HomeMy WebLinkAboutNew York 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:.
REDOUANE LIBRHIT
Whose place of business is:
RAMI, INC. DBA NEW YORK PIZZA
221 NORTH MAIN STREET
PERSON(S) IN CHARGE:
REDOUANE LIBRHIT
Permit Expires: December 31, 2019
Food Fee: $0.00
License Number: FS-63
BOARD OF HEALTH
'blichaeCHeaCey, Chairman
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FOR BOARD OF HEALTH USE ONLY
FOOD ESTABLISHMENT PERMIT APPLICA
(Application must be submitted at least 30 days before the planned"o""penjing"daTeJ^__
1) Establishment Name a W I Y) C 0 A I V e w i 0 'Y I 1 t z Z
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2) Establishment Address CJ f
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3) Establishment Mailing Address (if different)
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4) Establishment Telephone No
5) Applicant Name & Title: d ® AAA, Yi r e, k r
6) Applicant Address 7 7 / V 1 ' A 1'N __.
7) Applicant Telephone No.: 24 Hour Emergency No.:
-7�;,J,,? 9-eo5q_ 617 84z 39_30
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
O An Association
or partner.
(N,A Corporation
O An Individual
Name Title 1 Address
/ r�r!/ � 04 fj37 rn()1n2045
O A Partnership
I] Other legal Entity
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12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address:
Lj77 ®t/ Ma ki
Telephone No:
sJ�/� _ i 9 6)0 s9 24 Hour Emergency No
FAX:
E-mail:
j?jd5`hvi/! verb 1 (_0k —_
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:
t
L� l�
DEP Public Water Supply No: (If applicable)
16) No. of Food Employees:
17) DAYS/HOURS: 7 ���� -- _ i Je,Li � lr
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 101112001 in accordance with 106 CMR 590.003(A) Please attach copy of
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location. Permanent Location
22) Establishment Type
] Caterer $35.00
] Moblie Mobile Start Date:
] Retail ( Sq. Ft)]
Milk & Cream $10.00
Mobile End Date:
Food Service up to 100 INCLUDING
] Mobile Food Consession
Mobile Comments:
FOOD TRUCKS $175.00
NO PHF PREPARED ON SITE $100.00
21) Length of Permit
] Food Service up to 101 -200 $250.00
] Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Annual
E] Food Service up to 201 + $300.00
❑Pushcart $50.00 # of Pushcarts:
Residential Kitchen $100.00
---------
Seasonal
Seasonal Dates:
Supermarkets $400
i] Retail Food $125.00
Retail Snack Food $50.00
i] Temporary
Temporary Start Date:
] Tobacco Products $150.00
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Definotions: PHF- Potentially hazardous food (limeltemperalure controls required)
Non-PHF's -non-potentially hazardous food(no time/lemperature controls required)
(Check all that apply):
RTE- ready -to -eat foods (Ex. sandwiches, salads, muRns which needno furtherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
: ` 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
Delivery of Packaged PHFs
—--------
] Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Susceptible Population Facility
] Vacuum Packaging / Cook Chill
4; Reheating of Commercially
Processed Foods for Service Within 4 Hours
_
Use of Process Requiring di Variance
and/or HACCP Plan (including bare hand
] Customer Self -Service of Non PILE and Non-
Customer Self -Service
Perishable Foods Only
contact alternative, time as a public health
control)
Ice Manufactured and Packaged for
Retail Sale
E7 Preparation of Non-PHFs
Other Food Operations
Juice Manufactured and Packaged for
j Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
Offers ftTE PHF in Bulk Quantities
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
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 obtain copies of 105 CMR 590.000 and the federal Food Code.
-� 24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify Ender 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.
25) Social Security Number or Federal ID: o
26) 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 Corporate Name
"Social Security No. (Voluntany) or Federal
Identification Number
By: Corporate Officer (Mandatonj, 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 oflnvestigations
600 Washington Street
Boston, MA 02111
Uf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: 14(Aryvt ' w C > a Z r
Address: X_� f Y\ M (X1' 7,4—
City/State/Zip: MCA j4 S I't 'e / j Phone #:
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 me in any capacity.
8• ❑ Non-profit
[No workers' comp. insurance required]
3. M 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 #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 41.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's
City/State/Zip:
Policy # or Self -ins. Lie. #
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 certify,, under the pains and penalties ofperjury that the information provided above is true and correct.
Sienature: Date: IT ) .-). ( Z- , J (
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.mus.gov/dia
.
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YA IRS IDNTERNALNREVVENUEESERVICERY
CINCINNATI OH 45999-0023
RAMI INC
NY PIZZA
221 N MAIN ST
MANSFIELD, MA 02048
Date of this notice: 07-24-2019
Employer Identification Number:
84-2494202:-
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.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER
Thank you for applying for an Employer Identification Number (EIN). We assigned you
EIN 84-2494202. This EIN 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 FIN 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 FIN. 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 941
Form 940
Form 1120
O1/31/2020
O1/31/2020
04/15/2020
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-S 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.
FORM 153 The Commonwealth of Massachusetts DIA Use only
Department of Industrial Accidents
Office of Investigations - Dept. 153
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
http://ivww.niass.gov/dia Invest./SWO Inu,p #:
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169 of the Acts of 2002 amended M. G.L. c. 152, §1(4) by adding the following paragraph:
"This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of
the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the
propose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C."
Pursuant to M.G.L. c. 152, § 1(4) as amended, I/We the undersigned officers of:
Rami Inc 221 North Main St Mansfield MA 02048
(Name of Corporation and Address)
each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the
right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the
undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for
any injuries that may be sustained while in the employ of the above -named corporation.
Further, I/we the undersigned do understand that, should the above -named corporation hire or have in
its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said
corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by
M.G.L. c. 152, §25A.
I/We the undersigned have read and understand the statements and obligations as delineated above and
I/we have checked the appropriate box below my/our name(s) indicating my/our desire to be exempt or
not to be exempt from the provisions of M.G.L. c. 152.
Signed under the pains and penalties of perjury:
Mohamed Hassani 08/07/2019
S wish Print Name & Title Date.(mm/dd/yyyy)
�✓ i wish Co exercise my right of exemption or r wish NOT to exercise my right of exemption
Redouane Librhit 08/07/2019
Signature Print Name & Title Date (mm/dd/yyyy)
FV I wish to exercise my right of exemption or -T wish NOT to exercise my right of exemption
Signature Print Name & Title
❑ I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption
Date (mm/dd/yyyy)
Signature Print Name & Title Date (mm/dd/yyyy)
T wish to exercise my right of exemption or ❑ r wish NOT to exercise my right of exemption
Note: ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. IIIStrUCHOUS
on back. Form 153 — 7/2010
Pursuant to M.G.L. c. 152, §1(4) workers' compensation insurance "...shall be elective for an officer or director of
a corporation who owns at least 25% of the issued and outstanding stock of said corporation. Notwithstanding the
provisions of section 46 of this chapter, these provisions shall apply only if said corporate officer provides the
Commissioner of the Department of Industrial Accidents with a written waiver of his rights under this chapter.
The Commissioner of the Department of Industrial Accidents shall promulgate regulations to carry out the
purpose of this subsection. Violations of the terms of these provisions in any way shall subject said corporation to
the penalties set forth under section 25C of this chapter."
Therefore in accordance with M.G.L. c. 152, §1(4) and 452 CMR c. 8.00 et. seq.:
Such an exemption DOES NOT apply to employees of such a corporation who are not corporate
officers. Those employees must be covered by a valid workers' compensation policy at all times.
A copy of this form should be submitted to the insurance carrier on an annual basis, prior to the
renewal of any existing policy, as affirmation that the statements contained herein remain in effect. If
there has been ANY change in status of a corporate officer or director, a new Form 153 must be filed
with the DIA and provided to the insurance carrier.
Any corporation in which the corporate officers or directors own at least 25% interest in the
corporation may exercise their right to exempt said corporate officers or directors from the provisions
of the Massachusetts Workers' Compensation Act (M.G.L. c. 152).
If the corporation named on this form employs no persons other than the eligible corporate officer(s)
or director(s) who have exercised their right of exemption by signing the Form 153, said corporation
may legally operate without workers' compensation coverage. However, the corporation may not
employ any person other than those corporate officers or directors who have exercised their right of
exemption by signing the Form153. Should the corporation hire additional employees, workers'
compensation coverage must be obtained for those employees.
• The completed Form 153 must be submitted to the Department of industrial Accidents, Office of
Investigations for the exemption under M.G.L. c. 152, §1(4) to be invoked.
The policies and procedures surrounding the exemption of a corporate officer or director are
governed by 452 CMR 8.06 et. seq.
If your corporation is submitting this form in response to a notice or Stop Work Order (SWO) from
the DIA Office of Investigations, please write the Investigation ID Number or Stop Work Order
Number on that correspondence on the space provided in upper right hand corner of the front of this
form.
Instructions -
All eligible corporate officers must sign the form and indicate their choice to be exempt or not to
be exempt from the provisions of M.G.L. c. 152 by checking the appropriate box located under
their name and signature. Complete all information on the front of the form and submit it to:
Department of Industrial Accidents
Office of Investigations - Dept. 153
1 Congress Street, Suite 100
Boston, MA 02114-2017
For additional information visit our web site at <www.mass.gov/dia>. See 452 CMR c. 8.00 et. seq.
Form 153 — 7/2010