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Home My WebLink AboutSt. Gregory Church - 12/31/2021ee 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) Establishment Name ST- 6AF_Gokj 7NF- t7 EOL-6G�lAf%l CHURCH Establishment Address ) U 0 7 I t1 57 5 T- lM/JS F E-L i�1 M r9 02 0 4 Establishment Mailing Address (if different) p.U. BUK ;�93 Establishment Telephone No J-o-� 3_37- qy$b ----- - -J W� Applicant Name & Title: CA;-rH £ J10 L C(:>OPEJ'' 01 Flci NA/JR G�'yz Applicant Address F5 9 5 S - S _k fl0LKtckC) AAA 0 -1-3 q 3 Applicant Telephone No.: 7 gl 3q 24 Hour Emergency No.: Applicant Email S Ce off `o Gn Q 42tink - Yl et Owner Name & Title (if different from applicant) NIA / JA Owner Address Owner telephone number Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or CJ An Association partner. ❑ A Corporation Name Title Address ❑ An Individual — --- -----.- EO�,, AA� Partnership [. i, her legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CA-7IL2t >J L COO P£(?. Address: Telephone No: 7V %Q - 5 i 3 / 24 Hour Emergency No: FAX: AJ/A E-mail: s%Y�z o<� aolq'^cv2�a�h�ld� ne AltE-Mail: CCoofef 4.aY'jZ6A • ne-+ District Or Regional Supervisor (if applicable) I V 1 J"(/A Name & Title: / Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (if applicable) No. of Food Employees: /t� ji- DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: C'4 ffCe( A) Name of Person(s) In Charge Certified in Allergen Awareness Training —1-yLAC�(Z �tfff>1i{S Name of pest control company routinely inspecting the premises for evidence of pests 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. D Yes Does this establishment require a FOG permit? NT) if yes, please attach the FOG permit application. Length of Permit: Establishment Type: [ AAnnual Food $125.00 [� Mobile Food Consession ❑ Temporary �❑/Retail f_y 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: (J Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: [] Food Service up to 201 + $300.00 r] Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ❑ Residential Kitchen $100.00 Rain Date: ❑ Miik &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions: PHF-Potentially hazardous food(timeRempereture controls required) Check all that I Non-PHF'a-non-potentially hazardous tood(no dmeRemperature controls required) ( PP Y) RTE- ready -to -eat 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 Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs Susceptible Population Facility 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 EI Customer Self -Service of Non PHF and Non - contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) Retail Sale EJ Preparation of Non-PHFs u offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale i� Vacuum Packaging / Cook Chill ❑ Offers RTE PHF in Bulk Quantities __1 Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -bate 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obta(n copies of 105 CMIR 590.000 and the federal Food Code. Signature of Applicant: ( o7..f..✓lt,le.. Pursuant to MGL Ch.62C, see. 49A, I certify under and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: of perjury that I, to my best knov,4edge and belief, have filed all state tax returns The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IN www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Ley-ibly Business/Organization Name: GREEK ORTHODOX PARISH OF RTE 95/495 Address: 1007 WEST ST., PO BOX 293 City/State/Zip: MANSFIELD, MA 02048 Phone #: 508-337-9986 Are you an employer? Check the appropriate box: Business Type (required): 5. Q Retail 1. Q✓ I am a employer with 3 employees (full and/ or part-time).* 6. Restaurant/Bar/EatingEstablishment 2. ❑ I am a sole proprietor or partnership and have no 7. R Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. g. ❑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.Q Manufacturing no employees. [No workers' comp. insurance required]* 4. We are a non-profit organization, staffed by volunteers, 1 LQ Health Care I 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 infor notion. i;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 for my employees. Below is the policy information. Insurance Company Name: HARTFORD ACCIDENT ANS INDEMNITY COMPANY Insurer's City/State/Zip ONE PARK PLACE, 300 SOUTH STATE ST., 7TH FLOOR SYRACUSE, NY 13202 Policy # or Self -ins. Lic. # 45 WEC AC6RAA Expiration Date: 1 /28/22 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 penaltes 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 ce ' y, —unNq the Ins ayta g!)les of perjury that the information provided aboiw is true an correct. 641,1289 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.mass.gowam 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. AS d or 75 1 s- Signature of Individual or Corporate Name By: Corporate Officer (Mandatory. if Applicable) 04-3187147 **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:\U. cm\s1eit0Desktop\9cotrs DoewnentArood Establisiments- Temp\TAX CERTIFICATION FORM.doc 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): J Z 0 Normal Hours of Food Preparation Service: Monday Tuesday Thursday Friday Sunday Wednesday Saturday 11—)2, 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 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): In 3 6KnA SlviL Is dinnerware pre -rinsed before being washed?N�1 Yes No If yes, at what station/sink? 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 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 -Z 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 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?, How often is this grease storage unit emptied? Please list the vendor who removes the waste: 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. 1\1t/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. �L 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 L2<Z Date: aoa % Applicant Name (please print clearly) hef-i pg Cmfo� _`r Mansfield Board of Health Request for Fee Waiver for Food Permit Date C. I• We, 5:\:�ALR)�j `�K,"(%Ef otb&(L) CNUECH (restaurant/ organization) request a waiver of the Food Service Permit Fee for the following reason: ❑ This is a request from a town department. Please list the department: SK We are a 501(c)(3) organization and ALL proceeds earned will go directly to the organization. ❑ We are donating ALL proceeds earned directly to a 501(c)(3) organization. , Please list the organization: ❑ We are not charging a fee for food/drink being served. ❑ We are a religious organization. ❑ Other: Thank you, Signature Vice President Title *Please provide proof of valid 501(c)(3) status BOH Use Only _ Approved Denied Reason: Signature: Date: NOTICE m EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617) 727.4900 — http://www.ma.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that j (we) have provided for payment to our Injured employees under the above mentioned chapter by insuring with: Hartford Accident and Indemnity Company NAME OF INSURANCE COMPANY One Park Place, 300 South State St, 7th Floor Syracuse NY 13202 ADDRESS OF INSURANCE COMPANY 45 WEC AC6RAA 01/28/21 - 01/28122 POLICY NUMBER EFFECTIVE DATES 3 SUMMIT PARK DRIVE STE 525 INSURANCE SYSTEMS GROUP INC CLEVELAND OH 44131 (216)-236-7760 GREEK ORTHODOX PARISH OF 95/495 INC PO BOX 293 MANSFIELD MA 02048 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL. TREATMENT P The above named insurer Is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services In accordance with the provisions of the Workers Compensation Act A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the Insurer, if the treatment Is necessary and reasonably connected to the work related Injury. In cases requiring hospital attention, employees are hereby notified that the Insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 E Printed in U.S.A. � At : o � � \?� >«# \ .\ ( 0 \ (f � it's M § � ,}{ z [{ m ,\ 0 '#\ � � �. E Latt 60i'm Communna fazV.MauschwNts nce DW: tA5401Y 1,2 i:*om atoFaovacue Noaco Data: Fcbmnry 7 QChristopherC.6srdieg,Comndesionee MATexpeyarW: 10302618 mut govidur CERTIFICATE OF FN EMYE(ON h.lii�tay�l"Iill"I�Illlllllul.pp011�tb�1lpP'lll��lllll ® Onilit OR•fHODOXPARLSH OF R01UTE 95 >i 1007WESTST dCl MANSFBLD MA 02048-1027 . Attached below is your Certificate of Exemption (Form ST-2). Cut along the dotted line and display at your place of business. You musj report any change, of name or address. to us so that a revised ST-2.caa be issued. DETACH HERE .-------_-d_-....�....,rr_-... MASSACHUSETTS DEPARTMENT OF REVENUE Form ST-2 _�.. Certlff, oate of Exemption A 04 GREEK ORTHODOX PARISH OF ROUTS MA Taxpayer ID: 10302618 95-495INC Certificates Number: 2100783.104 PO BOX 293 MANSFIELD MA 02048-0293 This coddles that the argooization named above is an axerript )urehasarundor Chapter64H, section 6(d) or (e) of the Massaahusatis Oeneml Lsws. All pgmhases of tongible pornmal propmly by this organization are exempt from lament' to the extent that such property is used in the conduct of the business of the amohasar. Misuse of this certificate byany taX-oxampt organization ormu uthodzed use of this certificate by any individual will lead to revocation. Willful misuse of this "dificate is subjeet to criminal mentions of up to one year inprison and S10,000 ($50,000 for corporations) in fines, ibis cer0flamo is narotmnsfereble and may be suspended or revoked for fhilureio comply with state jaws and regulations. Effective Date: March 3, 2019 L''xpiraHon Date: March 2, 2029