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Home My WebLink AboutClassic Pizza 12/31/2018Commonwealth. 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 SERVICE 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:. MARIA LAFRENIERE Whose place of business is: CLASSIC PIZZA 242 CHAUNCY STREET PERSON(S) IN CHARGE: MARIA LAFRENIERE, OWNER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-11 BOARD OF HEALTH Miehaet 9McCtean, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS11 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name CLASSIC PIZZA 2) Establishment Address Y42 CHAUNCY STREET -... f, t 3) Establishment Mailing Address (if different) 242 CHAUNCY STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5150 5) Applicant Name & Title: MARIA LAFRENIERE, OWNER 6) Applicant Address 15 IDES HILL LANE, ATTLEBORO, MA 02703 7) Applicant Telephone No.: (508) 339-5150 24 Hour Emergency No.: (774) 25a2402 8) Owners Name & Title MARIA LAFRENIERE 9) Owner Address (If different from applicant) Owner's telephone number 5083395150 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers An Association or partner. A Corporation Name Title Address An Individual I A Partnership Other legal Entity i- - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: IMARIA LAFRENIERE, OWNER Address: 5 IDES HILL LANE, ATTLEBORO, MA 02703 Telephone No: ;(774) 254-2402 24 Hour Emergency No: (774) 254.2402 FAX: 1(508) 339-0103 E-mail: IMARIALAFRENIERE(a)YMAIL.COM Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: 24 Hour Emergency No: 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: 5 �11 17) DAYS/HOURS: 7 DAYS 10 AM - 10:00 PM 18) Name of Person In Charge Certified in Food Protection Management: MARIA LAFRENIERE If more than 3 individuals are certified, complete list is on file. Required as of 101112001 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: IJI Permanent Location 1,22) Establishment Type Caterer $25.00 Moblie Moblie Start Date: l Retail ( Sq. Ft) Milk & Cream $10.00 Moblie End Date: 11 j /1 Food Service up to 100 or --', Mobile Food & Consession $75.00 Mobile Comments: i up to 10' PHF display $125.00 21) Length of Permit: i,i Annual --] Seasonal Seasonal Dates: I Temporary Temporary Start Date: -_I Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 [ l Food Service - Institution ( Meals/Day) --� Manufacture Frozen Desserts/Ice Cream -- $25.00/freezer _._ I Pushcart $25.00 If of Pushcarts: 0 ❑ Residential Kitchen $100.00 [] Retail Food $100.00 Retail Snack Food $25.00 Tobacco Products $25.00 Temporary End Date:' Temporary Time: Rain Date:i 23) Food Operations �'i Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timeltemperature controls required) '(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercially Pre -Packaged Non-PHFs PHFCooked To Order I Hot PHF Cooked and Cooled or Hot - Sale of Commercially Pre -Packaged PHFs ,� Pren f PHFs For taw - _ Cold Holding Meal Service II _ 1 PHF and RTE Foods PreparedMeal Fore hI- g y Delivery of Packaged PHFs f AnimalrSigl Foods ended I Saleo Ro Susceptible Population P pFacility _. - ..L. Reheating of Commercially to be Prepared by Consumer I' Vacuum Packaging / Cook Chill Processed Foods for Within 4 Hours II Customer Self -Service of Non PHF and Non r 1 Customer Self -Service I Use of Process Requiring A Variance ACCPU la lu Perishable Foods Onlyernce Ice Manufactured and Packaged for 9 nd/or ntactime 9pubre health f Preparation of Non-PHFs Retail Sale -.- control) Other Food Operations 1 Juice Manufactured and Packaged for I I Offers Raw Or Undercooked Food Of Retail Sale -- Animal Origin Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food [ j Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health - --- - ! Total Permit Fee: $126.00 Payment is due with application I i 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°af 105 CMRU0.000 and..the federal Food Code. 24) Signature of Applicant: Jar `' �{'/i..__.---'" Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that 1, to and paid state taxes required under law. 25) Social Security Number or Federal ID: 82-2109162 26) Signature of Individual or Corporate Name: J'K'__ - _""� best knowledge and belief, have filed all state tax returns TAX CERTIFICATION FORM 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 "Social Security No. (Voluntary) or Federal Identification Number By: Corporate Officer (Mandatory, if Applicable) *This license will not be issued unless this 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 Massachusetts General Law Chapter 62C, section 49A. R:\HealthVan&s Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealtk of Massachusetts _. Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 wwtv.ntass.gov1dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITI'. Dglicant Information PI Business/Organization Address: Are y u an employer? Check the appropriate box: 1.3 1 am a employer with employees (full and/ Business Type (required): 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. g, Non-profit [No workers' comp, insurance required] 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.❑ Manufacturing no employees. [No workers' comp. insurance required]* I 1 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, Other with no empiovees. [No workers' comp, insurance req.] 12.0 -An}applicant that checks box 91 must also lilt 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 arganimlion should check box 91. I mn an employer that is pmvirliag workers' cTt pe(tsatioArnsteratice for my entplvees. Below is the pollik!"forflurdon. Insurance Company Insurer's Policy fl or Self- ins. Lic. #k& A I � y i� aI t A7.\"y_--px]tiiation Date: Attach a copy of the workers' compensation policydeclaration page (showing the policy numbSandik ?tIirai tgn 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 insuranccverage verification. certify, penalties of petty that Offlcial rise only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License v�s rrue and correct. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: __._ Phone �►co2D® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 08/31/2017 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(ies) 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 04971 -001 _rypMEpNrp ; CT _C J Murphy Ins Agenc 4971/p1/503 C J Murphy Ins Agency PEE"I�e Ex9L1FAlc_No.p_ Ery1p'I� 22 Fruit Street (ADDRESS:_service@ thefairwayagency_com - Taunton, MA 02780 j--- �. _.. 1NSURERLSLAFFOROING�99Jn.RAOE_._— _ t NAIC It _,_ 1_LNSURERA�_Associated Employers Insurance Company- I.33758 INSURED URERB — MRK Classic LLC :SIVRenC —.- 242 Chauncy Street INSURERD _.. _ — Mansfield, MA 02098 T ,, rrcoTIVII-ATC MI III REVISION NUMBER: VTHIS 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. - ICTS I I TYPE OF INSURANCE IW& _ _ VVBp-1 POLICY NUMBER_ , I ypp_ MJMWDD 11 M'YYI p O ICY E —� MMibO�)' LIMITS _ �— EACH OCCURRENCE -- GENERAL LIABILITY 15 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S - CLAIMS -MADE ]OCCUR 1 MCC)EXP (Any one person) �___ $ J PE �5 � GENERAL AGGREGATE PRODUCTS ,COMP/OP AGG $ -_ _ — GFNLAGGREGATELIMITAPPLIESPER. RO- POLICY -- — ___uECT_�ioc -- LIABILITY COMBINED SINGLE LIMIT B.-ia4c denll S — AUTOMOBILE I BODILY INJURY (For person) '.$ I ANY AUTO j BODILY INJURY (Per accident) S I-- ALL OWNEDF SCHEDULED AUTOS AUTOS !. --- Pf20PERTY DAMAGE I �P¢r S _._ _ NON -OWNED HIRED AUTOSaccident)-.-- AUTOS i i r LEADt ( UMBRELLA ( OCCUR EXCESS LIAR CLAIMS MADE I F � EACH EACH OCCURRENCES AGGREGATE - S — — _ $ OED RETENTIONS _� WppKgEERS CpMPFrNBATigN .. T—._-- �I{ PX IORV LIM--- -- _ - AND EM PLOVERS I.IAtlIL TY E L EACH ACCIDENT — 1 $ 500 000 00_ / N AVNY PPqRp'Pap� TTppRIP RT I XecunvE 0 fFIy E Cl N/A WCC-500-5017784-2017A 8/25/2017 8/2612018 (Mandatory ' fitl L� E.L. DISEASE- EA EMPLOYEE 5 �00,000.00_ If es es be un ar tltl d USCRIPTr�ON OF OPERATIONS beiq v — ____ __— - LE L. DISEASE POLICY LIMIT �._.-- - S I_ 500,000.00_. _A _- DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schodu to, it more space Is required) All Members are covered by the workers compensation policy. Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 7 ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD 5EP-07-2017(THU) 10;42 Tinos Insurance/Tinos Travel (FR\)508 880 5044 P.001/001 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803.0970 (800) 876-2765 NCCI NO 40059 POLICY NO. I WOC•600.5017784-2017A PRIOR NO. I NEW ITEM 1, The Insured: MRK Classic LLC DBA: Melling address: 242 Chauncy Street PEIN: "-*"9162 Mansfield, MA 02048 Legal Entity Type: Limited Llablllty Company Other workplaces not shown above: P. The policy period Is from 08/25/2017 to ::08/25120181" 12:01 a.m. standard time at the insured's mailing address, 3. 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 S.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: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy Includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All Information required below Is subject to verification and change by audit. Classifications Premium Basis Rates Coda Estimated Per$100 Estimated No, Total Annual Of Annual Romuneration Remuneration Premium INTRA 0330298 INTER SEE CLASSCODE 9CHEDII E Minimum Premium $2$7 Total Estimated Annual Premium $1,626 Gov Gov Deposit Premium $421 STATE GLASS MA 9079 State Assessments/Surcharges $1,192.00 X 4.55,6.�,0000°/�-�, $54 This policy, Including all endorsements, Is hereby countersigned by 08/29/2017 AWhOnnd eignafure ®fig Service Office: 54 Third Avenue Burlington MA 01803 WC 00 00 01 A (7-11) Includse copyrighted materlel of the National Counoll on Componatlon Innurenca, "sad with Its permission. C J Murphy Ins Agency 22 Fruit Street Taunton, MA 02780 d x w H � Q °� .� On z � Eal I= W o � \ \ 0 �ME \\\ ( \\\\ \ \\\ \ �\ i � \ m