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HomeMy WebLinkAboutSt. Gregory Church 12/31/2016Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Fool 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:. ST. GREGORY GREEK ORTHODOX CHURCH Whose place of business is: ST. GREGORY GREEK ORTHODOX CHURCH 1007 WEST STREET PERSON(S) IN CHARGE: TED CHINGRIS Permit Expires: December 31, 2016 License Number: FS -88 Food Fee: WAIVED BOARD OF HEALTH NichaecmcClean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS -88 FOOD ESTABLISHMENT PERMIT APPLICATION (-- pp ica ion -m- --- usFbe sufed at leas _3U-da—ys -before-e plannedening-fie) - 1 1) Establishment Name ST. GREGORY GREEK ORTHODOX CHURCH 2) Establishment Address 1007 WEST STREET 3) Establishment Mailing Address (if different) P.O. BOX 293 MANSFIELD, MA 02048 4) Establishment Telephone No (508) 337-9986 1 5) Applicant Name & Title: TED CHINGRIS 6) Applicant Address 29 LEONARD STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-2773 24 Hour Emergency No.: (508) 339-2773 8) Owners Name & Title ST. GREGORY GREEK ORTHODOX CHURCH 9) Owner Address (If different from applicant) 29 LEONARD STREET, MANSFIELD, MA 02048 Owner's telephone number 5083379986 10) Establishment Owned By. 11) If a corporation or partnership, give name, title, and home address of officers ❑ An Association or partner. ❑ A Corporation 1 Name Title Address EJAn Individual ❑ A Partnership _ I p ❑ Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: TED CHINGRIS Address: 129 LEONARD STREET, MANSFIELD, MA 02048 Telephone No: 1(508) 339-2773 24 Hour Emergency No: (508) 339-2773 FAX: -1-- E-mail: ITCH INGRIS(cD-VERIZON.NET L Alt E -Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: i Address: Lewl4gp _� T--_ &n�vs_%f� Telephone No: 24 Hour Emergency No: FAX: E-mail ,—�11 /IPC-R/S_ 1 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 4 17) DAYS/HOURS: 18) Name of Person In Charge Certified in Food Protection Management: TED CHINGRIS 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): 0 j20) Location: Permanent Location 22) Establishment Type u Caterer $12.50 ❑ Moblie Moblie Start Date: ❑ Retail ( Sq. Ft) ❑ Milk & Cream $5.00 Moblie End Date: Food Service up to 100 or ❑ Mobile Food & Consession $37.50 Moblie Comments: up to 10' PHF display $62.50 ❑ Manufacture Frozen Desserts/Ice Cream 1;19 Fn/framer 21) Length of Permit: ❑ Food Service up to 101 -200 W Annual or up to 25' PHF display $75.00 ❑ Seasonal Seasonal Dates: U Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 23) Food Operations Check all that apply): ❑ Food Service up to 201 + or 25'+ PHF display $137.50 ❑ Food Service - Institution ( Meals/Day) ❑ 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) Non-PHF's - 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-PHFs ❑ Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs ❑ Reheating of Commercially Processed Foods for Service Within 4 Hours ❑ Customer Self -Service of Non PHF and Non - Perishable Foods Only Preparation of Non-PHFs rV] PHFCooked To Order ❑ Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ Sale of Raw Animal Foods Intended to be Prepared by Consumer ❑ Customer Self -Service ❑ Ice Manufactured and Packaged for Retail Sale ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging / Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health 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 Irl 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 0 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 cop® 0105 CT 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. l 25) Social Security Number or Federal ID: 04-3187147 26) Signature of Individual or Corporate Name: 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. �`�: 6►2 ��"6 Dl�/ Tile ��=,� L.o 6� * Signature of Individual or Corporate Name (Mandatory) y: Corp rate Officer (Mandatory, if applicable) **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, aeciion 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: _ I— C-OZC G OP -K 6-Re_4_1 1: C 14-OR61-1 Address: 1"7 SJ City/State/Zip:_ &14- VS %-- IL= L D Are you an employer? Check h appropriate box: 1. 1 am a employer with employees (full and/ or part-time).* 2. ❑ 1 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. ['1 Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.❑ 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 workerscompensation insurance for my employees. Below is the policy information. Insurance Company Name: 9RrWT MtiAkCAI) TN,CQ%A (A (Rove Insurer's Address: 3 O� F.. �M 2- City/State/Zip: t rJGGr)A1A-T1 t)IA A y9­2,02� Policy # or Self -ins. Lic. #, 0 y CC CS 30:3 -7 Expiration Date: 10 ?_o 1,6 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 hereb�tifyCder t e pains and patties of'perjury that the information provtaed above is true ana correct Sirtature: �t �- �'� Date: S 1� 16 q.zi 6 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: www,mass.gov/dia Phone #: 0874154 GREAT AMERICAN INSURANCE CO IL 70 01 (Ed. 10 07) Policy No. PAC 400-25-75 - 01 Renewal Of PAC 400-25-75 - 00 POLICY COMNION DECLARATIONS NAMED INSURED GREEK ORTHODOX PARISH OF 95/495 INC. DBA ST. GREGORY AND ADDRESS: PO BOX 293 MANSFIELD, MA 02048 IN RETURN FOR PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. AGENT'S NAME AND ADDRESS: RENAISSANCE ALLIANCE INS SVC 981 WORCESTER ST WELLESLEY, MA 02482 3716 (Insurance is afforded by the Company named below, a Capital Stock Corporation: GREAT AMERICAN INSURANCE COMPANY POLICY PERIOD: From 1 0/01 /201 5 To 10/0112016 12:01 A.M. Standard Time at the address of the Named Insured This policy consists of the following Coverage Parts for which a premium is indicated. This premium may be subject to adjustment. Premium Commercial Administrative Offices GREAT AMERICAN 301 E 4th Street Cincinnati OH 45202-4201 INSURANCE GROUP 513 369 5000 ph 0874154 GREAT AMERICAN INSURANCE CO IL 70 01 (Ed. 10 07) Policy No. PAC 400-25-75 - 01 Renewal Of PAC 400-25-75 - 00 POLICY COMNION DECLARATIONS NAMED INSURED GREEK ORTHODOX PARISH OF 95/495 INC. DBA ST. GREGORY AND ADDRESS: PO BOX 293 MANSFIELD, MA 02048 IN RETURN FOR PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. AGENT'S NAME AND ADDRESS: RENAISSANCE ALLIANCE INS SVC 981 WORCESTER ST WELLESLEY, MA 02482 3716 (Insurance is afforded by the Company named below, a Capital Stock Corporation: GREAT AMERICAN INSURANCE COMPANY POLICY PERIOD: From 1 0/01 /201 5 To 10/0112016 12:01 A.M. Standard Time at the address of the Named Insured This policy consists of the following Coverage Parts for which a premium is indicated. This premium may be subject to adjustment. Premium Commercial Property do Commercial General L i a b i I i t Commercial Crime and Fidelity Commercial Inland Marine Commercial Equipment Breakdown Commercial Auto GPERMEMENM Commercial Umbrella TOTAL FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on the attached Forms and Endorsement Schedule, IL 88 01 (11/85). 0 U) _H y�--f IF.J _H u r -I 4 .H q) rte -rf ro 1-4 r -^^f 4-4 U) N U U) 0 ro 2i 4-I a Co � r -i CD � N +-' (U tll a4: 0. 7,0/Z0 39VJ SId9NIHS Q31 ELLZ666809 66:60 9Z0Z/9I/90 z *-04 z 0 79 W. kr) 'ke): E 9 r4 cd 4Q, W4 u us Z0/Z0 39VJ SId9IHO a31 ELLZ666809 66:60 9T0Z/9T/90 z k,, 42 A us Z0/Z0 39VJ SId9IHO a31 ELLZ666809 66:60 9T0Z/9T/90 Mansfield Board of Health We, 5 r ?& 6-ol:z Date / ©1- 114AI �%// Food Service Permit Fee for the following reason Thank you, Signature �2/p e 6--7-2y-- Title quest a waiver of the 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 applicantwho 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. "1Vhere 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