Loading...
HomeMy WebLinkAboutCousin's Pizza 12/31/2016Commonwealth 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 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:. FRANK MYLONAS Whose place of business is: COUSIN'S PIZZA & SUBS, INC. 660 EAST STREET PERSON(S) IN CHARGE: FRANK MYLONAS Permit Expires: December 31, 2016 License Number: FS -13 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH MichaeCMcCtean, Chairman Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health License to Sell Milk and Cream This is to certify that. FRANK MYLONAS having a place of business at: COUSIN'S PIZZA & SUBS, INC. 660 EAST STREET in the Town of Mansfield has been granted a license to sell MILK and CREAM and is subject to the Provisions of the Laws of the Commonwealth of Massachusetts, relating to the terms and conditions, and to the rules and regulations established by the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream and shall remain in force until 1213112016 unless previous to that time is suspended or revoked. Expires 12131/2016 License No.: FS -13 Scott Leite, Heaah .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY - Date received: Date Inspected: Approved By: Permit # Issued FS -13 IL- — -- -- - FOOD ESTABLISHMENT PERMIT APPLICATION -- - - - -- 1-�6c�n m�5e su-Tmiffe a east -3 -days �fore�Te pinned opening cTa�e) - pp __ -- 1) Establishment Name COUSIN'S PIZZA & SUBS, INC. 2) Establishment Address 660 EAST STREET 3) Establishment Mailing Address (if different) 44 CANNON FORGE DRIVE s FOXBOROUGH, MA 02035 4) Establishment Telephone No (508) 339-6243 5) Applicant Name & Title: FRANK MYLONAS 6) Applicant Address 44 CANNON FORGE DRIVE, FOXBOROUGH, MA 02035 7) Applicant Telephone No.: (soak sss•sssz 24 Hour Emergency No.: (617) sas-ozos 8) Owners Name &Title FRANK MYLONAS `9) Owner Address (If different from applicant) 44 CANNON FORGE DRIVE, FOXBOROUGH, MA 02035 Owner's telephone number (508) 668-8982 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association I or partner. O A Corporation j Name Title Address ❑ An Individual -- - ❑ A Partnership - 11 Other legal Entity 12 PersoDirectly Responsible es onsible For or D- aily Operations (owner, person perso- n-- in charge, supervisor, manager e-tc.) -- - Name & Title: FRANK MYLONAS Address: 144 CANNON FORGE DRIVE, FOXBOROUGH, MA 02035 (Telephone No: 1(508) 668-8982 24 Hour Emergency No: (611) 686-02066 FAX: - - - - E-mail: Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: :-mail: 24 Hour Emergency No: 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 5 17) DAYS/HOURS: 7 DAYS 10:30 AM - 10:30 PM 18) Name of Person In Charge Certified in Food Protection Management: ELIZABETH TSIANAKAS If more than 3 individuals are certified, complete list is on file. Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of certificate r-- 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): ❑ - -- -- 20) Location: Permanent Location ' 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) Moblie End Date: Iwo Food Service up to 100 or Moblie Comments: up to 10' PHF display $62.50 21) Length of Permit: W Annual i ❑ Seasonal Seasonal Dates: ] Temporary Temporary Start Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ Caterer $12.50 Milk & Cream $5.00 Mobile Food & Consession $37.50 ❑ Manufacture Frozen Desserts/Ice Cream $12.50/freezer ❑ Pushcart $12.50 # of Pushcarts: ❑ Residential Kitchen $50.00 ❑ Retail Food $50.00 ❑ Retail Snack Food $12.50 ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: j Rain Date: - - - -- - - J 23 Food Operations Definitions: PHF - Potentially hazardous food (time/temperature controls required) p Non-PHFs - non -potentially hazardous food(no time/temperature controls required) !(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non -PRFs ] 0 PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held __ __{- -- ---- - - — for More Than a Single Meal Service ❑ _— _ Sale of Commercial) PCommercially _ 9_ Cold Holding For Single Meal Service ❑ PHF and RTE FoodsPrepared For Highly ed PHFs F%.*] Preparation of PHFs For Hot And r❑ Delivery of Packaged PHFs—___--__ _ __ - I Susceptible Population Facility - -i ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours I - - - - _ _ __ -_ __-__— - -- 1 ❑ Use of Process Requiring A Variance /or HACOP ng Only L] Ice Manufactured and Packaged for contact ante native, time las i„ public heath ❑ Customer Self Service of Non PHF and Non- ❑ Customer Self -Service control) Perishable Food Orel - --- - e- ❑Preparation- Retail Sale I- 4 of Non-PHFs ! ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Other Food Operations j ❑ Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Retail Sale Animal Origin ❑ __ _ -_ - -- Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date �To be completed b j or Reconditioned Food I P Y the Board of Health --- - �� Total Permit Fee: $62.50 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: 5---' Pursuant to MGL Ch.62C, sed. 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. 25) Social Security Number or Federal ID: 04-2757-180 t 26) Signature of Individual or Corporate Name: ` l i Town of Mansfield Town of Mansfield - Board of Health 6 Park Row Mansfield, MA 02048 Application for Milk and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: COUSIN'S PIZZA & SUBS, INC. ADDRESS: 660 EAST STREET TELEPHONE AT LOCATION: (508) 339-6243 FAX NUMBER: OWNER OF BUSINESS: FRANK MYLONAS TELEPHONE OF OWNER: (508) 668-8982 FEDERAL ID/SS NUMBER: 04-2757-180 FEE: $5.00 PERMIT NUMBER: FS -13 SIGNATURE: DATE: .� %� 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. -a�' * Si nature of Indivi uor Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) -7 f U ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 'U'r www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses nnlicant Information Please -i Business/Organization Name: i 1 i t ` � � w, �` �t ,. Address: Ci /State/Zi tk ei d i V. i i 0 Phone #: U I 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. RestaurantBar/Eating Establishment 2. ❑ I am a,�s-Ole proprietor or partnership and have no 7. Office and/or Sales (incl, real estate, auto, etc.) c7loyees working for me in any capacity, g. Non-profit flo workers' comp, insurance required] 3. U 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] *4 11.[] Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'. comp. insurance req.] 1 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 provid' wor![ers' compensation instirance or my employees. Below is the policy information. i Insurance Company Name:lh Insurer's Address: € �r v City/State/Zip:` f.d Policy # or Self -ins. Lic. #, L "0U i 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 of perjury that the information provided above is true and correct: -7 f I ( 4 -f� Date' i Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office www.mass.gowoia Phone `C"RO® A CERTIFICATE OF LIABILITY INSURANCE DATE (MM/OD/YYYY) F11/16/2015 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 C & S Insurance Agency, Inc. 190 Chauncy Street/P.0 Box 406 Mansfield MA 02048 CONTACT Debra Gerraughty Ee. , (508)339-2951 Ne: (508)339-4811 AUDRIESS:Debbie@candsins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Sentinal Insurance Co LTD 11000 INSURED COUSINS PIZZA AND SUBS INC 44 CANNON FORGE DR FOXBORO MA 02035 INSURERS MAPFRE Insurance Co 23876 INSURERC:NorGUARD Insurance Conipany 31470 INSURER D: INSURER E: 1 INSURER F: COVERAGES CERTIFICATE NUMBERc2015 Cert 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, INSRLTR LTR TYPE OF INSURANCE ADDL BR POLICY NUMBER MMMIDDmYY PM UDS LIMITS X COMMERCIAL GENERAL LIABILITY D Gerraughty/DEBBIE EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE aOCCUR PRE ISES Eaoccurtence $ 1,000,000 MED EXP (Any one person) $ 5,000 OBSBAIL3300 4/1/2015 4/1/2016 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY a PRO- JECT LOC PRODUCTS - COMPIOP AGG $ 2,000,000 Policy Fee $ OTHER: AUTOMOBILE LIABILITY COMBINED SIGL LIMrr $ 1,000,000 Me accident BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BBDBBB 10/21/2015 10/21/2016 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per ax.denl $ X NON -OWNED HIRED AUTOS Ix AUTOS UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVEE.L. OFFICERIMEMBER EXCLUDED? a (Mandatory in NH) N I A COWC601724 8/1/2015 8/1/2016 PER OTH_ STATUTE I I ER EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more apace Is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) INS025 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn • Board Of Health ACCORDANCE WITH THE POLICY PROVISIONS. 2 Park Row AUTHORIZED REPRESENTATIVE Mansfield, MA 02048 D Gerraughty/DEBBIE ACORD 25 (2014/01) INS025 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD W Yl O N Ln ri O ® Z Z W F � a cd u O m U LL a a X W W U G O O E LL X V LU = c O O } a u v_ o U o L O N U- _0 - L c � N V C O N C 0 o y -0 N o Z `sLi Q 1[1���&Aj 111 qq 8"j" k'jMll I i Name of Recipient: FRANK MYLONAS Certificate Number: 2359244 Date of Completion: 6/3/2016 Date of Expiration: 61312021 The above-natrred person is hereby issued this certificate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in acrordance with 105 CMR 590.009(G)(3)(a). Deis certificate will lie validfor five (5) yearsftom date of'rompletion. Issued By: RESTAURANT ASSOC A`1 ION Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road, Suite 102 WwWrestaurant.org Southborough, D'1A 01772 508-303-9905 ts%siv. mares tauran tassoc. org 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company's name, address and phone number along with a certificate of insurance. Limited Liability Companies ¢LC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit, The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number., The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 www.mass.gov/dia Form Reviscd 5-26-05