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Home My WebLink AboutSt. Gregory Church 12/31/2018Commonwealth of Massachusetts y{y 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:. ST. GREGORY GREEK ORTHODOX CHURCH Whose place of business is: ST. GREGORY GREEK ORTHODOX CHURCH 1007 WEST STREET PERSON(S) IN CHARGE: TED CHINGRIS Permit Expires: December 31, 2018 Food Fee: License Number: FS-81 BOARD OF HEALTH Michael 9McCCean, Chairman WAIVED Milk & Cream E/1 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: ST. GREGORY GREEK ORTHODOX CHURCH having a place of business at: ST. GREGORY GREEK ORTHODOX CHURCH 1007 WEST 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-81 Board of Health michaeCb(cCCean, 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-81 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name 2) Establishment Address ST. GREGORY GREEK ORTHODOX CHURCH 1007 WEST STREET 3) Establishment Mailing Address (if different) P.O. BOX 293 4) Establishment Telephone No 5) Applicant Name & Title: TED CHINGRIS MANSFIELD, MA 02048 (508)337-9986 6) Applicant Address 29 LEONARD STREET, MANSFIELD, MA 02048 F 2017 7) Applicant Telephone No.: (508) 339-2773 24 Hour Emergency No.: (508) 339-2773 8) Owners Name & Title ST. GREGORY GREEK ORTHODOX CHURCH 9) Owner Address (If different from applicant) 29 LEONARD STREET, MANSFIELD, MA 02048 Owner's telephone number 5083379986 10) Establishment Owned By. ! 11) If a corporation or partnership, give name title, and home address of officers 1 An Association or partner. A Corporation Name Title Address J An Individual ❑ A Partnership LJ Other legal Entity - _ _.. -_- - 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) [Name & Title !TED CHINGRIS Address: 29 LEONARD STREET, MANSFIELD, MA 02048 Telephone No: i(508) 339-2773 24 Hour Emergency No: (508) 339-2773 FAX: E-mail: ITCHINGRIS(EDVERIZON.NET Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title: ITED CHINGRIS Address: 29 LEONARD STREET, MANSFIELD, MA 02048 Telephone No: 'i(508) 339-2773 24 Hour Emergency N, FAX: E-mail: TCHINGRIS@VERIZOW C,�,.2r c.x ;'St( 1_.c f C,c� tCL-r - ez v'7h ire 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) I 16) No. of Food Employees: 4 17) DAYS/HOURS: 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) �l 20) Location: [JJ Permanent Location 22) Establishment Type ❑ Moblie Moblie Start Date: ❑ Retail ( Sq Ft) Moblie End Date: Moblie Comments: 21) Length of Permit: [J Annual L j Seasonal Seasonal Dates: LJ Temporary ------ Temporary Start Date: Temporary End Date: Temporary Time: 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 j Food Service up to 201 + or 25'+ PHF display $276.00 ❑ Food Service - Institution ( Meals/Day) TED CHINGRIS ❑ Caterer $25.00 ❑d 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 Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous food (fimeltemperature controls required) Non-PHFs non -potentially hazardous food(no time/femperature 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 �-A PHFCooked To Order [ ] Hot PHF Cooked and Cooled or Hot Held - - - ----- [ _ Sale of Commercially Pre -Packaged PHFs - arat-------- -- -� t i Preparation of PHFs For Hot And for More Than a Single Meal Service _. -i -- - ----- - -- --- F Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly , -- ----- - - ---- F] Sale of Raw Animal Food Intended Susceptible Population Facility - Ls Reheating of Commercially to be Prepared by Consumer -- - - _._. - Vacuum- Packaging /Cook Chill Processed Foods for Service Within 4 Hours ---- - - -- Customer Self -Service of Non PHF and Non- --- ---- -- ---- Customer Self -Service ❑_ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only F Ice Manufactured and Packaged for contact alternative, time as a public health [ J Preparation of Non-PHFs Retail Sale control) Other Food Operations (I Juice Manufactured and Packaged for [] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers 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 completed by the Board of Health _-_- ----- -- Total Permit Fee: Payment is due with application F�� waived ._ ---- -__--- I, the undersigned, attest to the accuracy of the information provided in this application and affirm that- thee food ,Af establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have en instructed by ingr) 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, sec. 49A, I certify under the penalties of perjury that I, to my and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3187147 26) Signature of Individual or Corporate Name: 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 31 st of each year. NAME OF BUSINESS: ST. GREGORY GREEK ORTHODOX CHURCH ADDRESS: 1007 WEST STREET TELEPHONE AT LOCATION: (508) 337-9986 FAX NUMBER: (508) 337-9987 OWNER OF BUSINESS: ST. GREGORY GREEK ORTHODOX CHURCH TELEPHONE OF OWNER: 5083379986 FEDERAL ID/SS NUMBER: 04-3187147 FEE: $10.00 PERMIT NUMBER: FS-81 SIGNATURE: DATE: / 7 / -2-/ / / .7 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 Individual or Corporate Name 04�_ 31V`7l`f-7 **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 Docu cnts\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc \ The Commonwealth of Massachuseits Department of Industrial Accidents 1 Congress SYreei, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH TEEPERMITTING AUTHORITY. Applicant Information PIease Print Lel?ibl Business/Organization Name: .�T CTP C ie-✓/ 71tL '-TYK01,0e+.+A C-4Ue�C4 Address: . loo % U%CS+ U • X a9'� City/State/zip: AM 02-s99' Phone #:-5 0 t3 - 33 7-1 Are you an employer? Check the appropriate box: Business Type (required): I. Q'I am a employer with 7 employees (full and/ 5. ❑ Retail or part-time).* —i� 6. ❑ RestauranVL'ar/Eating Establishment 2. ❑ I am a sole proprietor or parhiership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8• KNon-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]* 11. ❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. rNo workers' comp, insurance req.l 12, ❑ Other *Am, aonlicant that checks box #1 must also fill out the **If the corporate officers have exempted themseNes, but the corporation has other employees, a workers' compcasa ion policy is required and such an organization should cbeck box 41. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy informadon. Insurance Company Insurer's Address: tl /T f- �r`1'%L'� P L- . B o0 S T4T`+- S17 7174 F-exW'," City/State/zp: sC- /J V 1 3 2v2 Policy # or Self -ins, Lie. #- O S' U�-' CC S 30 j .7 Expiration Date: V 2711 k Attach a copy of the workers' compensation policy declaration page (showing the policy number a d 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert&under the pains and penalties of perjury that the information provided above is true and correct: -5ob-337—Iq, L 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 w .mass.govidia Phone NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 — http://www.state.ma.ustdia As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I (we) have provided for payment to our injured employees under the p above mentioned chapter by insuring with: u °D HARTFORD ACCIDENT AND INDEMNITY COMPANY N NAME OF INSURANCE COMPANY 0 o ONE PARK PLACE, 300 S. STATE ST., 7TH FLOOR 4 CVRAf IT4F, MY 11207 ADDRESS OF INSURANCE COMPANY 08 WEC CS3037 ''01/28/17 POLICY NUMBER EFFECTIVE DATES 655 BOSTON ROAD SUITE 1A MERRIMACK VALLEY INS AGENCY INC BILLERICA MA 01821 NAME OF INSURANCE AGENT ADDRESS PHONE GREEK ORTHODOX PARISH OF<:95/495 PO BOX 293 MANSFIELD MA 02048 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 D Printed in U.S.A. Certificate of Achievement 4 ANSI ACCREDITED PROGRAM CERTIFICATE ISSUER #0633 National Restaurant Association 175 W. Jackson Blvd, Ste. 1500 Chicago, IL 60604-2814 800.765.2122 in Chicago area 312.715.1010 Restaurant.org I ServSafe.com This certificate is awarded to TED CHINGRIS Congratulations! You have completed ServSafe° Food Handler Employee Food Safety Online Course and Exam Ce,U icale Number 2901461 Date 5/12/2017 Expiration Date 5/12/2020 O .0 N Z r oo t z o C o U 0 4. o zU U � " Q Q 0 � ° �x R o Q ..L y G O y C w � tl y 4O l Mansfield Board of Health W Date liL % request a waiver of the Food Service Permit Fee for the following reason 0-�V - Thank you, Signature Title