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FOR BOARD OF HEALTH USE ONLY Permit #
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned
9,eX 24 2018
ba.
Establishment Name:C"-----
Establishment Address: 'ZLI L n h S S
Establishment Mailing Address (if different):
Sf�1�C
Establishment Telephone Not:
Applicant Name & Title:
Applicant Address: F) 1"N J r' n t L W as /`(S a C_
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Applicant Telephone No.: 24 Hour Emergency No.: / f � �
Applicant Email: (� C,_Mnt L , � J M
Owner Name & Title (If different from applicant):
Owner Address: SPN /y
Owner telephone number:
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home add: ess of officers or
Association
partner.
an
Corporation
U An Individual
Name Title Address
/`��Z�Y� (�/`r!a F�TiM, [A/C J�CG
El A Partnership
r ; t _ — �Q
/ ° \ A*, A`J��T�-L G
E�£ Other legal EntityL`��
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Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: A }\A Nl
Address: 1\% L 2 la W 'ta r✓ S b (_�7�(j j
Telephone No: 'j J 24 Hour Emergency No: Z" O
FAX:
Z U Q�-
E-mail:
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
q
Address: i✓ %,/
Telephone No: 24 Hour Emergency No:
FAX:
E-mail:
O Z�
�fl D
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Food Establishment Information
WATER SOURCE: r
SEWAGE DISPOSAL: " S (n/e /
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: Q Permanent Location
Establishment Type:
Caterer $35.00
0 Mobile Moblie Start Date:
0 Retail -NO FOOD PREP ( Sq. Ft) $125
Q Milk & Cream $10.00
Moblie End Date:
Mobile Comments:
'god Service up to 100 seats
INCLUDING FOOD TRUCKS $175.00
] Food Service for 101 -200 seats $250.00
, Mobile Food Consession
NO PHF PREPARED ON SITE $100,00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Length of Permit:
g
L Annual
Ell Food Service for 201+seats $300.00
E] Supermarkets $400
Pushcart $50.00 # of Pushcarts:
Residential Kitchen $100.00
Tobacco Products $150.00
Retail Snack Food $50.00
-----
P#I Seasonal
Seasonal Dates:
LH Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Food Operations:
(Check all that apply):
Definitions:PHF- Potentially hazardous food(fimeRemperatum corbels required)
Non-PHFs - non -potentially hazardous food(no fime/tempen tuns controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
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
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
€l 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
i! Vacuum Packaging / Cook Chill
=1 Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
n Customer Self -Service of Non PHF and Non-
Perishable Foods Only
Customer Self -Service
Q Ice Manufactured and Packaged for
Retail Sale
cl Preparation of Non-PHFs
Other Food Operations
Q Juice Manufactured and Packaged for
Retail Sale
[-i Offers Raw Or Undercooked Food Of
Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Offers RTE 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 vdth application H 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 9bt* copies of 105 CM%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 stale tax returns
and paid state taxes required under law.
Social Security Number or Federal ID: Q p
Signature of Individual or Corporate Name:\-
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
C !9 -"1 _ `3 216
"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\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department 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
ii
Address:
Phone #: C a d 17)sS S 9 e'
Are you an employer? Check the appropriate box: � "' * I Business Type (required):
1. Z I am a employer with 3 employees (full and/ 5. ❑ Retail
or part-time).* 6. [QAtestaurant/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] $• ❑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]** I .❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing thei, 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' compensation insurance for my employees. Below is the policy information.
.. � . i�i%1'i.�l•3!/�i,"L'�7.7it"Ti['._. i4���.
City/State/Zip:
Policy # or Self -ins. Lic. # s�!6 W66W We
Attach a copy of the workers' compensation policy
!off -Slob
2 w,_Z'�_ Expiration Date: _ _
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 ofperjury 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
www.mass.gov/dia
Phone
NOTICE OF ASSIGNMENT
EMPLOYER: COMBO I.D.
NIZAR AND FATIMA INC DBA BEST PIZZA 001126487
221 NORTH MAIN STREET
MANSFIELD, MA 02048 COVERAGE GROUP
1191639
The Waiver of Our Right to
Recover from Others Endorsement
is available on Pool policies.
Contact your agent for details.
AGENT R A REINBOLD INSURANCE AGENCY INC
OR JEANETTE BARRY
PRODUCER: 860 LANDRY AVENUE
NORTH ATTLEBORO, MA 02760
AGENCY FEIN: 042731859
STATUS OF EMPLOYER
Corporation
Coverage under this assignment
applies to Massachusetts
operations only. For coverage
outside of Massachusetts, contact
the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
HARTFORD UNDERWRITERS INS CO
TRAVELERS - RMD
P 0 BOX 5600
HARTFORD, CT 06102-5600
(800) 443-4404
CLASSIFICATION OF OPERATION
CLASS
ESTIMATED RATE
ESTIMATED
CODE
TOTAL ANNUAL
PREMIUM
--------------------------------------------
-----
REMUNERATION
-------------- ----------
----------
DRIVERS, CHAUFFEURS AND HELPERS-NOC-COMMERCIAL
7380
$11,000
5.96 $656
RESTAURANT NOC
9079
$41,880
1.03 $431
EMPLOYERS LIABILITY 500/500/500
9807
$50
STANDARD PREMIUM
$1,137
EXPENSE CONSTANT
0900
$338
TERRORISM CHARGE
9740
$16
TOTAL POLICY MINIMUM PREMIUM
$529
TOTAL ESTIMATED PREMIUM
$1,491
DIA ASSESS. 3.83%
$42
TOTAL EST. PREMIUM PLUS ASSESSMENT
$1,533
INSTALLMENT BASIS: Annual
DEPOSIT PREMIUM: $1,533
THIS IS NOT A BILL
COMMENTS
Coverage effective 12:01 AM on 01/02/19.
CARRIER NOTE: Certain information on the electronic application was initially reported
incorrectly or has changed. For the corrected information, refer to the attachments to
this application included in your application bundle.
DATE OF NOTICE: 12/20/18 PREPARED BY: Sherry Jones
EXT 516
* * VOLUNTARY DIRECT ASSIGNMENT * *
LETTERID: 5144632
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 - FAX (617)439-6055 • www.wcribma.org
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MA SOC Filing Number: 201850554420 Date: 12/6/2018 9:58:00 AM
The Commonwealth of Massachusetts Minimum Fee: $250.00
William Francis Galvin
Secretary of the Commonwealth, Corporations Division
One Ashburton Place, 17th floor
Boston, MA 02108-1512
Telephone: (617) 727-9640
Identification Number: 001357959
ARTICLE I
The exact name of the corporation is:
NIZAR AND FATIMA INC
ARTICLE 11
Unless the articles of organization otherwise provide, all corporations formed pursuant to G.L. C156D have the purpose
of engaging in any lawful business. Please specify if you want a more limited purpose:
ARTICLE III
State the total number of shares and par value, if any, of each class of stock that the corporation is authorized to
issue. All corporations must authorize stock. If only one class or series is authorized, it is not necessary to specify
any particular designation.
Par Value Per Share
Total Authorized by Articles
Total Issued
Class of Stock
Enter 0 if no Par
of Organization or Amendments
and Outstanding
Num of Shares Total Par Value
Mum of Shares
CNP
$0.00000
1,000 1 $0.00
0
G.L. C156D eliminates the concept of par value, however a corporation may specify par value in Article III. See G.L.
0156D Section 6.21 and the comments thereto.
ARTICLE IV
If more than one class of stock is authorized, state a distinguishing designation for each class. Prior to the issuance of
any shares of a class, if shares of another class are outstanding, the Business Entity must provide a description of the
preferences, voting powers, qualifications, and special or relative rights or privileges of that class and of each other
class of which shares are outstanding and of each series then established within any class.
ARTICLE V
The restrictions, if any, imposed by the Articles of Organization upon the transfer of shares of stock of any class are:
ARTICLE VI
Other lawful provisions, and if there are no provisions, this article may be left blank.
Note: The preceding six (6) articles are considered to be permanent and may be changed only by filing
appropriate articles of amendment.
ARTICLE Vll
The effective date of organization and time the articles were received for filing if the articles are not rejected within the
time prescribed by law. If a later effective date is desired, specify such date, which may not be later than the 90th day
after the articles are received for filing.
Later Effective Date: Time:
ARTICLE Vlll
The information contained in Article Vill is not a permanent part of the Articles of Organization.
a,b. The street address of the initial registered office of the corporation in the commonwealth and the name
of the initial registered agent at the registered office:
Name: BAOUABID WAHBY
No. and Street: 221 NORTH MAIN STREET
City or Town: MANSFIELD State: MA Zip: 02048 Country: USA
c. The names and street addresses of the individuals who will serve as the initial directors, president,
treasurer and secretary of the corporation (an address need not be specified if the business address of the
officer or director is the same as the principal office location):
Title
Individual Name
Address (no PO Box)
First, Middle, Last, Suffix
Address, City or Town, State, Zip Code
PRESIDENT
MOHAMMADASIF
5WHEELER AVENUE
CRANSTON, RI 02905 USA
TREASURER
MOHAMMADASIF
5WHEELER AVENUE
CRANSTON, RI 02905 USA
SECRETARY
BOUABID WAHBY
2281 DIAMOND HILL ROAD APT # D
WOONSOCKET, RI 02895 USA
VICE PRESIDENT
BOUABID WAHBY
2281 DIAMOND HILL ROAD APT # D
WOONSOCKET, RI 02895 USA
DIRECTOR
BOUABID WAHBY
2281 DIAMOND HILL ROAD APT # D
WOONSOCKET, RI 02895 USA
d. The fiscal year end (i.e., tax year) of the corporation:
December
e. A brief description of the type of business in which the corporation intends to engage:
PIZZA RESTAURANT
f. The street address (post office boxes are not acceptable) of the principal office of the corporation:
No. and Street: 221 NORTH MAIN STREET
City or Town: MANSFIELD State: MA Zip: 02048 Country: USA
g. Street address where the records of the corporation required to be kept in the Commonwealth are
located (post office boxes are not acceptable): C
MA SOC Filing Number: 201850554420 Date: 12/6/2018 9:58:00 AM
THE COMMONWEALTH OF MASSACHUSETTS
I hereby certify that, upon examination of this document, duly submitted to me, it appears
that the provisions of the General Laws relative to corporations have been complied with,
and I hereby approve said articles; and the filing fee having been paid, said articles are
deemed to have been filed with me on:
December 06, 2018 09:58 AM
WILLIAM FRANCIS GALVIN
Secretary of the Commonwealth
T OF
6mm� TR DNTARRNAL REVEENUEESEE TREASURY
P66��AA��0�llii��JJ CINCINNATI OH 45999-0023
NIZAR AND FATIMA INC
BEST PIZZA
221 N MAIN ST
MANSFIELD, MA 02048
121aJ-'MRJ0fupipZ01610IEM10IS0 401N
Date of this notice: 12-10-2018
Employer Identification Number:
83-2760914
Form: SS-4
Number of this notice: CP 575 A
For assistance you may call us at:
1-800-829-4933
IF YOU WRITE, ATTACH THE
STUB AT THE END OF THIS NOTICE.
Thank you for applying for an Employer Identification Number (BIN). We assigned you
EIN 83-2760914. This BIN will identify you, your business accounts, tax returns, and
documents, even if you have no employees. Please keep this notice in your permanent
records.
When filing tax documents, payments, and related correspondence, it is very important
that you use your EIN and complete name and address exactly as shown above. Any variation
may cause a delay in processing, result in incorrect information in your account, or even
cause you to be assigned more than one EIN. If the information is not correct as shown
above, please make the correction using the attached tear off stub and return it to us.
Based on the information received from you or your representative, you must file
the following form(s) by the date(s) shown.
Form 1120
04/15/2019
If you have questions about the form(s) or the due date(s) shown, you can call us at
the phone number or write to us at the address shown at the top of this notice. If you
need help in determining your annual accounting period (tax year), see Publication 538,
Accounting Periods and Methods.
We assigned you a tax classification based on information obtained from you or your
representative. It is not a legal determination of your tax classification, and is not
binding on the IRS. If you want a legal determination of your tax classification, you may
request a private letter ruling from the IRS under the guidelines in Revenue Procedure
2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue). Note:
Certain tax classification elections can be requested by filing Form 8832, Entity
Classification Election. See Form 8832 and its instructions for additional information.
IMPORTANT INFORMATION FOR S CORPORATION ELECTION:
If you intend to elect to file your return as a small business corporation, an
election to file a Form 1120-5 must be made within certain timeframes and the
corporation must meet certain tests. All of this information is included in the
instructions for Form 2553, Election by a Small Business Corporation.
(IRS USE ONLY) 575A 12-10-2018 NIZA E 9999999999 SS-4
If you are required to deposit for employment taxes (Forms 941, 943, 940, 944, 945,
CT-1, or 1042), excise taxes (Form 720), or income taxes (Form 1120), you will receive a
Welcome Package shortly, which includes instructions for making your deposits
electronically through the Electronic Federal Tax Payment System (EFTPS). A Personal
Identification Number (PIN) for EFTPS will also be sent to you under separate cover.
Please activate the PIN once you receive it, even if youhave requested the services of a
tax professional or representative. For more information about EFTPS, refer to
Publication 966, Electronic Choices to Pay All Your Federal Taxes. If you need to
make a deposit immediately, you will need to make arrangements with your Financial
Institution to complete a wire transfer.
The IRS is committed to helping all taxpayers comply with their tax filing
obligations. If you need help completing your returns or meeting your tax obligations,
Authorized e-file Providers, such as Reporting Agents (payroll service providers) are
available to assist you. Visit the IRS Web site at www.irs.gov for a list of companies
that offer IRS e-file for business products and services. The list provides addresses,
telephone numbers, and links to their Web sites.
To obtain tax forms and publications, including those referenced in this notice,
visit our Web site at www.irs.gov. If you do not have access to the Internet, call
1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office.
IMPORTANT REMINDERS
* Keep a copy of this notice in your permanent records. This notice is issued only
one time and the IRS will not be able to generate a duplicate copy for you. You
may give a copy of this document to anyone asking for proof of your EIN.
* Use this EIN and your name exactly as they appear at the top of this notice on all
your federal tax forms.
* Refer to this EIN on your tax -related correspondence and documents.
If you have questions about your EIN, you can call us at the phone number or write to
us at the address shown at the top of this notice. I£ you write, please tear off the stub
at the bottom of this notice and send it along with your letter. If you do not need to
write us, do not complete and return the stub.
Your name control associated with this EIN is NIZA. You will need to provide this
information, along with your EIN, if you file your returns electronically.
Thank you for your cooperation.
(IRS USE ONLY) 575A 12-10-2018 NIZA B 9999999999 SS-4
Keep this part for your records. CP 575 A (Rev. 7-2007)
Return this part with any correspondence
so we may identify your account. Please
correct any errors in your name or address.
CP 575 A
Your Telephone Number Best Time to Call DATE OF THIS NOTICE: 12-10-2018
( ) - EMPLOYER IDENTIFICATION NUMBER: 83-2760914
FORM: SS-4 NOBOD
INTERNAL REVENUE SERVICE NIZAR AND FATIMA INC
CINCINNATI OH 45999-0023 BEST PIZZA
221 N MAIN ST
MANSFIELD, MA 02048