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HomeMy WebLinkAboutGreat Woods 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:. CHRISTOS TSIANAKAS & FRANK TSIANAKAS Whose place of business is: GREAT WOODS PIZZA & GRILL 428 ELM STREET PERSON(S) IN CHARGE: KATHERINE TSIANAKAS, MANAGER Permit Expires: December31,2018 Food Fee: $125.00 License Number: FS-33 BOARD OF HEALTH MichaeCMcCCean, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By:( Permit #Issued FOOD ESTABLISHMENT PERMIT APPLJCA0N1 lull (Application must be submitted at leastdays before the 1) Establishment Name \ \nl R p anne, opening date) 2) Establishment Address ayvi ` ' 3) Establishment Mailing Address (if different) 4) Establishment Telephone No - AA • C) 5) Applicant Name & Title: \,� V\ `�` _ A A ..LA Y iv� 6) Applicant Address 'L. "\Y v-"C, / 7) Applicant Telephone No,: PP 24 Hour Emergency N ,: - 8) Owners Name & Title F '" — Off; j j V/ 9) Owner Address (If different from applicant) Owner's telephone number f 10) Establishment Owned By: e11 An Association 1D1 A Corporation ,r-� An Individual H A Partnership Id Other legal Entity 11) If a corporation or partnership, give name, or partner. Name Title ��yjg 5 I<, lav�ra �(ti.5 Pyes\ Af IAA title, and home address of officers Address 7 To0 G( l;-) N i _- G�\�luW6e��I1� VL,-QKSVAiYt� '1��G4�V l�yIVZ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: qLA ` 24 Hour Emergency No: FAX: E-mail: se Mw _ % 5 uUi c Alt E-Mail: 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: 15) SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) 16) No. of Food Employees:U, COL `(;7 17) DAYS/HOURS: Silo l©_ -`h S0J 10, .7L 0, 30 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 10/l/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): "3 20) Location: I Permanent Location Fi Mobile Mobile Start Date: Mobile End Date: Mobile Comments: Fs! Seasonal Seasonal Dates: Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type Retail ( ftC) Sq. Ft) 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 ri Food Service - Institution ( Meals/Day) P1 Caterer $25.00 F;4 Milk & Cream $10.00 Mobile Food & Consession $75.00 rg Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25,00 # of Pushcarts: !.3 Residential Kitchen $100.00 Retail Food $100.00 Retail Snack Food $25.00 0 Tobacco Products $25.00 23) Food Operations Definitions:PHF - Potentially hazardous food (tlme/temperxturo controls required) Non-PHFs - non -potentially hazardous food(no fime/temperatum controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) of Commercially Pre -Packaged Non-PHFs I I'PHFCooked To Order Processed Foods for Service Within 4 Hours Perishable Foods Only Other Food Operations preparation of PHFs For Hot And ;old Holding For Single Meal Service Tale of Raw Animal Foods Intended to be Prepared by Consumer ,ustomer Self -Service ce Manufactured and Packaged for Retail Sale tzp Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service 4G-! PHF and RTE Foods Prepared For Highly Susceptible Population Facility ED Vacuum Packaging / Cook Chill ED 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 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin E] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Catered Events or Institutional Food Service .❑ 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 n 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,GMR 5,q0.-Q00 and the federal Food Code. 24) Signature of Applicant: rz: 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. j 25) Social Security Number or Federal ID: 'A 'l y-" C ° (09t)(0 26) Signature of Individual or Corporate Name: Q v_ea ` N U(` i 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. ��Q4Wots Pal Signature of Individual or Corporate Name By: Corporate Nficer 00fenda, if Applicable) 909lo aD **Social Security No. (Voluntanj) 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. C:\Users\sleite\Desktop\Scou's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: tAlo? vc\�M , N Phone #: 17 Are you an employer? Check the appropriate box: Business Type (required): 1. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. �fj 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. [No workers' comp. insurance required] $• ❑ Non-profit 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 LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 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 provir ing workers' compensation insurance far my employees. Below is the policy information. Insurance Company Name: Insurer's City/State/Zip: �(� ( � Cy%— KN 1 ! O2 C? Policy # or Self -ins. Lie. Expiration 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 hereby certify, under tlepains andpenalties ofperjury that the information provided above is true and correct. Phone #: Sob •� l' �ZI—cQ 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia CORA?' CERTIFICATE OF LIABILITY INSURANCE 12/01/2017 nYYY) 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 endorsements . PRODUCER ACT Paychex Insurance Agency Inc CONTNAME PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE PHONE , 877-266-6850 F'O'X . 585-389-7426 E -MAILa. Certs@paychex.com ROCHESTER, NY 14620 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: NorGUARD Insurance Company 31470 INSURER B: GREAT WOODS PIZZA CORP 428 ELM STREET INSURER C: WRENTHAM, MA 02070 NSURER D: NSURER E: INSURER F: 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 MAYBE 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 I ADDL INSR SUBR 6VVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MMIDO/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY =)CLAIMS-MADE[:::]JCCUR DAMAGE TO RENTED $ $ MED EXP (Any one person) PERSONAL B ADV INJURY $ GENERALAGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: POLICY =PROJECT=LOc PRODUCTS - COMP/OP ADS $ AUTOMOBILE LIABILITY PANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS AUTOS O COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per p erson) $ BODILYdent) (Per (Per accPROPERTY $ PROPERTY DAMAGE (Per accident) $ UMBRELLA UAB=OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR = CLAIMS -MADE $ OEO RETENTION$ WORKERS COMPENSATION AND EMPLOYERWLIABILITY GRWC801166 12/05/2017 12105/2018°= X WCSTATUOTH- RYIIM'T E.L. EACH ACCIDENT $ 100,000.00 ANY PROPRIETOWARTNERrEXECUTNE OFHCERMEMSER EXCLUDED? N (Mandatory in NH) N N/A E.L. DISEASE EA EMPLOYEE $ 100,000.00 E.L. DISEASE POLICY LIMIT $ 500,000.00 Bye,dascdbeunder DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 6 Park Row DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY Mansfield, MA 02048 PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD E'a r o! E a m X W 0 0.' l rc F t ymy 0 C 9 Z W 0 C� G U_ ry EL M 0 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Naive of Recipient: KATHERINETSIANAMS Certificate Number: 21444'a Date of Completion: 1202015 Date of Expiration. '�2020 The above -named person is hereby issued this rerti crate for completing an allergen awareness training program recognized by the Massaehasens Department of Public Healtb in accordance with 105 MIR 590.009(G)(3)(a). Deis certificate will he valet for five (5) yeaisfrom date of completion. IssuedBl: NATIONAL z; .was RESTAURANT ASSOCIATION® Masm.husetts RestaurantAsmoation 800.765.n22 333 Turnpike Road, Suit. 102 wwwacstaunacorg Southbomugh,MA 01772 508-303-9905 wtm.maz Mumnt....eg