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Home My WebLink AboutGreat Woods 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:. CHRISTOS TSIANAKAS & FRANK TSIANAKAS Whose place of business is: GREAT WOODS PIZZA & GRILL 428 ELM STREET PERSON(S) IN CHARGE: CHRISTOS TSIANAKAS Permit Expires: December 31, 2016 License Number: FS -162 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH NichaeCNcCCean, Chairman Commonwealth of Massachusetts Town of Mansfield Board of Health License to Sell Milk and Cream This is to certify that. CHRISTOS TSIANAKAS & FRANK TSIANAKAS having a place of business at. GREAT WOODS PIZZA & GRILL 428 ELM STREET Town of Mansfield 6 Park Row Mansfield, MA 02048 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 1213112016 License No.: FS -162 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 -162 FOOD ESTABLISHMENT PERMIT APPLICATION pp ►ca ►on must -be su mi e a eas ays e ore e p anne opening da -t-0— — 1) Establishment Name GREAT WOODS PIZZA & GRILL 2) Establishment Address 428 ELM STREET 3) Establishment Mailing Address (if different) 428 ELM STREET MANSFIELD, MA 02048 JUN Gp 4) Establishment Telephone No 5) Applicant Name & Title: CHRISTOS TSIANAKAS 6) Applicant Address 2 TONY DRIVE, NORTH EASTON, MA 02356 7) Applicant Telephone No.: (508) 944-4631 24 Hour Emergency No.: (508) 297-2253 8) Owners Name & Title CHRISTOS TSIANAKAS & FRANK TSIANAKAS 1 9) Owner Address (If different from applicant) J Owner's telephone number 5089444631 10) Establishment Owned By: ❑ An Association * A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address -- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: CHRISTOS TSIANAKAS Address: 2 TONY DRIVE, NORTH EASTON, MA 02356 Telephone No: (508) 944-4631 24 Hour Emergency No: (508) 297-2253 1 _ - FAX E-mail: TSIANAKASP-AOL.COM Alt E -Mail: KATHY (508) 944-4176 13) District Or Regional Supervisor (if applicable) Name & Title: FRANK TSIANAKAS, PRESIDENT -— Address: 2 TONY DRIVE, NORTH EASTON, MA 0235 Telephone No: - (774)265-0242 24 Hour Emergency No: FAX: E-mail: 3at� E P a - � - ' - Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 17) DAYS/HOURS: 7 DAYS PER WEEK 18) Name of Person In Charge Certified in Food Protection Management: KATHERINE 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 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more): � - _� 20) Location: Permanent Location 22) Establishment Type ❑ Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) i] Milk & Cream $5.00 Moblie End Date: ❑�/ Food Service up to 100 or ❑ Mobile Food & Consession $37.50 j Moblie Comments: up to 10' PHF display $62.50 ❑ Food Service up to 101 -200 or up to 25' PHF display $75.00 ❑ Manufacture Frozen Desserts/Ice Cream 2.50 reezer ❑ Pushcart $12.50 # of Pushcarts: 0 -- -- 21) Length of Permit: R Annual ❑ Food Service up to 201 + or 25'+ PHF display $137.50 L] Residential Kitchen $50.00 ❑Retail Food $50.00 ❑ Seasonal Seasonal Dates: E]Food Service - Institution E]Retail Snack Food $12.50 ❑ Temporary Temporary Start Date: ( Meals/Day) ❑ Tobacco Products $12.50 Temporary End Date: Temporary Time: Rain Date: 23) Food Operations (Check all that apply): Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ❑ Sale of Commercially Pre -Packaged Non -PRFs WJ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service -1 ❑ Sale of Commercially Pre -Packaged PHFs -/❑ Preparation of PRFs For Hot And Cold Holding For Single Meal Service _ __ _ ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs ❑ rY 9 ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Vacuum Packaging / Cook Chill - - - ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service Perishable Foods Only contact alternative, time as a public health control) ❑ Ice Manufactured and Packaged for Retail Sale _ ❑ Preparation of Non-PHFs ❑ Offers Raw Or Undercooked Food Of Animal Origin s for Catered nal Food Service ed Events olr Instingle tutional ut o Other Food Operations ❑ Juice Manufactured and Packaged for Retail Sale Offers RTE PHF in Bulk Quantitiesares ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health _-" Total Permit Fee: $62.50 Payment is due with application ❑ 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 copies of 105 CMR 590.000 and the federal Food Code. 24) 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. 25) Social Security Number or Federal ID: 47-4096706✓✓ �r 26) Signature of Individual or Corporate Name: 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: GREAT WOODS PIZZA & GRILL ADDRESS: 428 ELM STREET TELEPHONE AT LOCATION: *** "} `°' FAX NUMBER: `** OWNER OF BUSINESS: CHRISTOS TSIANAKAS & FRANK TSIANAKAS TELEPHONE OF OWNER: 5089444631 FEDERAL ID/SS NUMBER: 47-4096706 FEE: $5.00 PERMIT NUMBER: FS -162 F 4-7 SIGNATURE: -` DATE: A-< f 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. * Signa ure of Individual or Corporate Name (Mandatory) o P k A �� By: Corporate Officer (Mandatory, if applicable) L4 ' q OR M(P ** 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 Goc�oa�oS www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name. Address: City/State/Zip: Phone #: °' a _fix 1 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] 8. 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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4, ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers'.comp. insurance req.] 12.❑ Other *Any applicant that checks box 01 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 t#1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy informat'on. Insurance Company Name. Insurer's Address: V° �L, . XV k Y C2 (-X ,-j a _: , J ; ....> City/State/Zip: l Policy # or Self -ins. Lia # 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 DTA for insurance coverage verification, do hereby ertify, nder the p 'ns and penalties of perjury that the information provided above is true and correct; i atu Date' Wo- F hone #• t ' ` '�7^ ( �) "} < 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 Person: Phone M www,mass.gov/dia -�' CERTIFICATE OF LIABILI'T'Y INSURANCE 06/07/2016D/YYYY) AC Olt L7" 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(les) 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 CONT CT Paychex Insurance Agency Inc PHONE 877-266-6850 F 1C NO), 585-389-7426 PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE E-MAILADD ESS, Certs@paychex.com ROCHESTER, NY 14620 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: NorGUARD Insurance Company 31470 INSURER B: GREAT WOODS PIZZA CORP 428 ELM STREET WRENTHAM, MA 02070 INSURER C: INSURER D: INSURER E: 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 DDL INSR BR D POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE[:�]OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ ENT AGGREGATE LIMIT APPLIES PER: POLICY [] PROJECT= LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS NDN-OWNED HIREDAUTOS AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) $ UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY GRWC600005 12/05/2015 12/0512Q16 WC X TO - STUMJOTH- E.L. EACH ACCIDENT $ 100,000.00 E.L. DISEASE - EA EMPLOYEE $ 100,000.00 ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? � (Mandatory In NH) IT] I N/A E.L. DISEASE - POLICY LIMIT $ 500,000.00 If yes, describe Under DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) CERTIFICATE HOLDER CANCELLATION PROOF OF COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD \ \ ( 0 \ ( ) jf as ( /) ; fi75 aj �\ } . � LO !� CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: KATHERINETRANAcns Certificate Number: 2144457 Date of Completion: 12wO.'s Date of Expiration: "0 The above-named person is her eby issued this cert�cate for completing an allergen awareness training program recognized by the Massachusetts Department of Public Health in accordance with. 105 CMR 590.009(G)(3)(a). This certificate will be valid for five (5) years from date of completion. Issued BT. A" Massachusetts Restaurant Association 333 Turnpike Road, SuRL 102 Southborough, MA 01772 508-303-9905 www.martstaumatasw org NATIONAL' RESTAURANT ASSOCI)MON. 800.765.2122 wwwsestaurant org 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 (LLC) 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 permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/)icense 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 burn 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 -MASSA -FE Fax # 617-727-7749 www.mass.gov/dia Form Revised 5-26-05