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HomeMy WebLinkAboutPapa Gino's 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:. PAPA GINO'S Whose place of business is: PAPA GINO'S 280 SCHOOL STREET, BUILDING J -UNIT 335 PERSON(S) IN CHARGE: CHRISTINE CORDEIRA, GENERAL MANAGER Permit Expires: December 31, 2016 License Number: FS -53 Food Fee: $62.50 Milk & Cream V BOARD OF HEALTH NichaeCNcCCean, 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.- PAPA hat. PAPA GINO'S having a place of business at: PAPA GINO'S 280 SCHOOL STREET, BUILDING J -UNIT 335 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 -53 Scott Leite, Health .Agent POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred May. 23,2016 4:29PM TD SanklA 508,-339-6405 No. 0287 P, 2 FOR BOARD OF HEALTH USE ONLY I Date received: Date Inspected: Approved By: Permit# Issued FS -53 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must lie 'It'166st 30 days bew6-m—e—p Fafi-f7bdbpening date) 1) Establishment Name PAPA GINO'S 2) Establishment Address 280 SCHOOL STREET, BUILDING J -UNIT 336 13) Establishment Mailing Address (if different) 600 PROVIDENCE HIGHWAY DEDHAM, MA 02026 14) Establishment Telephone No (508) 261-2330 6) Applicant Name & Title: A/P ASSOCIATE 16) Applicant Address 600 PROVIDENCE HIGHWAY, DEDHAM, MA 02026 7) Applicant Telephone No.: (M) 4614200 24 Hour Emergency No.: (401)UUZ.7280 8) owners Name & Title PAPA GINOS 9) Owner Address (If different from applicant) 600 PROVIDENCE HIGHWAY, DEDHAM, MA 02026 7—Owner's telephone number (781) 461-1200 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers LJ An Association or partner. 141 A Corporation Name Title Address LI An Individual F1 A Partnership R Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 'CHRISTINE CORDEIRA, GENERAL MANAGER Address. 280 SCHOOL STREET, MANSFIELD, MA 02048 Telephone NO: (508) 261-2330 24 Hour Emergency No: (401)062-7280 FAX: 1(,781) 752.,2210 E-mail:. ...... ----------- '(O.PAPAGINOS-COM Alt E -Mail: ..... .. 13) District Or Regional Supervisor (if applicable) ,Name &Title: TERRY SCHUILTZ"DM Address: 600 PROVIDENCE HIGHWAY, DEDHAM, MA 02026 Fii8i -1200 Telephone No: 24 Hour Emergency No., (781) 401 FAX: (781) 752-2210 E-mail, I-SCHULTZ@PAPAGIN08,00M Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL' TOWN i DEP Public Water Supply No: (if applicable) 16) No, of Food Employees; Z 0. t 17) DAYS/HOURS; SUN -SAT 10 AM -10 PM 18) Name of Person In Charge Certified in Food Protection Management: G1�►'�S �+ "C' e"J01140 If more than 3 individuals are certified, complete list is on file. I Required as of 10/f/2001 In accordance with 105 CMR 590.003(A) Pleaso attach copy of cerfifloata 10) Person Trained In Anil -Choking Procedures (If 25 Seals or more): 20) Location: Q Permanent location ❑ Mobile Moblio start Date: Mobile End Dale: Mobile Comments: 21) Length of f7ermit: Q Annual ❑ Seasonal Seasonal Datos: _l Temporary Temporary Start Date: Temporary End Date: Temporary Time: 22) Estabilshment Typo ❑ Retell ( Sq. Ft) © Food Service up to 100 or up to 10' PHF display $126.00 �] Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up Io 201 + or 25'+ PHF display $275.00 "' "_" ❑ Food Service - Institution ( MealelDay) ❑ Caterer $25.00 Q Milk & Cream $10.00 ❑ Mobile Food & Consesslon $75.00 ❑ Manufacture Frozen Desserislice Cream $25.00/freezer r-1 Pushcer($25 # of Pushcarts: ❑ Residential Kitchen $100.00 ❑ Retail Food $100.00 ❑ Retail Snack Food $26.00 ❑ Tobacco Products $25.00 Rein Date- 233%) ate: _ _.-- _...... . ....... !(Check ) Food Operationsr Delrnlflons: PHF-PolonllaW hszerdous rood (Umollomporafuro controlsrequhed) Non•PHF's - non•polon flatly hazardous food(no (1mMompofaluro controls nrquhed) !(Check all that apply): RTE - teadydo•eal foods (Ex. sand,vlchcs, soleds, mutons ivhloh neednoW(horprocoss/ng) , _ ... ... © Sale of Commercially Pre -Packaged Non-PHF (❑ Sale of Commercially Pre -Packaged PHFs E]Dativeof Packaged PHFs g'Reheating of Commercially Processed Foods for Service Within 4 Hours Q Customer Solf•Service of Non PHF and Non - Perishable Foods Ont a © PHFCooked To Order Q Preperaliori of PHFs For Hot And Cold Holding For Single Most Service ❑ Sale of Raw Animal Foods Intonded to be Prepared by Consumer sar7=Service © Hot PHF Cooked and Cooled of Hot Held for Moro Than a Single Most Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging f Cook Chill ❑ use of Process Requiirng A Variance andlor HACCP Plan (including bare hand I - ' ' contact alternative, time as a ©Preparation of Non-PHFs •� El Ice Manufactured and Packaged for public health Retall Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Rolail Sale Animal Origin Otters RTE PHF In Buik Quantities © Prepares Food/Single Moats for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out•of•Dote or Reconditioned Food To be completed by the Board o%Neuffh Total Permit Fee: $125.00 Payment Is due with application ❑ waived I, the undorsignod, attest to the accuracy of the information provided In this application and affirm that the food establishment opo ration will comply with 105 CMR 500.000 and all other applicable law. I have boon instructed by the board of health on how to obtain copies of x,05 CMfi X90.000 and the federal Food Code. 24) SlgnaRue of Applicant: Pursuant to MGL Ch.620, sec. 49A, i certify under t enuflies of perjury that I, to my best knowledge and belief, have flied all state tax returns and pard state luxes required under law. 25) Social Security Number or Federal 1D: 33.0491264 _ 20) Signature of individual or Corporate Name: 4CL c Town of Mansfield Town of Mansfield - Bound of Health 6 Park Row Mansfield, MA 02048 Application fof' Milts and Cream Permit I hereby make application for a MILK AND CREAM PERMIT, which expires on June 1st of each year. NAME OF BUSINESS: PAPA GINO'S ADDRESS: 280 SCHOOL STREET, BUILDING J -UNIT 335 TELEPHONE AT LOCATION: (508) 261-2330 FAX NUMBER: (781) 762-2210 OWNER OF BUSINESS: PAPA GINO'S TELEPHONE OF OWNER: (781) 461-1200 FEDERAL ID188 NUMBER: 33-0491264 FEE: $10.00 PERMIT NUMBER: FS -52 F SIGNATURE: DATE: S/`� 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. aa * Sig4ture of Individual or Corporate Name (Mandatory) t�— By: Corporate Officer (Mandatory, If applicable) 33 — e99 _l26 � ** 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 fall 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 ofM'assacliusetts Department ofXndustrial Accidents 1 Offloe ofXKVestigations X Congress Street, Suite .100 Boston, MA 02114-20X 7 wiviv.mass.gov/dia Workers' Compensation insurance Affidavit: Ocrteral Businesses Business/Organization Are you alt employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ -or part-time),* ' 2. ❑ I am a sole propirletor 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.] *Any applicatitthat checks box # I must also fill out the section below showing the #: 50�-2LQi-a330 _ l'rttit Fortin ^` Business Type (required): 5. L1 Retail 6. ❑ RestaurantlBar/Eating Establishment. 7. ,El Office andlor Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.❑ Health Care 12.[] Other 1..., to vultlyulutmull tloltuy IOlormarton. -Ic Ino corporate oatcers nave exempted themselves, but the corporation has other employees, a workers' compensation, policy is required and such an organization should check box #i. - tarn an employer that is providing workers' ompensallon lnscerat ee foryV ecnp gees Below i t/te icy t formation. . Insurance Company Name. • Insurer's Address:_ � p�DS�' /o City/State/Zip: _ l V i D cc( 5 OJA A) o r-? y (A % - Policy # or Self -ins. Lio. # '�7(D8 % ( 2_ SP 3 Expiration Date; (�S D 1 eId — Attach a copy of the workers', compensation policy declaration page (showing the policy number and expira ion 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 file 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 cep, uqftr the palr�s and periahles ofperfury that the tnforinationpro4ded aoove is trice and correct Official use only. Do not write In flits area, to be completed by city or town ofJlclal City or Town: Permit/License # Issuing Aittkor(ty (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk Q; Gieensing Boat'd 5, Selectmen's Ofttee 6. Other t: Contact Person: Phone #• www.mass.gov/dia The Commonwealth of Massachusetts P_rtnt F_o'rtii Department of Industrial Accidents Office of Investigations I Congress Sheet, Suite 100 t Boston, MA 02114-20.X 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Oenerat Businesses Applicant Information Please Pr rnt LeiribIV Business/Organization Name: Address: Ciwstate/Zip: Are you an employer? Check the appropriate box: 1. ❑ 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] 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.] Phone #: Business Type (required): 5. 0 Retail 6. ❑ Restaarant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11.0 Health Care 12. E-] Other_ • w mei ••..a•., .11a, U.— UVA nL MUSE also nu our me section below showing their workers' compensation policy information. **[f 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 A. - I ion an employer that is providing workers' compensationt insurar ce foryy etnp yees. Below is lite licy i formation. Insurance Company Name: i i n r.j. �. Lr r j}� `,,,� / ,��„ _ �� ,r /. . Insurer's Address:_ p�30Sf j /� /t City/State/Zip: _ 1V t nrrl 5 �uJA7. Policy # or Self -ins. Lic. #_ Expiration Date: O J 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 certo, under thepains andpena/ties ofperjury that the Information provided above Is true and correct Signature: Date Phone #• 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 41,Licens4Board 5. Selectmen's Office 6. Other Contact Person: Phone n .� GERTII~ICATE OF LIP CERTIFICATS IS ISSUED AS A MATTER OF INFORMATION 0 :T(FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENI OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIT, RESENTA'IIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. )RTANT: (f the certificate holder is an ADDITIONAL. INSURED, ti terms and conditions 17 the pol(cy, certain policies may require an ficate holderin lieu ofsuch endorsement{sj. 'ER r & Company venue of the Americas rk NY 10019 Specialty Brands Holdings, LLC 260 Franklin St. Suite 1860 Boston, MA 02110 SPEC13RA-01 SBORTNIKHR I3IL,ITY INSURANCE DATE(MMIbDhWY) 7/1612015 &Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS , EXTEND OR ALTER THE COVERAGE AFFORDED SYTHE POLICIES ITE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED e pOINAes) must be endorsed. If SUBROGATION IS WAIVED, subjectto endorsement. Astatement onthis certificatedoes notconferfights tothe CONTAcr NAME: PHONE ) FAx 1(212) 696.3460 arc No E.1 :4 (212 596 3400 arc Na EMAIL ADDRESS• INSURER(SIAFFOROING COVERAGS NRIC# INSURERA:United Sfates Eire Insurance Company 21143 INSURERB:Charter Oak Fire Insurance company 25645 INSURERO:National Union Fire Ins. GO. of Pittsburgh PA 19445 INSURmp:Crum & Forster Indemnity Company 31348 INSURERS: INSURERF• IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVEBEENISSUED'fOTHEINSUREDNAMEDA OVEFORTNEPOUCYPERIOD ATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CON'IRACTOROTHERDOCUMENTWI'fHRESPECTTOWHICHTHIS IFtCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES pESCRIBED HEREIN IS SUBJECTTOALL'fHETERMS, 7stoNs AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. COMMERCIAL GENERAL UAB! LnY CLAIMS•MApE � OCCUR v L -n SUMASATE LIMITAPPUES PER: PODGY ❑ jECF LOC OTHER: ,OMDBILELIABILITY ANYAUTO ALLOWNEDSCHEDULED AUTOS MX AUTOS HIREDAUTOS NOAUTNOOSWNED UMBRELLAUA13 X OCCUR MESSUA13 Hien.. MMIUMITrY i 1tAMfDD1VVVV1LIMITS EACHOCCURRENCE S 06130/2015 06130!2016 PREMISES Eaoccurrenrz S 4 MED EXP (Anyone personj is NIA1 rUUyz6yL63 1 06/30/2015 S ION OFOPERATIONSILOOK11ONSJVEHICLESRCORD1o1,AddiflonalRemaftSchadulo, may beauachedirmorespaeersrequTredj Sank is named as additional InsUred with respectto the operations of the named insured and as required bywritten contract 10; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POL(GY PROVISIONS. AUTHORIZED REPRESENTATIVE MULM FS-COMPJOPAGG S 5 06/3012015 06130/2016 COMDINEDSINGLELIMIr S Ea acddenl BODILYINJURY(Perperson) S BODILY INJURY(Peracadenj S PROPERTYDAMAGE S Peracodenl S 06/30/2015 06/30/2016 EACHOCCURRENCE S AGGREGATE $ NIA1 rUUyz6yL63 1 06/30/2015 S ION OFOPERATIONSILOOK11ONSJVEHICLESRCORD1o1,AddiflonalRemaftSchadulo, may beauachedirmorespaeersrequTredj Sank is named as additional InsUred with respectto the operations of the named insured and as required bywritten contract 10; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POL(GY PROVISIONS. AUTHORIZED REPRESENTATIVE (/ ++ ++ C z '� U N J LL CL 0�1 — O) F@ a N ++ co tc .� E d 'ate 2 2 O N E 2 C E E CL - np •O. �o cnvwwScnw w O O a to D �.wa�,wc� „� z 93.`. ^ � W�1 C •��� �n�ViQ O �yM Lo LOC C � x 2U, W W £ n N W m �- CJ O n Z.2 n_'n x w .. LU c = O .� O V U N w 0 O E a U O y 90 LL i = w0. CCO CU C a O i C O u a LL0uj Z a ®� .� m rr N O N N O 41 ' L O Us � 0 N 4 41 o N ++ Wfuz z ) u N i _ N ^ G N °u •�: `s T a� (n u VU N `? N42 ^ � W�1 i••�m - •��� �n�ViQ �yM Lo LOC x 2U, W W o s N W O O n Z.2 n_'n LU 6 C U1 E r a v i O m u U i U i WN:.^ ^ W U �• � LL a O CN O m N w w a O amu 0 0-j ® W M r •��� i1O n �yM Lo LOC NA C A ` O O 'w O A A Z O N o N W /f d�� »� ,«_ p inos: :Aizz�aia w -- G:=- GRILLED SANDWICHES COMPANIES PGHC HOLDINGS INC PAPA GINO'S HOLDINGS CORP PAPA GINO'S INC PAPA GINO'S FRANCHISING CORP D'ANGELO'S SANDWICH SHOPS INC DELOPS INC PROGRESSIVE FOOD INC CURRENT OFFICERS MARK DEBLOIS 184 FOREST STREET SHERBORN, MA. 01770 PRESIDENT, CHIEF OPERATING OFFICER COREY WENDLAND 41 FIELDSTONE LANE FALMOUTH, ME 04105 CHIEF FINANCIAL OFFICER Papa Gino's Inc. 600 Providence H« -y. Fax Server 10/20/2015 11:46:05 AM PAGE IS "11102H1111111111 MASSACHUSETTS DEPT. OF REVENUE PO BOX 7066 BOSTON, MA 02204 MARK E. NUNNELLY, COMMISSIONER CHARLENE HANNAFORD, ACTING DEPUTY COMMISSIONER 2430 Notice 80619 PAPA GINO'S INC. TIP ID 330 491 264 600 PROVIDENCE HWY Date 10/15/15 DEDHAM MA 02026-6848 Bureau CERTIFICATE CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE OP The Commissioner of Revenue certifies as of the above date, that the above named individual or entity is in compliance with Its tax obligations payable under M.G.L. c. 62C, including corporation excise, sales and use taxes, sales tax on meals, sales and use tax on Boats/RV, withholding taxes, room occupancy excise and personal income taxes, with the following exceptions. This Certificate certifies that individual taxpayers are in compliance with income tax obligations and any sales and use taxes, sales tax on meals, withholding taxes, and/or room occupancy taxes related to a sole proprietorship. Persons deemed responsible for the payment of these taxes on behalf of a corporation, partnership or other business entity may not use our automated process to obtain a Certificate. This Certificate does not certify that the entity's standing as to taxes such as unemployment insurance administered by agencies other than the Department of Revenue, or taxes under any other provisions of law. Taxpayers required to collect or remit the following taxes must submit a separate request to certify compliance: Alcoholic Beverage Excise, Cigarette Excise, International Fuels Tax Agreement, Smokeless Tobacco or Ferry Embarkation. THIS IS NOT A WAIVER OF LIEN ISSUED UNDER GENERAL LAWS, CHAPTER 62C, SECTION 52. Very truly yours, Charlene Hannaford, Acti eputy Commissioner AGIMY CUSTOME;C210: SPE013RA 01 ASMITH LOC#:2 n ADDITIONAL REMARKS SCHEDULE Page 'I of •[ NAMEDINSURED Specialty Brands Holdings, L1.0 $e Company, LLC ago Providence Highway IBM oedhatn, MA 02026 3E 4 Nalccoa>± BE I imig P 4 er cmeeare:S)rR PAGE •i NAL REMARKS )ITIONAL MMARKS FORM IS A SCHUDUM TO ACORD FORM, 7M0l;R: ACORO25 FORM•fITLT;: GerttHcateofMabllltyinsurance s: tat gamed Insureds: b0s, Inc. 1no's Holdings, Corp. ino's Franchising corporation ino'WD'Angelo Card Services, Ino. to Franchising Corp. lo's Sandwich Shops, [no. Lith & Wollensky Restaurant Group, Inc. Miami, L.L.C. (DE) .C., L.L.C. (DE) 3a Wollensky of Poston LLG (DE) %Wollensky of Houston LLC (DE) :sky Beverage, Inc. )n S&W, L.P. ,f Las Vegas, L.L.G. (DE) if Philadelphia, LLC (DE) & Wollensky of Ohio LLC (DI;) & Wollensky of America LLC hington Avenue corp. ,t Grill 1 Holdings, Inc. S, Inc. Pointe hospitality, Inc. st Grill 1l essive Food, Inc. & Wollensky Atlantic Wharf LLC Chicago, L.L.C.