HomeMy WebLinkAboutStefano's Pizza & Sub Shop - 12/31/2021-,gI-I.i
FOR BOARD OF HEALTH USE ON�Y�� Permit # Issued`
FOOD ESTABLISHMENT PERMIT
CATION
(Application must be submitted at least 30 days before the planned
Establishment Name 5 % � F4 1,jo 'S 1_/L2q- 9- 5-�6
Establishment Address `?jc3 &K 4-A-c:) -6+ •• $-t I4- /'5 r'1 c Z-A 14-1>9
Establishment Mailing Address (if different)
�U26
Establishment Telephone No - -3 3 sj , 6 // !
Applicant Name & Title: 5 G /S 5. 4= ti
Applicant Address �-C> i-fl e__+-f
Applicant Telephone No.:,0511S - g�C- 24 Hour Emergency No.: �� `r. - ')1!9i � p3
Applicant Email 't-rij !01. -_� t_-+? (EZ> 1 C L-az » (spy
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
Ll An Association partner.
>( A Corporation Name Title Address
1-1 An Individual -Tus S ' sD /,41(�.tf of_
L_' A Partnership L,/gi,! p rYgr�k Ju/�vS�3ti V)0 6r-, /'lit 5/_
F Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
Address: v
Telephone No: 62;IW, -- 94-/- S 24 Hour Emergency No:
FAX:
E-mail: 7to b r55 earl 4K� / "l tx� , t z"?'/
Alt E-Mail:
District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
Food Establishment Information
WATER SOURCE: i� "Y �� �'f"��� r� SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) No. of Food Employees:
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
Name of Person(s) In Charge Certified in Allergen Awareness Training
I rv.95 iv�5 J'g4dV
Name of pest control company routinely inspecting the premises for evidence of pests
jo or more, a person trained in manual choke saving procedures will be onsite at all times
If there is seating for 25 peojp
food is being prepared. LtrYes
Does this establishment require a FOG permit? 1C �_ if yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
Annual
Food $125.00 n Mobile Food Consession
❑--�
_I Temporary
//Retail
Lr!Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00 Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00 $ 25.00/freezer
Temporary End Date:
L Food Service up to 201 + $300.00 ,_I Pushcart $50.00 #of Pushcarts:
Temporary Time:
U permarkets $400 Lll Residential Kitchen $100.00
Rain Date:
[; Milk & Cream $10.00 ;rf Caterer $35.00
Food Operations: Definitions:PHF- Potentially hazardous food(timeRemperature controls required)
(Check all that apply): Non-PHFs - non -potentially hazardous food(no 6me/temperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing)
L Sale of Commercially Pre -Packaged Non-PHFs _ PHFCooked To Order U Hot PHF Cooked and Cooled or Hot Held
IJ Sale of Commercially Pre -Packaged PHFs L I Preparation of PHFs For Hot And for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
U Sale of Raw Animal Foods Intended
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 U Ice Manufactured and Packaged for control)
=1 ( Preparation of Non-PHFs Retail Sale v Otters Raw Or Undercooked Food 01
❑ Juice Manufactured and Packaged for Animal Origin
Other Food Operations Retail Sale
[J Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities 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 complywith 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtai pies of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant:
Pursuant to MOIL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: Oq 3A qti (4� 2 `f -
Y/
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-4, 3)L,4t(�2
"Social Security No. (Voluntary) or Federal
Identification Number
1
4:: a �, d 5 ?___1 —,
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\Scou's 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.govldia
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:K• b tit ' 21� ��N • �-`
—3v
sr—
City/State/Zip: 04-1-rhone #:
Are y an employer? Check the appropriate box:
Business Type (required):
1.
I am a employer with /% employees (full and/
5. ❑ R tail
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
3.❑
[No workers' comp. insurance required]
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,
12.❑ Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box #I 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 #l.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company N
Insurer's
. M . -4� tit eC-L� .
lez ]% A
City/State/Zip: /L� 1 + ►Z"-2q t It /I t7l `G�= ✓ C, c7 7 <I, / / �n
Policy # or Self -ins. Lic. # i�� f'-- "' �`�� "97�.?J� 1J �% —aspiration Date: 7 ^I'd�
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 certi , under the pains and penalties of perjury that the information provided above is true and correct.
Phone #• 5_1t:> c' "_ 3 a I? - /� ///
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
/o -- A C> — aZ
Issuing Authority (circle one):
1. Board of Heath 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office
6. Other
Contact Person: Phone
www.mass.gov/dia
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name:
Address: 3 0 C N- 9,>/ -r 25 7
Mailing Address: f [ '� r=i G��-0 14714..
Phone/Fax Number: F-c' iR a u i
Email: q� 4 L� �`/� =d • C�s� e
Contact Person/Title for Grease Traps: 7 —�-;ft44
Name of Company scheduled to pump internal grease trap(s) monthly: VV✓—'�1�' j ��
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 ( 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 acknowledge that the information submitted in these documents is true, accurate and complete.
Signed � `ia�
Date
Print Name ZA46- t/r ✓t5 F2/-5 45 ti
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):
Normal Hours of Food Preparation/Service:
Monday
Thursday
Sunday
Tuesday / / — � Wednesday —/ d
Friday /J 6O Saturday // _t C)
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
%
Handwashing sink
—
Commercial Dishwasher
Bar sink
—
Mop Sink
Garbage Disposal
Ice Making Machines
Fryolators
Grills or Ovens
Exhaust Hoods
r —
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?
Yes
No
i7
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
Grease Trap 2
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Gr se Removal Unit (GRU/Interceptor)?
Yes No Size gallons
Where is the existing outdoor GRU located? Ij
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?
Where is the grease storage unit located? pmaw <—
How often is this grease storage unit emptied? t-')Ckj' -' t"y
Please list the vendor who removes the waste: 6iCc i ��� r t r 6'�l `z
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
forTestin and Materials) Standards for compostability.
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.
/
y 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 , Date: C' —,A �� V
Applicant Name (please print clearly)
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: LIM MYSIOK-eisseN
Certificate Number: 231w24
Date of Completion: 3 2016
Date of Expiration: 5I3r2021
The above -named person is hereby issued this rerti6rate
for completing an allergen awareness training program
recognized ly the Massachusetts Department of'Pubfrr Health
-- in arrordame with 105 MR 590.009(G)(3)(a).
41 This certificate will be valid P1, five (5) pears ftwn date ofTompletion.
Issued By:
IIIIIU
NATIONAL.
RESTAURANT
ASSOCIATION,
Murachuutts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
xuwMw nntorg
Southborough,MA 01772
508-303-9905
u ..marcshurant..e.org
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: THOWS 9i33EN
Certificate Number: 2313762
Date of Completion: erv201e
Date of Expiration: Y=021
The above -named person is berely issued this certifrte
Pr completing an allergen awareness training program
rerognized ly rbe Massmhnsetts Department ofPublir Health
in arrordanre with 105 CMR 590.009(G)(Y)(a).
7bit certiirte will be valid for, five (5) years from date of?ompletimt.
Issued By:
mug
NATIONAL
ARES
SSTAU ION,.
Masrachuutts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
I w V.nsnu uneorg
Southborough, MA 01772
508-303-9905
wsysv murex taunnnswc.org
Date:
077—'
« the Alw
•ys
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Food
Yfle 4711lC lie
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The Always Food Safe Company
Allergen Awareness
Employee Food Safety Online Course & Exam
2/20/2020 (validt until 2/20/2023)
Course reference: AA
Learnerreference: 425925
This training is approved for i continuing education hour toward the initial or
recertification application for ACF certification
Nick Eastwood The Always Food Safe Company
President 899 Montreal Circle , St. Paul, MN 55102.
The Always Food Safe Company www.alwaysfoodsafe.com
WA��A
010
C,PIi� / ��.fiSeue�r2r�2L`z:� lr�uf�fr'e�lr�:
Date:
Jack Mysiuk
yloca �n dclece� efar���lef�
O The Always Food Safe Company
Allergen Awareness
Employee Food Safety Online Course & Exam
2/5/2020 (validt until 2/5/2023)
Course reference: AA
Learner reference:
409350
This training is approved for 1 continuing education hour toward the initial or
recertification application for ACF certification
.;-A exhu.nn.i Th. Al.... 9nnd C.f. Cnm nano
Approval 9: 163594
ANSI
ACCREDITED
RE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 26158
POLICY NO, AWC-400-7038139-2020A
PRIOR NO. AWC-400-7038139-2019A
ITEM
1. The Insured: KD ENTERPRISES INC
DBA: STEFANOS PIZZA & SUB SHOP
Mailing address: 30 CHAUNCY ST FEIN: **-***5674
Mansfield, MA 02048
Legal Entity Type: Corporation
Other workplaces not shown above:
2. The policy period is from _04/18/2020 to 04/18/2021 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,066 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code
Estimated
Per$100
_
Estimated
No.
Total Annual
Of
Annual
Remuneration
Remuneration
Premium
INTRA 000113956
INTER SEE
CLASS CODE SCHEDU
E
Minimum Premium $479 Total Estimated Annual Premium $6,944
OV GOSV Deposit Premium $5,379
[STATE CLASS
MA 1 9079 State Assessments/Surcharges
$6,484.00 x 3.5100% $228
This policy, including all endorsements, is hereby countersigned by ��--'P"/� �—'�z— 03/19/2020
Authorized Signature Date
Service Office:
54 Third Avenue
Burlington MA 01803
WC 00 00 01 A (7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
Aby Zemack
187 Oaks Road
Framingham, MA 01702
PROCEDURES FOR ISSUING CERTIFICATES OF INSURANCE FOR SOLE
PROPRIETORS AND PARTNERSHIPS
Certificates of Insurance issued by carriers on or after May 1, 2007 shall be issued according
to the following procedures.
Before issuing a Certificate of Insurance, the carrier shall review their policy to determine
the legal status of their insured. If the legal status is that of a sole proprietor or
partnership, the carrier must determine whether any coverage elections are reflected on the
policy. Based on the carrier's findings, one of the following comments (in bold) shall be
shown in the Comments section of the Certificate of Insurance form.
COVERAGE ELECTIONS
LEGAL ELECTIONS/EXCLUSIONS
STATUS REFLECTED ON POLICY
Sole Sole proprietor has not elected
Proprietor coverage
Sole proprietor has elected coverage
Partnership No partners have elected coverage
All partners have elected coverage
Some but not all partners have
elected coverage
COMMENT FOR
CERTIFICATE OF INSURANCE
"The workers' compensation policy
does not provide coverage for
<NAME>."
"<NAME> is covered by the
workers' compensation policy."
"No partners are covered by the
workers' compensation policy."
"All partners are covered by the
workers' compensation policy."
"<NAMES> are covered by the
workers' compensation policy."
AND
"<NAMES> are not covered by the
workers' compensation policy."