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Home My WebLink AboutCousins Pizza & Subs 12/31/2018Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 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:. FRANK MYLONAS Whose place of business is: COUSIN'S PIZZA & SUBS, INC. 660 EAST STREET PERSON(S) IN CHARGE: FRANK MYLONAS Permit Expires: December 31, 2018 Food Fee: $126.00 License Number: FS-16 BOARD OF HEALTH MichaeCMcCCean, Chairman Milk & Cream W 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., having a place of business at: COUSIN'S PIZZA & SUBS, INC. 660 EAST 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 1213112018 , unless previous to that time is suspended or revoked. Expires 1213112018 License No.: FS-16 Board of Health MichaeCbtcCCean, Chairman POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-16 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name COUSIN'S PIZZA & SUBS, INC. 2) Establishment Address 660 EAST STREET 3) Establishment Mailing Address (if different) 44 CANNON FORGE DRIVE 4) Establishment Telephone No 5) Applicant Name & Title: FRANK MYLONAS FOXBOROUGH, MA 02035 339-6243 6) Applicant Address 44 CANNON FORGE DRIVE, FOXBOROUGH, MA 02035 7) Applicant Telephone No.: (508) 668-8982 24 Hour Emergency No.: (617) 686-0206 8) Owners Name & Title FRANK MYLONAS 9) Owner Address (If different from applicant) 44 CANNON FORGE DRIVE, FOXBOROUGH, MA 02035 Owner's telephone number (508) 668-8982 10) Establishment Owned By: 11) If a corporation or partnership give name, title, and home address of officers I !An Association or partner. I; A Corporation Name Title Address 1 7 An Individual A Partnership I Other legal Entity_—-- 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: (FRANK MYLONAS Address: 44 CANNON FORGE DRIVE, FOXBOROUGH, MA 02035 Telephone No 1(508) 668-8982 24 Hour Emergency No: (617) 686-0206 FAX: E-mail: ICOUSINSPIZZA106@VERIZON.NET 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 5 17) DAYS/HOURS: 7 DAYS 10:30 AM - 10:30 PM 18) Name of Person In Charge Certified in Food Protection Management: 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: Permanent Location 22) Establishment Type I.--.' Moblie Moblie Start Date: I ❑ Retail ( Sq Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: I'y Annual I Seasonal Seasonal Dates: [1 Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Ld] Food Service up to 100 or up to 10' PHF display $125.00 ❑ 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 ❑ Food Service - Institution ( Meals/Day) ELIZABETH TSIANAKAS ❑ Caterer $25.00 [] Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream I"J $25.00/1'reezer Pushcart $25.00 # of Pushcarts: 0 ❑ Residential Kitchen $100.00 Retail Food $100.00 ❑ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF- Potentially hazardous food (time/temperature controls required) Non PHF s - non -potentially hazardous food(no timeRemperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) ;_ _._ ------ --__..-_------ -- ._--------- -I Sale of Commercially Pre -Packaged Non-PHFs !1 Sale of Commercially Pre -Packaged PHFs rI _, 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 li ] Preparation of Non PHFs Other Food Operations i 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 ❑ Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Oripin RTE PHF in Bulk Quantities i_ ] Prepares Food/Single Meals for Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be Y completed b the Board of Health P - Total Permit Fee: $125.00 I Payment is due with application i- a 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 of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, s(c. 49A, I certify under A 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: 04-275 -7160 26) Signature of Individual or Corporate Name: 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 December 31st of each year. NAME OF BUSINESS: COUSIN'S PIZZA & SUBS, INC. ADDRESS: 660 EAST STREET TELEPHONE AT LOCATION: (508) 339-6243 FAX NUMBER: OWNER OF BUSINESS: FRANK MYLONAS TELEPHONE OF OWNER: (508) 668-8982 FEDERAL ID/SS NUMBER: 04-275 -7180 FEE: $10.00 PERMIT NUMBER: FS-16 SIGNATURE: �A �' . DATE: TAX CERTIFICATION FORM 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. SigFre of lnclyal or Corporate Name "Social Security No. (Voluntary) or Federal Identification Number C,-w� gue 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:\HmIthVane's DocumentAPERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 r, www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/ or part-time),* 2:0 lam a sole proprietor or partnership and have no employees working for me in any capacity. t-tW/`q.�.o 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. FNo workers' comp. insurance req.] Phone Business Type (required): S. ❑ Reta' 6. estauram/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. 0 Non-profit - 9. ❑ Entertainment 10.0 Manufacturing 11.0 Health Care 12.[] Other ;Any applicant that checks box #Imust also fill out the section below showing their Workers compensation policy information. c-If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such as organization should check box #1. I am an employer that isproviding �f�\Joprk/rs'hcomppe t1i ninsu' /ranl �e f/p�1�, iny�re ptoyees. Below is the policy informadmi. Insurance Company Name: IIC'illlA��C 1�II(.�AM 1)1�I1�y Insurer's City/State/Zip; Policy # or Self -ins, Lie. #- L V W Attach a copy of the workers' compensation Expiration Date: li I I V I V 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 certify, under the pains and penalties of perjury that the information provided ab& is fue and correct. 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: Phone 4� �® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYYI t1/0912017 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 have ADDITIONAL INSURED provisions or 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 enciofsement(s). PRODUCER CONTACT Debra Gerraughly NAME: C & S Insurance Agency, Inc. PNHCNnE (508)339Q951 FAX (508)339-4811 Ext. No): 190 Chauncy Street/P. Box 406 E AIL Debbie candsms.00m ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC9 Mansfield MA 02048 INSURER A: foremost Signature insurance Company 41513 INSURED INSURERS: Commerce Insurance Co 34754 COUSINS PIZZA AND SUBS INC. INSURER c: NorGUARD Insurance Company 31470 44 CANNON FORGE DRIVE INSURER D: INSURER E FOXBORO MA 02035 INSURER F: COVERAGES CERTIFICATE NUMBER: 2017 COI REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - INSR ETA rypE OFADDLSUBR INSO WVD PODGY NUMBER POLICY EFF MMIDOA'YYY POLICY EXP MMIDDNYYY LIMITS X COMMERCIAL GENERALLIABILITY C LAIMSMADEOCCUR EACH OCCURRENCE $ 2,000,000 ORETITEO PREMISES Eaoccu 7,000,000 $ MEDEXP(Anyone Person) $ 5,000 PERSONAL&ADV INJURY S 2,000.000 A PPS012640977 04/26/2017 04/26/2018 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY ❑ jECT LOG GENERALAGGREGATE g 4,000,000 PRODUCTS -COMP/OPAGG g 4.000,000 LBMED 5 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLELIMIT Ea accident $ 7,000,000 BODILY INJURY (Per person) $ ANYAUTO B OWNED GCHEDULED AUTOS ONLY AUTOS BBDBBB 10/21/2017 10/21/2018 BODILY INJURY(Peracddenl) $ X HIRED X NON-01 EO AUTOS ONLY /� AUTOS ONLY PROPERTY DAMAGE PeracdEenl g $ UMBRELLADAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS OAS CLAIMS -MADE BED I I RETENTION $ S G WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTNE YIN OFFICERIMEMBER EXCLUDED? (Mandatoryin NH) NIA COWC827517 08l01/2017 08/07@018 - X STER ATUTE EORH E.L. EACH ACCIDENT $ 500,000 EL DISEASE - EA EMPLOYEE 3 500,000 Ryes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD lot, Additional Remarks Schedule, may be atlacbed if more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 2 Park Row AUTHORIZED REPRESENTATIVE Mansfield MA 0204E n/ . '�. r-k* y§ n 1988-2015 ACORD CORPORATION_ All rinhfs reesrued ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD OD N O N n Ln N N N rI m T F— LU co Q N J W M Name of Recipient: FRMK MvtoNAS Certificate Number: 23em44 Date of Completion: 602916 Date of Expiration: 01312021 'Ibe above aam ll+,u mt it be,eby isser J this t h litn7e /0h romplaing at,olle,lee eewateerl raining p og)"m nragnis -d by rbe Ala sa hnre7tr LApintmew o/ Peb/v J-leal7b in arordanre c0ilb 105 CAIR 590..009(GJ(3)(g). Ibis av'7iltmlr eui/(br va/iJ Joh,/ive (.S)1'eurs frohn dale o/�roe�lriiau- lssurd by: NAHONA f> ,. ' Rl, IMIRANI ASSUC IAPION„ A9pss:rlmnlla Rcaeurmu 16uncnvfim 800,765.2122 333r11r11pik, R011d, S111tP 102 \NV\V.R6MIIf1111 t.1r!(( Snudlbomugb, NIA 01772 508-303-9905 1. nw.ma�aarnvvmissncog