HomeMy WebLinkAboutDeco's Italian Cuisine 2 12/31/2016Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
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:.
YUCEL OZCAN, OWNER
Whose place of business is:
DECO'S ITALIAN CUISINE
365 NORTH MAIN STREET
PERSON(S) IN CHARGE:
YUCEL OZCAN, OWNER
Permit Expires: December 31, 2016
Food Fee: $62.50
License Number: FS -98
BOARD OF HEALTH
MicFiaeCvicCCean, Chairman
Milk & Cream O
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:
YUCEL OZCAN, OWNER
having a place of business at:
DECO'S ITALIAN CUISINE
365 NORTH MAIN 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 un,1213112016 , unless previous to that time is suspended or revoked.
Expires 1213112016
License No.: FS -98
Board of Health
NichaeCMcCCean, Chairman
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
FOOD ESTABLISHMENT PERMIT APPLICATION
- (Application must be submitted at least 30 days before
the planned opening date)
1) Establishment Name C 0 '5 -DA It'a t) CU
Telephone No:
24 Hour Emergency No:
FAX:
3) Establishment Mailing Address (if different)
�K
Alt E -Mail:
4) Establishment Telephone No 3 3
5) Applicant Name & Title:
7) Applicant Telephone No.:,,,1,1'y 24 Hour Emergency No.:
8) Owners Name &Title b7clik',
9) Owner Address (if different from applicant)
Owner's telephone number _6��S - -/Y& -
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
An Association
or partner.
lei'A Corporation 44C
Name Title
Address
I An Individual
0; Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
13)District CrRegional Supervisor
-�applicable) -
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Alt E -Mail:
13)District CrRegional Supervisor
-�applicable) -
Telephone No:
24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
14) WATER SOURCE: 15) SEWAGE DISPOSAL:
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:! w
17) DAYS/HOURS: ' ' X3164- S' A,% 1 1� I' 1/W
18) Name of Person In Charge Certified in Food Protection Management:
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
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: LtyPermanent Location 22) Establishment Type C Caterer $25.00 �y
L] Moblie Moblie Start Date: Retail ( Sq. Ft) L14,milk & Cream $10/10
Moblie End Date: Food Service up to 100 or r�� [] Mobile Food & Consession $75.00
Moblie Comments: up to 10' PHF display $125.00 Manufacture Frozen Desserts/Ice Cream
21) Length of Permit: D Food Service up to 101 -200 $25.00/freezer
[VrAnnual or up to 25' PHF display $150.00 [-; Pushcart $25 # of Pushcarts:
L-1 Seasonal [] Food Service up to 201 + L I Residential Kitchen $100.00
or 25'+ PHF display $275.00
Seasonal Dates: i Retail Food $100.00
j_] Temporary n Food Service - Institution (i, Retail Snack Food $25.00
Temporary Start Date: ( Meals/Day) [; ] Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
Definitions: PHF - Potentially hazardous food (time.4emperature controls required)
Non-PHFs - non -potentially hazardous food(no time,4emperature controls required)
RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
[ Sale of Commercially Pre -Packaged Non -PRFs
LVPHFCooked To Order
L] Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
[ ] Preparation of PRFs For Hot And
Cold Holding For Single Meal Service
[L] PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
�; Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercial)
_ 9 y
Processed Foods for Service Within 4 Hours
[7] Vacuum Packaging / Cook Chill
-- - -- - -- L] Use of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
Customer Self -Service of Non PHF and Non-
Perishable Foods Only
D Customer Self -Service
F1 Ice Manufactured and Packaged for
Retail Sale
1 Preparation of Non-PHFs
Other Food Operations [ Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for
Catered Events or Institutional Food Service
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food To be completed by the Board of Health
Total Permit Fee:
Payment is due with application 1' waived
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 copie of 105 CfR 590 00 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 4 1 certify under t p nalties of rjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required un r law.
25 Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name: IX -3'' ��'
Town ofMansfield
Town ofMansfield_ Bo°~'f ofHealth 6Park 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: De o6),-17- li�.��
TELEPHONE ATLOCATION: 23q' &9<7 -
FAX NUMBER:
OWNER OFBUSINESS: Ywel
��
TELEPHONE OFOVVNER: '
FEDERAL ID/SS NUMBER:
PERMIT NUMBER:
SIGNATURE:
DATE:
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.
"Social Security No. (Voluntary) or Federal
Identification Number
Ila
c,/LL°
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\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
> I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information/� p Please Print Legibly
Business/Organization Name: �eeo S Balli rl 0ttt8;tie 10;WAAJ kes7-0_a i11 & .-,W—
Address: J(Pg /V xai/9 R, "
City/State/Zip: �f�f4,54e /d, /YI.14&--20 --%f Phone #: Sa8
Are you an employer? Check the appropriate box:
1. BI am a employer with 6Z- employees (full and/
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
employees working for me. in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, §1(4), and we have
no employees. [No workers' comp. insurance required]*
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp; insurance req.]
Business Type (required):
5. ❑ Retail
6. �Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Nan -profit
9. ❑ Entertainment
10.0 Manufacturing
11. [j Health Care
12.❑ 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 # 1.
I am an employer that Is providing workers' compensation insurance for my employees, Below is the policy information.
Insurance Company Name; �]{- ��i �.L�S lfli®[✓t'1�1'1:1 '� ��/Ylr�t'iiV� OF L'�AIaVI;-I JT
Insurer's Address: Oft1C fdWt'A SQLJARk,
City/State/Zip:
Policy # or Self -ins. Lic. # ) �' — 9 14 3 3 0 6 9' . •— 16 `®_�, 2 " G 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 certily, under,(he pains and penalties of perjury that the Information provided above is true and correct.
pg- yy���/oZv
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/Tdwn Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone
www.mass.gov/dia
TRAVELERS WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: UB -9H330694 -16-42-G
NEW -16
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
7 NCCI CO CODE: 12637
INSURED: PRODUCER:
OZCAN RESTAURANTS LLC BENS CARE AGENCY LLC
DBA DECOS ITALIAN CUISINE 1260 CREEK ST
365 N MAIN STREET WEBSTER, NY 14580
MANSFIELD, MA 02048
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period i5 from 11-17-16 to 11-17-17 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) 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 our liability under Part Two are:
Bodily Injury by Accident: S 100,000 Each Accident
Bodily Injury by Disease: $ 500,000 Policy Limit
Bodily Injury by Disease: $ 100,000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC NE NH NJ NM NV NY OR OR PA RI SC SD TN TS UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY
DATE OF ISSUE: 11-17-16 BE
OFFICE: ALBANY N.Y. 002
PRODUCER: BMM CARS AGENCY LLC DCQ22
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: YUCEL OZC-
Certificate Number: 2655084
Date of Completion: 1118/2018
Date of Expiration: 111812021
lbe aho w -named person is herelly issued this ert�&ate,
foreompletinganallergen quarenes Ininingprogrant,
rec%niu, by the JWffs athusetts Department ofRahlie Health
in aawd nTre zdth 105 UvIR 590.009(G)(3)(a).
D.ris eertifitwte will he valid for fw (5j yean f rom date ofeonrpletian.
❑ o
Issued By.
NAi4C) At a
< %
ASSOCIATION,
Massachusetts Restaurant Association
800.765.2122
333 Turnpike Road, Suitt 102
WA w.restaurant.org
Southborough,10A 01772
508-303-9905
w\w;.marestaurantaswccorg