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HomeMy WebLinkAboutDeco's Italian Cuisine - 12/31/2021FOR BOARD OF HEALTH USE ONLY % Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION Wk 06, (Application must be submitted at least 30 days before the planned opening `dWQ�a✓ Establishment Name Deco's Italian Cuisine Establishment Address 365 N. Main St, Mansfield, MA 02048 Establishment Mailing Address (if different) Establishment Telephone No 508-339-6995 Applicant Name & Title: Yucel Ozcan Applicant Address 46 Pratt St. #8, Mansfield, MA 02048 Applicant Telephone No.: 508-446-4204 24 Hour Emergency No.: 508-446-4204 Applicant Email DecosPizza@gmail.com Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. ® A Corporation Name Title Address 11 An Individual Yucel Ozcan Owner 46 PrattSt. Mansfield MA 02048 Kimberly Ozcan Member 46 Pratt St. Mansfield MA 02048 1-1 A Partnership 11 Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Yucel Ozcan Address: 46 Pratt St. Mansfield MA 02048 Telephone No: 508-446-4204 24 Hour Emergency No: 508-446-4204 FAX: n/a E-mail: DecosPizza@gmail.com AltE-Mail: YucelOzcanl@gmail.com District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: Public SEWAGE DISPOSAL: Public DEP Public Water Supply No: (If applicable) No. of Food Employees: 5 part-time DAYS/HOURS: Mon -Sat 11-10 Sun 11-9 Name of Person(s) In Charge Certified in Food Protection Management: Yucel Ozcan Name of Person(s) In Charge Certified in Allergen Awareness Training Yucel Ozcan Name of pest control company routinely inspecting the premises for evidence of pests Flynn Pest Control If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. ® Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: 0 Annual N tail Food $125.00 i� Mobile Food Consession Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 El Manufacture Frozen Desserts/Ice Cream Temporary Start Date: I] Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: El Food Service up to 201 + $300.00 El Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: ® Milk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions: PHF- PotenUallyhazardous/had(daWemperature controls mryuireco a Non-PHFs - non -potentially hazardous /ood(no fimeRemperaturo controls required) (Check all that apply): RTE -mady-toeat foods(Ex. sanoWches,salads, muffins which need no turtherprocessing) D Sale of Commercially Pre -Packaged Non-PHFs [A PHFCooked To Order [j Hot PHF Cooked and Cooled or Hot Held (] Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service [7 Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer self-service and/or HACCP Plan (including bare hand and/or Customer Self-service of Non PHF and Non- alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) ® Preparation of Non-PHFs Retail Sale [] Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging! Cook Chill ❑ Offers RTE PHF in Bulk Quantities it Prepares Food/Single Meals for ❑ Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 obtair/cebles of }05 CM9590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, E e . 49A, I certify and paid slate taxes require under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 814326704 of pedury that 1, to my best knowledge and belief, have filed all state tax returns ACC>Ra CERTIFICATE OF LIABILITY INSURANCE °A E 0/29/202029/2020 THIS CERTIFICATE IS 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 CONSTITUTE CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER C 8 S Insurance Agency, Inc. 190 Chauncy St Mansfield MA 02048 Co TAc Lisa Fonseca NAME: PNCNNo Etl : (508) 339-2951 Pac No : (508) 339A811 AoDRESS. Lise@candsins.cem INSURER(S) AFFORDING COVERAGE NAIC,7 INSURERA: Travelers Insurance -Preferred INSURED Ozcan Restaurants LLC, DBA: Deeds Italian Cuisine 365 N Main Street Mansfield MA 02048 INSURERS: INSURERC: INSURER D: INSURERE: INsuRERF: COVERAGES CERTIFICATE NUMBER. 202OCerlof Liab REVISION NUMBER: THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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. LTR TYPEOFINSURANCE INSD WVD POLICYNUMBER MMMD OLICY FF POLICY EXP MMMDM'YY LIMITS A li MERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 6805R238577 11/17/2020 11/17/2021 EACH OCCURRENCE $ 1,000.000 PREMISES Eeocwmence $ 300,000 MEDEXP(An eneperson $ 5,000 I PERSONALaADVINJURY $ 1,000,000 GEN'LAGGREGATE UMITAPPLIES PER: PHI LOC POLICY 0 OTHER: JECT$ GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 •WNED AUTOMOBILE LIABILITY AANYAUTO SCHEDULED AUTOS ONLY AUTO.NAWN HIRED NOED AUTOS ONLY 1 AUTOS ONLY BA2N949815 02/23/2020 02/23/2021 COMBINED SINGLE LIMIT Ea a ddenQ $ 1,000.000 BODILY INJURY (Per Person) $ BODILY INJURY (Per Ice/and E PROPERTYDAMAGE PeraoddmI $ $ A X UMBRELLA UAB EXCESS LIAB OCCUR CLAIMSMADE CUPSR238882 11/17/2020 11/17/2021 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 LIED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTINE ❑ OFFICERIMEMBER EXCLUDED? (Mandatwy in NH) Byes, describe under DESCRIPTION OF OPERKRONSbelow NIA U85R238645 11/17/2020 111171202, X1 S ATUTE ETµ E.L. EACH ACCIDENT $ 500,000 E.L DISEASE -EA EMPLOYEE $ 600,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is requlred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 02048 ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD Y ti Q w R a R R� o. a 4 f� �x 9 w fi w 3 C :l N < N _ rn o o m r O D Z �M S � z del r) y� rn x y4, PATRIOT/SERVICES, INC. Your Greve Trap Pro & Drain Specialist P.O. Box 294 Bridgewater, MA 02324 us oN N (508)697-9565 1 (800) 449-4480 (508)759-0979 www.PatriotServicesMa.com Dare of Service6-1 Customer Nhme ��= `� Address Job Address (if different than customer) Temm PO # Inm ice # 2)(2 �I Phom # City /i)'iej." 'II Zip OF WORK . i that a dWy Stuthoriud to order wl �pprove�the w�ork�regt�ed. Tbb ie to acicoo�ekd�e oon>pktion of the oboes described soak whid� bss been dale to my oanplete ��� Customer Name OTHER TAX TOTAL DISCOUNT TOTAL DUE R Apt. # to Customer i iwu Addmu 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. ature of Indilq i ual or Qorporate Name 81-4326704 **Social Security No. (Voluntary) or Federal Identification Number Yucel Ozcan Ozcan Restaurants LLC 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:\Usem\sleite\Desktop\Scotts Documentffood Establishments-Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of lndustrialAccidents Office of Investigations Lafayette City Center ' 2Avenue de Lafayette, Boston, MA 02111-1750 _ www massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization 365 N. Main St Deco's Italian Cuisine City/State/Zip: Mansfield, MA 02048 Phone #: 508-339-6995 Are you an employer? Check the appropriate box: Business Type (required): 1. ■❑ I am a employer with 5 PT 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. ❑ 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 4. ❑ no employees. [No workers' comp. insurance required]** We by 11.❑Health Care are a non-profit organization, staffed volunteers , with no employees. [No workers' comp, insurance req.] 12.❑ Other *My applicant that checks box #] 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 providing workers' compensation insurance for my employees. Below is tine policy information. Insurance Company Name: C & S Insurance Agency, Inc. Insurer's Address: 190 Chauncy St City/State/Zip: Mansfield, MA 02048 Policy # or Self -ins. Lic. # UB5R238645 Expiration Date: 11/17/2021 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under § 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 ppins and penalties of perjury float 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: Issuing Authority (check one): 108oard of Health 2.❑ Building Department 5,❑ Selectmen's Office 6. ❑Other Contact Permit/License 3.00ty/TownClerk 4.❑Licensing Board Phone #: www.mass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT & FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: Deco's Italian Cuisine Address: 365 N. Main St. Mansfield, MA 02048 Mailing Address: 365 N. Main St. Mansfield, MA 02048 Phone/Fax Number: 508-339-6995 Email: DecosPizza@gmail.com Contact Person/Title for Grease Traps: Yucel Ozcan, Owner Name of Company scheduled to pump internal grease trap(s) monthly: Patriot Services Inc. Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest Patriot Services Inc. • Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments Fee 3 grease interceptors/traps or less and/or 1 yellow grease collection $50 container Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the information submitted in these documents is true, accurate and complete. Date 11A,1112,0 Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): 28 Normal Hours of Food Preparation/Service: Monday 11-10 Thursday 11-10 Sunday 11-9 ,h Tuesday 11-10 Friday 11-10 Wednesday 11-10 Saturday 11-10 Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 1 1 3 compartment sink 1 n/a Handwashingsink n/a n/a Commercial Dishwasher n/a n/a Barsink 1 n/a Mop Sink n/a n/a Garbage Disposal n/a n/a Ice Making Machines 2 n/a Fryolators 3 n/a Grills or Ovens 2 n/a Exhaust Hoods n/a n/a Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): By private company Is dinnerware pre -rinsed before being washed? x Yes No If yes, at what station/sink? 3 bay sink attached to GRU Pa Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 1 Please list fixtures attached to each grease trap Grease Trap 1 3 bay sink Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes X No Size gallons Where is the existing outdoor GRU located? If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owners Name: _ Property Owners Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? yes Where is the grease storage unit located?' outdoors adjacent to dumpster How often is this grease storage unit emptied? & MO. Please list the vendor who removes the waste: /v6 LJCa li'o D/iSe-% TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. x I have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. x I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. x I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature Applicant Name (please` -(print clearly)