HomeMy WebLinkAboutDeco's Italian Cuisine 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:.
YUCEL OZCAN, OWNER
Whose place of business is:
DECO'S ITALIAN CUISINE
365 NORTH MAIN STREET
PERSON(S) IN CHARGE:
YUCEL OZCAN, OWNER
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-98
BOARD OF HEALTH
-%lichae(McC(ean, Chairman
Milk & Cream V
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:
YUCEL OZCAN, OWNER
having a place of business at:
DECO'S ITALIAN CUISINE
365 NORTH MAIN 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-98
Board of Health
MlchaeCMCCCean, Chairman
POST THIS LICENSE IN A CONSPICUOUS PLACE
This license shall not be sold, assigned or transferred
0
vl FOR BOARD OF HEALTH USE ONLY Permit# Issued FS98
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name DECO'S ITALIAN CUISINE
2) Establishment Address 365 NORTH MAIN STREET
3) Establishment Mailing Address (if different) 46 PRATT STREET #8 2017
MANSFIELD, MA 02048
11 4) Establishment Telephone No (508) 339-6995
5) Applicant Name & Title: YUCEL OZCAN, OWNER
6) Applicant Address 46 PRATT STREET #8, MANSFIELD, MA 02048
7) Applicant Telephone No.: (608) 446-4204 24 Hour Emergency No.: (608) 446A204
i
8) Owners Name & Title YUCEL OZCAN, OWNER
9) Owner Address (If different from applicant) 46 PRATT STREET #8, MANSFIELD, MA 02048
Owner's telephone number (508) 446-4204
-
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
A Partnership— --
Other legal Entity
-
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name &Title: YUCEL OZCAN, OWNER
Address: 146 PRATT STREET #8, MANSFIELD, MA 02048
Telephone No: 1(508) 446-4204 24 Hour Emergency No: (506) 446-4204
FAX: i
E-mail 'YUCELOZCAN1@GMAIL.COM
Alt E-Mail: KIMBERLYOZCAN@GMAIL.COM -
13) District Or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No: 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:
17)DAYS/HOURS: MON - SAT 10 AM - 10 PM SUN -11AM-9PM
18) Name of Person In Charge Certified in Food Protection Management: YUCEL OZCAN
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): FV1
20) Location:
[] Permanent Location
Moblie Moblie Start Date:
Moblie End Date:
Moblie Comments:
21) Length of Permit:
!J, Annual
Seasonal
Seasonal Dates:
, Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
22) Establishment Type
!... I Retail ( Sq. Ft)
]I Food Service up to 100 or
up to 10' PHF display $125.00
_ I Food Service up to 101 -200
or up to 25' PHF display $150.00
-. Food Service up to 201 +
or 254 PHF display $275.00
L] Food Service - Institution
( Meals/Day)
f_ ] Caterer $25.00
.1 Milk & Cream $10.00
-..] Mobile Food & Consession $75.00
-1 Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
!. Pushcart $25.00 # of Pushcarts: 0
Residential Kitchen $100.00
_...',, Retail Food $100.00
] ] Retail Snack Food $25.00
i] Tobacco Products $25.00
Ram Date: i,
23) Food Operations Definitions: PHF - Potentially hazardous food (time/temperafure controls required)
Non-PHFs - non -potentially hazardous /ood(no time/temperature controls required)
.(Check all that apply): RTE-
ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
y Pre -Packaged Non-PHFs
Sale of Commercially
IJi PHFCooked To Order
Hot Cooled
,Hot PHF Cooked and Cooled or Hot Held'I
Sale of Commercially Pre -Packaged PHFs
I Preparation of PHI's For Hot And
I
r-�
for More Than a Single Meal Service
- Delivery of Packaged PHFs
-
Cold Holding For Single Meal Service
alConsumerFoods lended
Sale of Animal
HIF and RTE Susceptible Foodt Pr paarre' dFor Highly
Reheatingof CommerciallyI
Pre a by
p
I_] Vacuum Packaging /Cook Chill
Processed Foods for Service Within 4 Hours
_._. -...__.._.;,
Customer Self Service of Non PHF and Non-
�� I Customer Self Service
]_.use of ProcessRequiringa
and/or HACCP Plan (including bare chand I'I
Perishable Foods Only _
I Ice Manufactured and Packaged for
contact alternative, time as a public health
P
I' 1 Preparation of Non -PH -Fs -
Other Food Operations
control
r _] Retail
Manufactured and Packaged forA J Offers Raw Or Undercooked Food Of
Retail Sale Animal Origin
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
To be completed by the Board of Health
Total Permit Fee: $125.00
Payment is due with application ] waived 'I
Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food
establishment operation will comp with 105 CMR 590.000 and all other applicable law. I have been instructed by the
board of health on how to obtaiyf Zies oj1105 CyW,]R 590.000 and the federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sW. 49A, I certify ur
and paid state taxes required under law.
25) Social Security Number or Federal ID: 81.
26) Signature of Individual or Corporate Name:
of perjury that I, to my best knowledge and belief, have filed all state tax returns
CfJ )SfvC--
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: DECO'S ITALIAN CUISINE
ADDRESS: 365 NORTH MAIN STREET
TELEPHONE AT LOCATION: (508) 339-6995
FAX NUMBER:
OWNER OF BUSINESS: YUCEL OZCAN, OWNER
TELEPHONE OF OWNER: (508) 446-4204
FEDERAL ID/SS NUMBER: 81-4326704
FEE: $10.00
PERMIT NUMBER: FS-98
SIGNATURE:
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.
4W 6 ze w
By: Corporate Officer (Mandatory, if Applicable)
"Social Security No. (Voluntary) or Federal
Identification Number
*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:\Health\J=&s Doc=ents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doo
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
u,pwww.mass.gov/dla
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Business/OrganizationName:t/if",�„5 clTLt�Q2/iGtd /�%� /V.�'9� /L��I�/iL�Ct/LI� .�.�
Address:
City/State/Zip: AIZ7 2S&IVY /%%.9 QY0 y(f Phone 4:
Are you an employer? Check the appropriate box:
Business Type (required):
1. [ij"fam a employer with employees (full and/
5. 0 Retail
or part-time).*
6. �estaurant(Bar/Eating Establishment
2: 0 1 am a sole proprietor or partnership and have no
7. Q Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑ 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, El Manufacturing
no employees. [No workers' comp. insurance required]*
I I ❑ Health Care
4. ❑ We are a non-profit organization, staffed by volunteers,
12,❑ Other
with no employees. [No workers' comp, insurance req.]
*Any applicant that checks box #1 must also fill out the section below A..g theirworkers' compensation policy information.
*4If the corporate ofbeers have exempted tbcrosclvn, but the corpom6on has other employees, a workers' compensation policy is required and such an '
organization should check box 41.
1 am an employer that is providd workers' compensation insurance for my employees. Below is the policy information.
Insurance
q� q ( v
Insurer's Address: z�,/o C/eek t'
City/Statdzip: AX� 6,.`�-/�g',�/ -r /y5 D 0 �1
Policy # or Self -ins, Lic. # 9'14,330& 1'7-" [ d ' t/ Expiration Date: 1
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 fore
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 ceryfy, undchthe pains and penalties ofperjury that the information provided above is true and correct
Official use only. Do not mite in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of Health Z. Building Department
6. Other
Contact Person
Permit/License
3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
Phone
TRAVELERS+ WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: UB-9H330694-17-42-G
RENEWAL OF (UB-9H330694-16-42-G)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
1. NCCI CO CODE: 12637
INSURED: PRODUCER:
OZCAN RESTAURANTS LLC GENE CARE AGENCY LLC
DBA DECOS ITALIAN CUISINE 1260 CREEK ST
365 N MAIN STREET WEBSTER, NY 14580
MANSFIELD, MA 02048
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 11-17-17 to 11-17-18 " 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our 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: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN
MO MS MT NC HE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY
DATE OFISSUE: 10-09-17 SH
OFFICE: ALBANY N.Y. 002
PRODUCER: BENE CARE AGENCY LLC DCQ22
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