HomeMy WebLinkAboutStefano's 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:.
THOMAS BISSEN
Whose place of business is:
K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS
30 CHAUNCY STREET
PERSON(S) IN CHARGE:
THOMAS BISSEN, PRESIDENT
Permit Expires: December 31, 2016
License Number: FS -75
Food Fee: $67.50
Milk & Cream V
BOARD OF HEALTH
'AlichaeCMcClean, 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:
THOMAS BISSEN
having a place of business at:
K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS
30 CHAUNCY 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 until 1213112016 unless previous to that time is
suspended or revoked.
Expires 1213112016
License No.: FS -75
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 -75
FOOD ESTABLISHMENT PERMIT APPLICATION
implication must be submitted -at least W -days before the planned opening date
1) Establishment Name K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS
2) Establishment Address 30 CHAUNCY STREET
3) Establishment Mailing Address (if different) 30 CHAUNCY STREET r
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-6111
5) Applicant Name & Title: THOMAS BISSEN, PRESIDENT
F6) Applicant Address 50 HIGH STREET, BELLINGHAM, MA 02019
j 7) Applicant Telephone No. (506) 966-5004 24 Hour Emergency No.: (506) 966-5004
8) Owners Name & Title THOMAS BISSEN
9) Owner Address (If different from applicant) 50 HIGH STREET, BELLINGHAM MA 02019
Owner's telephone number (508) 966-5004
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
❑ An Association or partner.
V A Corporation Name Title Address
El An Individual
❑ A Partnership I %M ° OVA -
El Other legal Entity
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: THOMAS BISSEN, PRESIDENT
Address: - 50 HIGH STREET, BELLINGHAM, MA 02019
�— 06�
Telephone No: ((5081 966-5004 24 Hour Emergency No: (508) . � oo-Y
FAX: -- - - --- -
E-mail: -y
Alt E -Mail:
13) District Or Regional Supervisor (if applicable)
[Name & Title:
Address:
,Telephone No: li 24 Hour Emergency No:
FAX:
E-mail:
Food Establishment Information
14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN
DEP Public Water Supply No: (If applicable) 16) No. -of Food Employees: 18
17) DAYS/HOURS: MON-SUN 11:00 AM - 10:00 PM
18) Name of Person In Charge Certified in Food Protection Management: PATRICK MCETTRICK LISA MYSIUK-
If more than 3 individuals are certified, complete list is on file. BISSEN
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) Please attach copy of THOMAS BISSEN
certificate
19) Person Trained in Anti -Choking Procedures (If 25 Seats or more):
20) Location: V Permanent Location
❑ Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
Annual
❑ Seasonal
Seasonal Dates:
❑ Temporary
Temporary Start Date:
I
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
(Check all that apply):
22) Establishment Type
❑ Retail ( Sq. Ft)
FV1 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
n 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 (timeAemperature 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
--u- _ -
me
----- -- - __-
❑ Customer Self Service of Non PHF and _N o -
Foods Only
Pre aration of Non-PHFs
❑d 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
control)
Other Food Operations 1 ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
❑ Catered Events or Institutional Food Service
�❑ Offers RTE PHF in Bulk Quantities
- -
Prepares Food/Single Meals or
❑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 ypith 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtain ces 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: 04-3245674
26) Signature of Individual or Corporate Name: 62� t a = - . A
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: K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS
ADDRESS: 30 CHAUNCY STREET
TELEPHONE AT LOCATION: (508) 339-6111
FAX NUMBER:
OWNER OF BUSINESS: THOMAS BISSEN
TELEPHONE OF OWNER: (508) 966-5004
FEDERAL ID/SS NUMBER: 04-3245674
FEE: $5.00
PERMIT NUMBER: FS -75
SIGNATURE:7L,
g
DATE:
I certify under the penalties of perjury that 1, 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)
r
By: f Corporate 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, 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;
Address:
City/State/Zip: *. 44ione #:
Are you an employer? Check the appropriate box:
L I am a employer with t' ` employees (full and/
or part-time).*
2.0 I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3.0 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]*
4.0 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers',comp. insurance req.]
Business Type (required):
5. 0 Retail
6. estaurant/Bar/Eating Establishment
7. 0 Office and/or Sales (incl, real estate, auto, etc.)
8. ❑ Non-profit
9. ❑ Entertainment
10.0 Manufacturing
U. n Health Care
12.0 Other
*Any applicant that checks box # I 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 ant an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name; " t W C,4xJ Cly v E�
tl
Insurer's Address:`
City/State/Zip: C 4 , e 4. Z' thl
Policy # or Self -ins. Lic. #, �,I Expiration Date: "I -
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
Investieations of the DIA for insurance coverage verification,
I do hereby certify nder the pains andpenalties ofperjury that the information provided above is true and correct.
f
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Ce, ®"e, "
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/oia
Phone #:
CERTIFICATE OF LIABILITY INSURANCE
6YYY)
DATE (MMIDDIY
04/20/2016
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
NAME: CATHY
ZEMACK INSURANCE AGENCY
PHONE (508) 872 — 9999 PAX 508 872 — 939
AIC No, Ext): (A/C,a):(508) )
E-MAIL
ADDRESS:
187 OAKS RD
INSURER(S) AFFORDING COVERAGE NAIC #
EACH OCCURRENCE $
INSURER ATECHNOLOGY INSURANCE CO
FRAMINGHAM, MA 01702
INSURED
INSURER B:
Kd Enterprises Inc.
PRODUCTS - COMP/013 AGG $
$
INSURER C :
D/B/A STEFANO'S PIZZA AND SUB SHOP
INSURERD:
INSURER E:
30 CHAUNCY ST
INSURER F:
Mansfield, MA 02093
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.
INSR
LTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
POLICY EFF
(MMIDDIYYYY)
POLICY EXP
(MMIDDIYYYY)
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑ OCCUR
EACH OCCURRENCE $
DAMAGE 10 an.
PREMISES (Ea occurrence) $
MED EXP (Any one person) $
PERSONAL &ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO -
JECT LOC
PRODUCTS - COMP/013 AGG $
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
r
(Ea accident) $
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
(Per accident)
$
UMBRELLA LIAR
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y
ANY PROPRIETORIPARTNERfEXECUTIVE - N
OFFICER/MEMBER EXCLUDED? m
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
TWC3467094
4/15/16
/
4/15/17
CSTAT - O
TORY LIMITS ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
CERTIFICATE HOLDER CANCELLATION
CUMBERLAND FARMS, INC
INSURANCE COMPLIANCE
PO BOX 12010 -CF
HELMET,CA 92546-8090
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRA71ON DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
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In a
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: THOMAS siSSEN
Certificate Number: 2313752
Date of Completion: 5/312018
Date of Expiration: 5/3/2021
The above-named person is hereby issued this certificate
for completing an allergen awareness training program
recognized by the Massachusetts Department of Public Health
in accordance with 105 CMR 590.009(G)(3)((7).
Deis certificate will be valid fbrfive (5) yens from date ofcompletion.
Issued By:
gffiffil
NATIONAL
RESTAURANT
ASSOCIATION,,,
Massachusetts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
�mrestaurant.org
Southborough, MA 01772
508-303-9905
N"m marestaurantassoc.org
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: LISA MVSIUK-BISSEN
Certificate Number: 2313624
Date of Completion: 5rd12016
Date of Expiration: s13r2021
The above-named person is hereby issued this certi*ate
for completing an allergen awareness training program
recognized by the Massachusetts Department of Publir Health
in accordance with 105 CMR 590.009(G)(3)(a).
Deis certificate will be valid for five (5) years f ronr date ofcompletion.
Issued By:
NATIONAL
CI URAON,.;
ASS
Massachusetts Restaurant Association
800.765.2122
333 Turnpike Road, Suite 102
www.restaurant.org
Southborough, MA 01772
508-303-9905
NhrV.marestaurantassoc.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/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