HomeMy WebLinkAboutNY Pizza (Rami, Inc.) - 12/31/2021FOR BOARD OF HEALTH USE ONLY Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned
Establishment Name V a ! .T)'t (
Establishment Address .1 ) l� M AI'N
Establishment Mailing Address (if different)
S'i M 014SI-PYd!a, MAOS0111
Establishment Telephone No eq
Applicant Name & Title:q9 $tlAV1 I Creel de m T
Applicant Address 913- I n-� f L^ �t fi vt i C 5't1- t dye' b v ry , MP
Applicant Telephone No.: j�;/ I 9 j D 24 Hour Emergency No.: SMM1n
Applicant Email P i" 6 V1 S 0 ' y "( , "'q tom)
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
El An Association
6LA Corporation
El An Individual
O A Partnership
Cl Other legal Entity
If a corporation or partnership, give name, title, and home address of officers or
partner.
Name
Title
Address
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: 1 a5rm141 MA11(k0er
Address: J J /"/fit�Ctt9te , r (9 l�bidr MA o_q_L)3-
Telephone No: (� jJ _ �� 91 Z-5 3 % 24 Hour Emergency No:
FAX: /� (� I
E-mail: Ny1 YY)6j9/SltrIg G"�(�ytry(Xt �.c2,,Kj
Alt E-Mail: 0
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE: 'TO W h
SEWAGE DISPOSAL: b wyt
DEP Public Water Supply No: (If applicable)
No. of Food Employees:
ppj
DAYS/HOURS: I AI aa) J wJ 7 16N'W', — ) Q f tt")
Name of Person(s) In Charge Certified in Food Protection Management:
you5se IF I' r�®Its
14ovssoi>i ('ANora�
_
Name of Person(s) In Charge Certified in Allergen Awareness Training
yoi4o_,'rF 1-irsscr�l
Name of pest control company routinely inspecting the premises for evidence of pestsEadfAl &,—s
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. 0 Yes
Does this establishment require a FOG permit? V t_5 If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
5< Annual
❑ Retail Food $125,00 0 Mobile Food Consession
Temporary
° Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 0 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00 $25.00/freezer
Temporary End Date:
Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts:
Temporary Time:
El Supermarkets $400 E] Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00 0 Caterer $35.00
Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous food(no lime/lemperature controls required)
RTE - ready-to-eal foods (Ex. sandwiches, salads, muffins which need no further processing)
[ Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order ❑ 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
Delivery of Packaged PHFs Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Sale of Raw Animal Foods Intended
E] Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand
Customer Self -Service
Customer Self -Service of Non PHF and Non- contact 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
El Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities El 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 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. �'/'//,//� ///� /%
Social Security Number or Federal ID: 1/ / Y'✓V 1
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 By: C rporate Officer (Mandatory, if Applicable)
yI-"21 V �� q 3"5-
*"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\sleite\Desktop\Scull's Docutnents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
y Boston, MA 02111
wwrv.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: ) Ama1'm r
City/State/Zip: 1'tOM S h'P el , fff] dace Ca }� Phone #: �� � -- �, �Ci - �� X 0V
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.
[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 100 Manufacturing
no employees. [No workers' comp, insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers, I L❑ Health Care
with no employees. [No workers' comp. insurance rep.] 12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**tf 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 far my employees. Below is the policy injarmtation.
Insurance Company
Insurer's
City/State/Zip: %✓i./ /i/&g tt 80 YYP t A ( q to 3
Policy # or Self -ins. Lic. # R A (Al C-a �? / / /,-�P_ 3 Expiration Date: %/
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 ofpeijtrry that the information provided above is true and correct.
Phone #' t�: l J- Z-1-,/, 9 J 0
Ojjttcial use only. Do not write in this area, to be completed by city or town ojjicial.
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 Person: Phone #:
www.nrass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment N
Address: z2 I IU MarP, s - f lrAi4CL°l dl. A nor) i{ g
Mailing Add
Phone/Fax Number: 6 � �S -q - '5-S! as
Email:
Conta
Name of Company scheduled to pump internal grease trap(s) monthly: Dbt yotf i l i'ywj m /.1a vt'fif-
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
• 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'IT_/, �/e7
r I /f
Print NameSS/d f9/
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): 7
Seating Capacity (Actual Count): 19
Normal Hours of Food Preparation/Service:
Mondays �67n
Thursday
Sunday
Tuesday 4
Friday _ ,t
Wednesday 11,3 W )0 y,,
Saturday de !! — A,
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
3 compartment sink
AA
Handwashing sink
d
Commercial Dishwasher
(%
Bar sink
0
Mop Sink
0
Garbage Disposal
®
Ice Making Machines
/
N,9
Fryolators
NO
Grills or Ovens
Ivp
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
Is dinnerware pre -rinsed before being washed?
If yes, at what station/sink?
1/11� Yes
No
2
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to each grease trap
Grease Trap 1
3 g
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)? V/19
Yes
Where is the existing outdoor GRU located?
No Size gallons
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators? yP
Where is the grease storage unit located? /CIA .I (Z' r,C e
How often is this grease storage unit emptied? � 1,�1.. /
Please list the vendor who removes the waste: NP a ✓PArI- IA4 /
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.
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.
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.
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 /��// /na Date:
Applicant Name (please print clearly) / 6h64m e-d L42 ESL! m 1
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United Hauling, Inc.
200 FRIBERG PARKWAY #4001
WESTBORO, MA 01581
Phone: (508) 543-1389
Fax:(978) 206-2622
UNITED MATERIAL MANAGEMENT
CUSTOMER NO
046936
INVOICE DATE
1/1/2020
INVOICE NO
0000458842
CUSTOMER PO
DUE UPON RECEIPT
BALANCE FWD
$226.00
PAYMENTS
$0.00
CREDITS
$0.00
CHARGES
$113.00
BALANCE DUE
$339.00
CURRENT
1-30 DAYS
31-60 DAYS
61-90 DAYS
OVER 90 DAYS
BALANCE DUE
$ 113.00
$ 0.00
$ 113.00
$ 113.00
$ 0.00
$ 339.00
To process credit cards & setup payments, please visit WWW.UMM.NET and choose customer login.
To receive email invoices choose Manage Paperless.
DATE FREQUENCY DESCRIPTION QUANTITY RATE AMOUNT
New Charges
Site 046936-0001- NY PIZZA -221 N MAIN ST, MANSFIELD
11/01/2020 - 11/30/2020 Weekly 2 YD FRONT LOAD TRASH
11/01/2020 - 11/30/2020 COMMERCIAL DISPOSAL CHARGE
1.00
1.00
Total New Charges:
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT
United Hauling, Inc.
200 FRIBERG PARKWAY #4001
WESTBORO, MA 01581
Phone: (508) 543-1389
NY PIZZA
221 N MAIN ST
MANSFIELD, MA 02048-2214
$110.00 $110.00
$3.00 $3.00
$113.00
CUSTOMER NO
INVOICE DATE
INVOICE NO
BALANCE DUE
046936
11/1/2020
0000458842
$ 339.00
CHECK NO
AMOUNT ENCLOSED
Be sure to write your customer number on your check
R�
v/BBerks/hiiree Hathaway
41M-i A R D Companies
Worker's Compensation and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Co.
Policy Number RAWC119420
Renewal of RAWC087023
NCCI No. [25844]
Policy Information Page
[1]Named Insured and Mailing Address
Ram! Inc
DBA/TA NY Pizza
221 N Main St
Mansfield, MA 02048
Federal Employer's ID XX-XXX4202
Additional Names of Insured
(N2) NY Pizza
Agency
ROBERT M. ZAGAMI INSURANCE AGENCY
555 Bridge Street
Weymouth, MA 02191
Agency Code: MAROZA10
Insured is Corporation
[2] Policy Period
From November 14, 2020 to November 14, 2021, 12:01 AM, standard time at the insured's mailing
address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $100,000
Bodily Injury by Disease - each employee $100,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [31A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 1,443
Total Surcharges/Assessments $ $38.00
Total Estimated Cost $ $1,481.00
INTERNAL USE xx Page - 1 - Information Page
MGA : RAWC119420 WC 000001A
Date 10/10/2020
MANOTE
Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com R;
AC"Rof CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
12116/20
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), 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 endorsement(s).
PRODUCER
NAME:
Robert M. 2agami Insurance Agency
ONPH All
aC NE. Ems; 781-3374033 Aldo: 781.337-4103
REss: bzagami@rmzinsurance.com
aoOagami@rmzinsurance.com
555 Bridge Street
MA 02191
INSURERS AFFORDING COVERAGE
NAIC it
INSURER A: AM Guard / NorGuard
INSURED
INSURERS: _
INSURER C:
Rami Inc
dba NY Piva
221 North main St
INSURER D:
INSURER E: _
Mansfield, MA 02048
INSURER F :
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 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.
NSR
LTR
TYPE OF INSURANCE
kODLiUHR
INSD
MD
POLICY NUMBER
POLICY EFF
JMMIDDNYYYJ
POLICY EXP
(MMIDDNYYY)LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑ OCCUR
EACH OCCURRENCE
$
PREMISES Ea occurrence
$
MED EXP (Any oneperson)
$
PERSONAL B ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY [::]JECCT �LOC
OTHER:
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
$
AUTOMOBILE
LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
S
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
5
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
CEO I
I RETENTIONS
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatary in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
RAWC087023
11114/20
11/14121
PER OTH-
X STATUTE ER
E.L. EACH ACCIDENT
$ 100,000
E.L. DISEASE - EA EMPLOYEE
$ 100,000
E.L. DISEASE -POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
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.
reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD