service up to 101 -200 $250.00
0 Food Service up to 201 + $300.00
Ej Supermarkets $400
NO PHF PREPARED ON SITE $100.00
0 Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
0 Pushcart $50.00 # of Pushcarts:
i] Residential Kitchen $100.00
Retail Food $125.00
0 Retail Snack Food $50.00
Length of Permit:
An
"An nual
Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations
(Check all that apply):
Definitions:PHF-Potentially hazardous food(fimefiemperstum controls required)
Non-PHFs- non -potentially hazardous food(no fimefiemperatura controls required
RTE- ready -to -eat foods (Ex. sandwiches, salads, mu/fins which need no further processing)
0 Sale of Commercially Pre -Packaged Non-PHFs
P FCooked To Order
0 Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
0 Sale of Commercially Pre -Packaged PHFs
[` Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
0 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)
0 Customer Self -Service of Non PHF and Non-
Perishable Foods Only
0 Customer Self-service
Ice Manufactured and Packaged for
Retail Sale
0 Preparation of Non-PHFs
Other Food Operations
i] Juice Manufactured and Packaged for
Retail Sale
0 Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Mas for
Catered Events or Institutional Food Service
0 Offers RTE PHF in Bulk Quantities
0 Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
To be completed by the Board of Health
Total Permit Fee: t I I,o U 0
Payment is due with application 0 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 obtain copies of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law.
Signature of Individual or Corporate Name:
Social Security Number or Federal ID:
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.
Sidnature of Indivi6afor Corporate Name
27S��I�b
"Social Security No. (Voluntary) or Federal
Identification Number
By: Corporate Officer (Mandatory, i(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.
CAUserslsloiteU)esktoplScoa's Documems\Food Establishments- TemIATAX CERTIFICATION FORMAd
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
u,p www.massgov/dia
Workers' Compensation Insurance davit: General Businesses
N
FA
Phone
Are you an employer? Check the appropriate box:
Business T pe (required):
L ❑ I am a employer with employees (full and/
S.❑ I
or part-time).*
2. ❑ I
6. Restaurant/Bar/Eating Establishment
am a sole proprietor or partnership and have no
7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
,pfiployees working for me in any capacity.
8• ❑Nom-profit
[No workers' comp. insurance required]
3. We area corporation and its officers have exercised
9. ❑ Entertainment
their right of exemption per c. 152, § I (4), and we have
10. ❑ Manufacturing
no employees. [No workers' comp, insurance required]*
❑ We by
11.❑Health Care4.
are a non-profit organization, staffed volunteers,
with no employees. [No workers' comp. insurance req.]
12. ❑ Other
'My applicant that checks box #1 most 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 providirMworhers' coren�ntton tnsurance fqr my employees. Below is the policy information.
Insurance Company
Insurer's
City/State/Zip: IW ipl y m
Policy # or Self -ins. Lic.
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.
I do hereby
penalties ofperjury that the information provided
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
correct.
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
wwwanass.gov/dia
A� v" CERTIFICATE OF LIABILITY INSURANCE
°p"�`"
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELYAMEND, EXTEND OR ALTER THE COVERAGEAFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(8). AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy( ) must have ADDITIONAL INSURED Provisions or be"domed.
If SUBROGATION IS WAIVED, subject to the terns and con fftlons ofthe poky, certain policies may require an andomemmd. A slatementon
this ceNSCate does not center rights to the certificate healer in ray of such endOfsementh(s).
FItODUCEn
C & S Inmmu ceAgency. Inc.
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NA� � Dare Gertaughly
Pnoii o— �509) 339-2951 (508) 339 4811
�Debb'b@=dshs.w;n
190 Chancy StmeM.O Box 405
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a15Ug9R(6IAFFORDaa1 OOVEMGE
WUCa
Mansfield MA 02048
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INSWINIFIA: foremostsignaWreinsurmlce0ompany
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COUSINS PIZZA AND SUBS INC.
w91M6Rt; NorGUARD Insurance ComP-y
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wSURER E:
FOXBORO MA 02035
THIS IS TO CERTIFY THAT THE POUGES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POUCY PERIOD
INDICATED. NOTWTHSTANDINGANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENTUTTH RESPECTTO VMGHTHIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THE INSURANCEAFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUB IECTTOALLTHETERMS.
IXCLUSIDNSAND CONDITIONS OF SUCH POLICIES. LIMNS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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EACH OCCURRENCE
4 2.000.000
RAISES
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PERSONALSADLreiIURY
$ 2.000.000
PPS012640977
04/26/2018
04282018
GENLAGGREGAIE DMRAPPIIES PEIt:
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GENFRALAGGRE M
$ 4.000.000
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DESCRIPTM OFOPERAT10NSILOCATIONSIYEHIOLES (ACORO tO1,AddNRW RemuYc SchMWG mayppeWCM1W amorespacA ls.equtred)
GM Really Trustee &Trustee George Glarepoums are addi5onal ilswed on the above General LIaN4 Pofivy,
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SHOULDANYOFTHE ABOVE DESCRIBED POUCIES BE CANCEL LED BEFORE
THE EXRRATION DATE TNEREOF, NOTICE WILL BE DELIVERED IN
GM Really Trustee& Tmstes George Giaropoums ACCORDANCEWHH THE POLICY PROVISIONS.
P.O. Box 233
Walpole MA 02035 I lLr, �-.
reserved.
N.VRV Oa (LUleN3) Tne ACORO name and 1090 are registered marks of ACORD
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Name of ReC1plP.nt: PRANK MV60NAS
Certificate Number: 2359244
1)a1:e of Completion: 61312016
:Date of Expiration: Oa31202.1
Urr above-aumwl poseur is hereby ia'u,rd t(rLr errlihlaPr
.Ja, pan/�(Jing mt d1l •rSvr, umwrnrtn nruuingprgtn✓nt
ra,�<ahu d hp the Ala-...idmu Its Apa iunvu a/ Publi: Health
ill arroaderrrc cuixb 105 t:d/R 500.00V(G)(3)(a)•
Ibis , i ni/imtr a ill be valid /!n./i'ae 15))vv,::, flna, date o/?aarf+letinu.
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