The URL can be used to link to this page

Home My WebLink AboutClassic 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:. MARIA LAFRENIERE Whose place of business is: CLASSIC PIZZA 242 CHAUNCY STREET PERSON(S) IN CHARGE. MARIA LAFRENIERE, OWNER Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-9 BOARD OF HEALTH NichaeCHeatey, Chairman 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) 1) Establishment Name �� t - — 2) Establishment Address 3) Establishment Mailing Address (if different) 4) Establishment Telephone No t 6) Applicant Name & Title 6) Applicant Address j 7)Appli nt Tel hone No.: 24 Hour Emer ncy N .. 8 Owners Name & Title 9) Owner Address (If different from applicant) Owner's telephone number 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers El An Association or partner. El A Corporation O'An Individual Name Title Address 0 A Partnership O Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address'. -- Telephone No: `---- - — d 24 H_ur Emergent No: �� J FAX: E-mail: Alt E-Mail: ,,. � 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information 14) WATER SOURCE: 15) SEWAGE DISPOSAL: 16) NO. Of Food Employees: Cf DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management:. If more than 3 individuals are certified, complete list is on file, \ Required as of 10/1/2001 In accordance with 105 CMR 590.003(A) Please attach copy of certificate 19) Person Trained In Anti -Choking Procedures (If 25 Seats or more): El 20 Location: Permanent Location 22) Establishment Type Q Caterer $35.00 40. Mobile Mobile Start Date: 11D etail ( Sq. Ft) Q Milk & Cream $10.00 Mobile End Date: Mobile Comments: �/�j'!{Food Servic o UDING FOOD TR KS $175.00 Q Mobile Food Consession NO PHF PREPARED ON SITE $100.00 E Manufacture Frozen DessertsiIce Cream 21) Length of Permit: R' sir Annual 0 Food Service up to 101 -200 $250.00 $25.001freezer �i Food Service up to 201 + $300.00 Pushcart $50.00 1F of Pushcarts: ❑ Residential Kitchen $100,00 ---------- Seasonal Seasonal Dates: Supermarkets $400 E] Retail Snack Food $50.00 Q Temporary Temporary Start Dale: Q Tobacco Products $150.00 Temporary End Dale: Temporary Time: Rain Date: 23) Food Operations Derinitions;PHF- Potentially hazardous food (Rme/lemperelure controls required) Non-PHFs - non -potentially hazardous feod(no time/lemparalum controls required) (Check all that apply): RTE- reedy -to -eat foods (Ex. sandwiches, salads, mulans which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs [ ; PHFCooked To Order E] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service trS! Sale of Commercially Pre -Packaged PHFs F] Preparation of PHFs For Hot And EJ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Cold Holding For Single Meal Service Q Delivery of Packaged PHFs 0 Sale of Raw Animal Foods Intended to be Prepared by Consumer a Reheating of Commercially Q Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours Use of Process Requiring di Variance HACCP Plan (including bare hand I[],. Customer Self -Service of Non PHF and Non- E3 Customer Self -Service Perishable Foods Only y contact altemalive, time as a public health contact control) Q Ice Manufactured and Packaged for Retail Sale I[]i Preparation of Non-PHFs Other Food Operations EJ Juice Manufactured and Packaged for QQ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin E] Prepares Food/Single Meals for Q Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service E] Retail Sale of Salvage, Out -Of -Dale To be completed by the Board of Health or Reconditioned Food Total Permit Fee: Payment is due with application I] waived I, the undersigned, attest to the accuracy of the infoi establishment operation will comply with 10¢ CMR E board of health on how to obtain copies-,qf!)05 CMR 24) Signature of Applicant: provided in this application and affirm that the food and all other applicable law. I have been Instructed by the 0 and the federal Food Code. 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 stale taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: / ""-w— 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 By: Corporate Officer (Mandatory, if Applicable) Viz- *"Social Security No. (Voluntary) or Federal Identification Number *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\s1cite\Desktop\8cotVs DocumenlslFood Eslablishinenls- T=pWAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents b 1 Congregg Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Are ypu an employer? Check the appropriate box: 1. M I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required]' 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. [ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.❑ Health Care 12.❑ 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 has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is prAding workers' coompensfdon t,Kesurance fcor my employees. Below is the policy information. Insurance Insurer's City/State/Zip: Policy # or Self -ins. Lic. r xpirauon Lain: U Attach a copy of the workers' compensation policy declaration page (showing the policy number a d expir tion 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, jyndef the pains d penalties of perjury that the Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License is true ana correct. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5, Selectmen's Office 6.Other Contact Person: NOU-16-2019 13:32 From:C.J.MURPHY INS.RGCY. 508 824 0635 To:15082617498 P.3/3 ACORIr� CERTIFICATE OF LIABILITY INSURANCE DATa1MMOW") 11.15.201e THIS CERTIFICATE 1$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT ComrrUYE A CONTRACT BETWEEN THE Issum INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT! H the urtMrate holder Is an ADDITIONAL INSURED, the pollay(les) must be endorsed. B SUBROGATION IS WAIVED, subject to the lenm and conditions of the policy, certain policies may mqulm an endorsement. A Statement on this Derllgcala does not corder rights to the certificate holder in lieu of such endorsemant(s), PRODUCER C.J. MURPHY INSURhNCE.AGENCYINC. 22 Rut Street P.O, Box 3 Taunton, MA 02780 AM , JEFF ! 608.82A-7855 � 508.824063e Nut CJMURPHYINS(apGMAIL.COM WSURPRIeI NACN ` EMPLOYERSINSURANCE wsualRA ASSOCIA7L•U EMPLOYERS INSURANCE CO INSUI M R K CLASSIC, LLo dWa CLASSIC PIZZA 242 CHAUNCY $I MANSFIELD MA 0200 18U11lR e INSURERCv NuwEaD: WMAIERE: mSURER p, COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMEN7, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. QA LM "OrMURAKII mappir POLICYNIIMaF POLICY d71' LMM GENORALUASIM" EACH OCCURRENCE $ COMMERCIAL. GENERAL LNRII ITT 9YAM MIS[81FArcm,nAn -"- f OLmiwamADE❑OCCUR EXP(MyAnepmonl !„ _MED PERSONAL A AOV 1WURV -f _ 0ENERALAGCdIEr+A7E A. AFNL AGGREGATE LIMIT APPLIEG PERT PA DUC S-OOMP/OP AGG POLICY M IMP L& f AUT011091La L6191Lr1Y 3^ ANY AUTO eOOILY INJURY(PmpP6en) H ALL 0�b AUHIOSULFP BODILY IMURY(Pm mi0orl) f BALSFF,11 A 0. I+rAccleanl - f _ WRCOAUt08 NONOWNED AUTOR f UMI)RILLA UA11 OCCUR EACPIGCCUARFNf,F f AGGREGATa S VC949LIAR CLA M-MADC RETFM f WORNERS COMPlNSATION w A ATU. OTu. X '(MUWraryln AND aMPLOYERY LIAaILFYY ANY PROPNETOIWAArwnmxfim)TIVE YIN OFFIr.0.`W. sa ENauoenv Np MIA WCC. 600. 6DI7794 8.25.2018. 0-I25.2019 ' f.l.. F.AUHACCIOENT 8 500.000 E.L. OISEAEE •EA EMALOYE f 600,000 u yys. Mtollw OnWr DE9 ON OFO 0 6A. o. F.LOIBPASE-POLICY LIMB t 600:000- DEfORIpIWx OF OPRRATION9l LOCATNR/S/VlNILTlf (AHyM ACDR0109, Add0Anr1 MIIIAIIu fAAAduN,kmory aperA la l.gldnd) • PIZZA PARLOR CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES $a CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL Be DEUVERSO IN TOWN of MANSFIELD ACCORDANCE WITH Me POLICY PROVISIONS, 6 PARK Rd AUTHOWEEOREPREMNYAnve MANSFIELD, MA 02048 r ACORD 25 (2010/05) 01988-2010 ACO RPORA'"Oy All fight* rammed. The ACORD home and logo are registered marks of ACORO NOV-16-2018 13:31 From:C.J.MURPHY INS.AGCY. 50B B24 0635 To:15082617498 P.2/3 ACORD� CERTIFICATE OF LIABILITY INSURANCE °1 is o s' PROOUCER C.J. MUR{'IY MURANCG AGENCY INC. THIS CERTIFICATE IS ISSUED AS A mATTER OF INFORMATION ONLY AND CONFERS NO RlGNT3 UPON THE HOLDER. THIS CERTIFICATE DOES NOT AMEND, ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE EXTEND OR BELOW. INSURERSAF�FROR_DI_NGCOVERAGE INSURF.RA: UNIyN MUTUAL ._. ._•• "—"' NAICi1 22 Fruit Street - P.O. Box 3 T nton, MA_02780.... ____........ —._ _._.. INaURCA _.__._ INsuRERa: _.,,. M R K CLASSIC dlbla CLASSIC PIZZA 242 CHAUNCY ST MANSFIELD, MA 02048 NsuREa'D: NSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PQLICYPERIOD INDICAYEO. NOTWI714STANOING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T1418 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE.PWCIES DESCRIBED HEREIN IS SUaJECTTO ALL THE'rERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. ACGRECATE LIMITSSHOWN MAY NAVE DEEN ADDUCED aY PN0 CWMS. IMSi blitFOUCYNUMDER PpuOV PFPgCTAlS POLR:V PxPmATNNI UYRS am GRNERAL LNB4RY FACH OCCURRENCE . i ...__: 1,(10 ,DO ._ 'OANAGETORENTED ISESJFo„�,,,�.sa s BO,000 CQLIMERW. CCENERAIJARIUTY _ MEDDIPIAnroa mmo) 61001) _ DIAAISNADE L' I OCCUR PERBONALAADVIWURY i 1,000,00 a/ BUSINESSOWNER BOP10000.199 5-11-2018 5-11-2019 2.000,000 MENENALAUGHeGAIt i _.......ERPF._ GGN'LAGGIREGATE LINITAPPLIER PFH: PROOUGTa•C011PAPAGG 2,OOD 00 i -_ ,. .,,. _ .. POUDY n, LOC AUTO 0MCUARRM COMMIMEDUNCLEUISt ANY AUTO (Ea rI 'U) ._ ALL OWNED AUTOS OODILYIMJURY i SCHEOULEDAUTOS (PerpY hI, BODILYINJURY HIREDAUTOS 1 NON-ONMEDAIIrOS (Pa'hedaMl) PROPERTY DAMAGE i - (PoeAV11nN) GARAGELNRURy AI.RD,ONLY.FA_ACCJDFNI'. i ANYAUTO OTHER THAN EAACC i i AUTOUNLY: AGG IXCESSNMBPELLAUABIUTY FACHOCCURNF.NCE s OCCUR L CLNMSMAOE S .. ..— .. _..— DEDUCTIBLE + i Rr: rEYnoN a WCSTATIA O H • 1R COYPENBATIOM AMP El.UCHMGDE!!P JDLPLDYFRa•LJe9am mpwy ANY OFyoFIRCCEWUCMQ0 AG CL�DGO'l IVE F1dEEAEF.•F.AMPLOYFF _3_ E ••. ••-.—._.— E.L.dREAaE-fbLICY UMI7 SR'CNLPRRJISS bdmv OYHRR LIQ OR LAB 1 AO R RATE LIQUOR LIABILITY BOP.0000.199 5-11-2018 5-114019 LIMIT: $ 500,000 DEacavRDNuoaErArroMErLacATloxarvEHCLESJeacLUmowaamEDBYOJDoxsa+EYNsvenuvaoylwoxn PIZZA PARLOR TOWN of MANSFIELD 6 PARK Rd MANSFIELD, MA 02048 SHOULDANY OF YHEABOVE DESCRMEDPOUGES BECANCELLEU BEFORE THE E:O MMON DATE THEREOF, THE "WNG EMURER yALL ENDEAVOR TO I" _ DAYO MRTTEN NOTICE TO THE CERTIi7CATE HOLDER NAMED TO THE LEFT, BUT FAGYRE TO DD DO ENALL IMPpaE Np OB MWM OR LUA%jTy OF AW IOND UPON THE MUAEA, Ra AGENW OR I I �} L z I \ \ \ \ Q \ / \\\\ \ tc \ \ )\\; � /