HomeMy WebLinkAboutOrthodox Cong. Church 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:.
ORTHODOX CONGREGATIONAL CHURCH
Whose place of business is:
ORTHODOX CONGREGATIONAL CHURCH
17 WEST STREET
PERSON(S) IN CHARGE:
MATTHEW GEMINIANI
Permit Expires: December 31, 2018
Food Fee:
License Number: FS-73
n. 0
BOARD OF HEALTH
34ichaeCMcC(ean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit # Issued FS-73
FOOD ESTABLISHMENT PERMIT APPLICATION
(Application must be submitted at least 30 days before the planned op'eni�6 ate 2(u(s
1) Establishment Name ORTHODOX CONGREGATIONAL CHURCH
2) Establishment Address 17 WEST STREET
3) Establishment Mailing Address (if different) 17 WEST STREET
MANSFIELD, MA 02048
4) Establishment Telephone No (508) 339-4793
5) Applicant Name & Title: MATTHEW GEMINIANI
6) Applicant Address 55 KING ARTHUR WAY, MANSFIELD, MA 02048
7) Applicant Telephone No.: (508) 878-7868 24 Hour Emergency No.:
8) Owners Name & Title ORTHODOX CONGREGATIONAL CHURCH
9) Owner Address (if different from applicant) 17 WEST STREET, MANSFIELD, MA 02048
Owner's telephone number (508) 3394793
10) Establishment Owned By:
11) If a corporation or partnership, give name, title, and home address of officers
[ I An Association
or partner.
C I A Corporation
Name Title Address
❑ An Individual
❑ A Partnership
V Other leaal Entity.___
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
MATTHEW GEMINIANI
Address:
Telephone No:
15 IAN KEAT OR C/O ORTHODOX CONGREGATIONAL CHURCH
.-_.__.....__....._-_-
(508) 878-7868 24 Hour Emergency No:
(508) 339-4793 CALL FIRST
FAX:
E-mail:
MATTGEM(a)COMCAST.NET
Alt E-Mail:
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. 1
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Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable)
6� V MCf,A e I� /�t (IL
"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.
C:\Usem\sleite\Desktop\Scotrs Domanems\Food Establisbmen(s- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwminass.gov/din
Workers' Compensation Insurance Affidavit: General Businesses
Business/Organization Name:
Address: ( I eS 1 5
v4
Phone #: J--O L ' S-%(- _ 1 ,Y6 f
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. ❑ 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.
8. ❑ Non-profit
[No workers' comp, insurance required]
I ❑ 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]*
11.0 Health Care
4. We are a non-profit organization, staffed by volunteers,
with no emnloyees. [No workers' comb. insurance rea.]
12.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomwtion.
**If the corporate ofticeis have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should check box #I.
I am an employer that is providing workers' compensation drrsurance for my employees. Below is tdee policy ire formation.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy # or Self -ins. Lic. # Expiration Date:
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 cer9' , rder IkS pains and penalties of perjury that the information provided above is trite and correct.
Sienatur . Date: L —( �9` /,Y-
Official use only. Do not write in this area, to be completer/ 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 #:
www.mass.gov/dia
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CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: MATTnewceMINIANi
Certificate Number: 26wM9
Date of Completion: 11a912o16
Date of Expiration: 1112 rz021
77)e above twined person is bereby issued this cert!flrate
for cowple ing an allergen awareness training program
rerogitiud by the Mass arbusefts Department of Prrblie Healtb
in accordance with 105 CMR 590.009(G)(3)(a).
Ibis rerti#cale will be valiAjor, five (5) years from date ofronyVelion.
Issued By:
Massachusetts Restatuant Association
333 T .pike Road, Suite 102
Southborough,MA 01772
508-303-9905
mvsemaresta.mntasssoe.org
NATIONAL C
RESTAURANT
ASSOCIATION,,
800.765.2122
..resnava.torg