HomeMy WebLinkAboutMansfield House of 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:.
EZZAT A. ZAKHARY
Whose place of business is:
MANSFIELD HOUSE OF PIZZA, INC
175 NORTH MAIN STREET
PERSON(S) IN CHARGE
EZZAT A. ZAKHARY
Permit Expires: December 31, 2016
License Number: FS -40
Food Fee: $67.50
Milk & Cream V
BOARD OF HEALTH
MichaeCvlcCCean, Chairman
Commonwealth of Massachusetts
Town of Mansfield
Board of Health
License to Sell Milk and Cream
This is to certify that:
EZZAT A. ZAKHARY
having a place of business at:
MANSFIELD HOUSE OF PIZZA, INC
175 NORTH MAIN STREET
Town of Mansfield
6 Park Row
Mansfield, MA 02048
in the Town of Mansfield has been granted a license to sell MILK and CREAM and
is subject to the Provisions of the Laws of the Commonwealth of Massachusetts,
relating to the terms and conditions, and to the rules and regulations established by
the Board of Health, of the Town of Mansfield governing the sale of Milk and Cream
and shall remain in force until 1213112016 unless previous to that time is
suspended or revoked.
Expires 12131/2016
License No.: FS -40
Scott leite, Heaah Agent
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FS -40
FOOD ESTABLISHMENT PERMIT APPLICATION
- -
_(Ap_p_1ication mus esu r►mi e afTea--s-t- a� �-e or�pTa—hne—d-openin--g--d-aTe) ;I
1) Establishment Name MANSFIELD HOUSE OF PIZZA, INC
2) Establishment Address 175 NORTH MAIN STREET -I
3) Establishment Mailing Address (if different) 175 NORTH MAIN STREET
MANSFIELD, MA 02048 ,'
j 4) Establishment Telephone No (508) 339-6400
i
5) Applicant Name & Title: EZZAT A. ZAKHARY, PRESIDENT
6) Applicant Address 24 LANCASHIRE DRIVE, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 269-4133 24 Hour Emergency No.: (508) 269-433 (508) 339-7768
8) Owners Name & Title EZZAT A. ZAKHARY
9) Owner Address (If different from applicant) 24 LANCASHIRE DRIVE, MANSFIELD, MA 02048 '
Owner's telephone number (508) 269-4133
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
W A Corporation Name � , , � Title C � - Address �$ �
❑ An Individual -e' __ v Pets _ P1� L ae) o� 5 re � -
❑ APartnership f) �'f' 7';?�%► p�(' ' 7 -
❑ Other legal Entity r
12) Person Directly Responsible For Daily Operations (owner, 4erson in charge, supervisor, manager etc.)
Name & Title: (EZZAT A. ZAKHARY
1 Address: 24 LANCASHIRE DRIVE, MANSFIELD MA 02048
Telephone No: (508) 339-7768 24 Hour Emergency No: (508) 269-4133 (508) 339-7768
FAX:
E-mail
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
FAX:
E-mail:
24 Hour Emergency No:
Food Establishment Information
14) WATER SOURCE: TOWN15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 2 {
17) DAYS/HOURS: MON-SUN 11:00 AM - 11:00 PM -
18) Name of Person In Charge Certified in Food Protection Management: EZZAT A, ZAKHARY
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: W Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
W Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
❑ Retail ( Sq. Ft)
Food Service up to 100 or
up to 10' PHF display $62.50
❑ 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
Definitions: PHF Potentially hazardous food (time/temperature controls required)
23) Food Operations 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
PHFCooked To Order
❑d Hot PHF Cooked and Cooled or Hot Held
---
❑ Sale of Commercially Pre -Packaged PHFs
- - ----- --
n 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
- - -- -- -- - - -
--- ---
F1 Sale of Raw Animal Foods Intended
Susceptible Population Facility
Reheating of Commercially
to be Prepared by Consumer
❑ Vacuum Packaging / Cook Chill
Processed Foods for Service Within 4 Hours
Use of Process Requiring A Variance
F-1and/or
❑ Customer Self -Service of Non PHF and Non-
❑Customer Self -Service
HACCP Plan (including bare hand
Perishable Foods Only
____ __ _____
- -
❑ Ice Manufactured and Packaged for
contact alternative, time as a public health
E] Preparation of Non-PHFs
Retail Sale
contro )
Other Food Operations
❑ factured and Packaged for
Offers Raw Undercooked Food Of
L]Animal
Retail Sale
Or gOr
in
-- - - -
❑ Prepares Food/Single Meals for
❑ Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service ,
❑ Retail Sale of Salvage, Out -Of -Date
I or Reconditioned Food
___ p - y _--
To be com leted b the Board of Health
I
- — _- - - -
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 andit other applicable law. I have been instructed by the
board of health on how to obtain copies of 105 CMR 590.000 ar)a the federal Food Code.
24) Signature of Applicant = -+
Pursuant to MGL Ch.62C, se&. 49N, I certify under the
and paid state taxes required under law.
25) Social Security Number or Federal ID: 04-329J697
26) Signature of Individual or Corporate Name: '
of perjury that I, to my best knowledge,and belief, have filed all state tax returns
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: MANSFIELD HOUSE OF PIZZA, INC
ADDRESS: 175 NORTH MAIN STREET
TELEPHONE AT LOCATION: (508) 339-6400
FAX NUMBER:
OWNER OF BUSINESS: EZZAT A. ZAKHARY
TELEPHONE OF OWNER: (508) 269-4133
FEDERAL ID/SS NUMBER: 04-3291697
FEE: $5.00
PERMIT NUMBER: FS -40
SIGNATURE: '
t,
DATE: �L
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 (Mandatory)
By: Corporate Officer
(Mandatory, if applicable)
0 L-1 - j z? I/r2 I
** 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
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information / Please Print Legibly
Business/Organization Name: )'1' i= .i/f't
Address: � Mb
Ci
Vfione #: ?� " >� t r! f j
Are you an employer? Check the appropriate box:
LU i am a employer with 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]
1 ❑ 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.]
*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 emplo ees. Below is the policy information.
Insurance Company Name: 1) <rL, I ensaJ [J k (A M o Q. \ G,r _ l W - Co
Insurer's Address:Q2,2 D YOcy-N 0-,s 5 _D t o ,,m 0-0,_2 V,,Q
City/State/Zip:
Policy # or Self -ins. Lic. #�ili� 1 ���(�� 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.
1 do hereby certify, under the pains and penaltsof,
--- - '_ If
that the information provided above is true and correct
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
Permit/License #
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Contact Person: Phone
www.mass.gov/dia
WORKERS COMPENSATION AND EMPLOYERS' LIABILTY
INSURANCE POLICY ---- INFORMATION PAGE
INSURE's-z: POLICY NO: WE128868A
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY
222 AMES STREET RENEWAL
DEDHAM, MA 02026 NCCI Company No: 21059
Account No:
FEIN: 04-3291697
ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS:
MANSFIELD HOUSE OF PIZZA INC BOYNTON INSURANCE AGENCY,
175 N MAIN ST INC
MANSFIELD MA 02048 72 RIVER PARK STREET
NEEDHAM, MA 02494
AGENT NO.: 20272
LEGAL ENTITY: CORPORATION
OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification Schedule)
ITEM 2. . POLICY PERIOD: From: 11/05/2015 To: 11/05/2016
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
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:
$
500,000
each accident
Bodily Injury by Disease:
$
500,000
policy limit
Bodily Injury by Disease:
$
500,000
each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to
verification and change by audit.
Total Estimated
Minimum Premium: $ 219 Annual Premium: $ 944
Audit Period: ANNUAL Additional / Return Premium:
Comments
Issued At: r �;
Date: 09/25/2015 Countersigned by t
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
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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/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 -MASSA -FE
Fax # 617-727-7749
www,mass.gov/dia
Form Revised 5-26-05