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Home My WebLink AboutGeno's Restaurant 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:. JOHN J. SPIEZIO Whose place of business is: GENO'S RESTAURANT AND LOUNGE 409 NORTH MAIN STREET PERSON(S) IN CHARGE: JOHN SPIEZIO, MANAGER, OWNER Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-31 BOARD OF HEALTH MichaeCMCCCean, 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: JOHN J. SPIEZIO having a place of business at GENO'S RESTAURANT AND LOUNGE 409 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-31 Board of Health 34ichae[34cCCean, 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-31 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address GENO'S RESTAURANT AND LOUNGE 409 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 409 NORTH MAIN STREET 4) Establishment Telephone No MANSFIELD, MA 02048 339-8771 5) Applicant Name & Title: JOHN J. SPIEZIO, MANAGER 6) Applicant Address 409 NORTH MAIN STREET, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 339-8771 8) Owners Name & Title 9) Owner Address (if different from applicant) Owner's telephone number 24 Hour Emergency No,: (508) 339-8771 (508) 241-3229 JOHN J. SPIEZIO 409 NORTH MAIN STREET, MANSFIELD, MA 02048 (508)339-8771 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 ( I An Individual A Partnership -J Other legal Entity -__-__- ____ ___ ____ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: JOHN SPIEZIO, MANAGER, OWNER Address: i409 NORTH MAIN STREET, MANSFIELD MA 02048 Telephone No (508) 339 8771 24 Hour Emergency No (508) 339-8771 (508) 241-3229 FAX: (508) 339 0148 E-mail: Alt E-Mail 13) District Or Regional Supervisor (if applicable) E-mail: G--✓lb A+ AoC. FAX' -- --- -- '17NTV8Ah?9:fll0 Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No. (If applicable) 16) No. of Food Employees 5 17) DAYS/HOURS: MON-SAT 11 AM-9 PM SUN 12 PM-9 PM 18) Name of Person In Charge Certified in Food Protection Management: DENNIS REDDING 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 ❑ Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: [y] Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: [y',, Annual jl Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Dafe ❑ 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) ❑ Caterer $25.00 ❑./ Milk & Cream $10.00 [_] Mobile Food & Consession $75.00 ❑ 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 ❑ Tobacco Products $25.00 23) Food Operations Definitions: PHF-Potentially hazardous food (timelemperature controls required) Non-PHFs - non -potentially hazardous food(no timeRemperature controls required) Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) Sale of Commercials ❑ Commercially Pre -Packaged Non-PHFs [] PHFCooked To Order ❑Hot PHF Cooked and Cooled or Hot Held „ ---- — ----- (.] Sale of Commercially Pre Packaged PHFs (.] Preparation of PHFs For Hot And - for More Than a Single Meal Service ]Delivery of Packaged PHFs - Cold Holding For Single Meal Service ---- ----------- ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ----- ---- ------------ ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer [] Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ------------- --- ----------- ❑ Use of Process Requiring A Variance L ] Customer Self Service of Non PHF and Non- ] Customer Self -Service and/or HACCP Plan (including bare hand Perishable Foods Only ❑Ice Manufactured and Packaged for contact alternative, time as a public health Preparation of Non-PHFs Retail Sale contro Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities [] Prepares Food/Single Meals for --____ __ Catered Events or Institutional Food Service or Reconditioned Food To be completed by the Board of Health Total Permit Fee: 125.00 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 with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies oj�195pMR590.00))0 Oay the fed I Foo�Code. 24) Signature of Applicant: l�`. Pursuant to MGL Ch.62C, sec. 49A, ertify under th enallies of and paid state taxes required under law. 25) Social Security Number or Federal ID: 04 2736676 26) Signature of Individual or Corporate Name: I, to my best knowledge and belief, have filed all state tax returns 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: GENO'S RESTAURANT AND LOUNGE ADDRESS: 409 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-8771 FAX NUMBER: (508) 339-0148 OWNER OF BUSINESS: JOHN J. SPIEZIO TELEPHONE OF OWNER: (508) 339-8771 FEDERAL ID/SS NUMBER: 04 2736676 FEE: $10.00 PERMIT NUMBER: FS-31 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. Signature of Indiv' al or Co rate e "Social Security No. (Voluntary) or Federal Identification Number t'eoV-4� Ci1-t2.2-5 7� 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:UiealthUane's Documents\PERMIT 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 PERMUTING AUTHORITY. Applicant Information Please Print LtgjblV Bus iness/Organization City/State/Zip: e2- Are you an employer? Check the appropriate box: 1 m a employer with employees (full and/ or part-time).* 2: ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No 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, rNo workers' comp, insurance req.] N. -% v -_' Business Type (required): 5. ❑ Retail 6, estauranttBar/Eating Establishment 7. Q Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 L ❑ Health Care 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 bas ether employees, a workers' compensation policy is required and such au organization should check box #1. am an employer that is providing workers' compensation insurance for my employees. Below is the policy Information. Insurance Company Insurer's Address: �1 z6✓2-tx? O- 1r- City/State/Zip: 6 4 - �,6 Policy # or Self -ins. Lie. #- CL+ / 7/ C)2—S i Z5 �'7 Expiration Date: 61g--"(/a 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. do hereby certify, u r t e p/aarr�tj/!�/n/�jpynaldes ofperjury that the information provided above is trdue-aand correct el 3,2 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 ACORH CERTIFICATE OF LIABILITY INSURANCE DATE(MMI2DIYYYY) 10/25/2017 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 YHE 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 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 endorsement(s). PRODUCER NUNS: Boynton insurance Boynton Insurance Agency PHONE (781)449-6786 'No)- (781)149-4269 72 River Park Street ADDRESS: certincates@boyntonine.com INSURER(S)AFFORDING COVERAGE NAICa Needham MA 02494 INSURERA: Merchants Mutual Insurance Group INSURED INSURER B: Spiezio Enterprises Inc, DBA: Geno's Italian Restaurant INSURER C: 407-411 North Main Street INSURER D: INSURERE: INSURERF: Mansfield MA 02048 COVERAGES CERTIFICATE NUMBER: CLI7102512597 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. LTR TYPEOFINSURANCE POLICY NUMBER MMI00 MMIDD UNITS x COMMERCIAL GENERAL LIABILITY CLAIMSMADE x OCCUR EACH OCCURRENCE $ 2,000,000 DAMAGE pORtpTED PREMISES Ea occurrence $ 100,000 MED EX? JAny one neon $ 5,000 PERSONAL aADV INJURY $ 2.000,000 A CMP9155980 04/10/2017 04/1012018 GEML AGGREGATE LIMIT APPLIES PER: x POLICY ❑ J'EOT LOC GENERALAGGREGATE $ 4,000,000 PRODUCTS-COMP/OPAOG $ 4,000,000 $ OTHER: I AUTOMOBILE LABILITY COMBINED SINGLELIMIT Ea ecaMe d $ BODILY INJURY (Par pareon) $- -- ANVAUTO - - _ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per acddenq $ PKUMIKI Y OMAOt (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLAUAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERIPLIABILITY YIN ANY PROPMETOR/PARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yea, describe under DESCRIPTION OF OPERATIONS below NIA WCA9100757 06/24/2017 0612412018` PER OTH• STATUTE R E.L. EACHACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 A Liquor Liability CMP9156986 04/10/2017 04/10/2018 Common Cause Limit Aggregate Limit $1,000,000 $1.000,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarke Schedule, may be attached if more space is required) 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. 01908.2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016/03) The ACORD name and logo are registered marks of ACORD i Z 0 W cr- U) Z 0 W. Y.:. b x LO