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HomeMy WebLinkAboutTrattoria Della Nonna 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:. KENNY M. DEFAZIO Whose place of business is: TRATTORIA LA CUCINI DELLA NONNA 160 NORTH MAIN STREET PERSON(S) IN CHARGE: KENNY DEFAZIO Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-94 BOARD OF HEALTH Nichaet'McCtean, Chairman Milk & Cream ❑O 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. KENNY M. DEFAZIO having a place of business at: TRATTORIA LA CUCINI DELLA NONNA 160 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-94 Board of Health MichaeCMcCCean, 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-94 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name TRATTORIA LA CUCINI DELLA NONNA 2) Establishment Address 160 NORTH MAIN STREET s .) '. hAJ`) 3) Establishment Mailing Address (if different) 160 NORTH MAIN STREET MANSFIELD, MA 02048 4) Establishment Telephone No (508) 339-5432 5) Applicant Name & Title: KENNY DEFAZIO 6) Applicant Address 88 HIGH STREET, MANSFIELD, MA 02048 7) Applicant Telephone No. (508) 339-0133 - HOME 24 Hour Emergency No (508)725-3649 (508)B09-0892 8) Owners Name & Title KENNY M. DEFAZIO 9) Owner Address (If different from applicant) 88 HIGH STREET, MANSFIELD, MA 02048 Owner's telephone number (508) 725-3649 10) Establishment Owned By: 11) If a corporation or partnership, give name title, and home address of officers CJ An Association or partner. A Corporation Name Title Address Ll An Individual A Partnership ii_Other legal Entity 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: KENNY DEFAZIO Address: 88 HIGH STREET, MANSFIELD, MA 02048 Telephone No: (508) 725-3649 24 Hour Emergency No: (sob) 725-3649 (509) 809.0992 FAX: (508) 339-4680 I E-mail: KENCHFY(a)HOTMAIL.COM Alt E-Mail: - 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: FAX: E-mail: 24 Hour Emergency No Food Establishment Information 14) WATER SOURCE: TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: TUE - SAT 4 PM - 10 PM 16) No. of Food Employees: 5 18) Name of Person In Charge Certified in Food Protection Management: KENNY DEFAZIO 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 .zy.;, certificate DEVIN SHENKAR 19) Person Trained in Anti -Choking Procedures (If 25 Seats or more). IV] 20) Location: JI Permanent Location 22) Establishment T e �[ Caterer $25 00 Moblie Moblie Start Date: Moblie End Date: Moblie Comments: 21) Length of Permit: [ Annual I _, Seasonal YP Retail ( Sq. Ft) Iyl 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 Seasonal Dates: ] Temporary Food Service - Institution Temporary Start Date: ( Meals/Day) �V Milk & Cream $10.00 ❑ Mobile Food & Consession $75.00 Manufacture Frozen Desserts/Ice Cream $25.00/freezer Pushcart $25.00 # of Pushcarts: 0 LJ Residential Kitchen $100.00 Retail Food $100.00 _ Retail Snack Food $25.00 ❑ Tobacco Products $25.00 Temporary End Date: i Temporary Time: Rain Date: 23) Food Operations Definitions:PHF- Potentially hazardous fooddiimiltemperature controls required) Non-PHF's non -potentially hazardous food(no time/temperatum controls required) ;Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) [ Sale of Commercially Pre -Packaged Non PHFs ,I V1 PHFCooked To Order I ] Hot PHF Cooked and Cooled or Hot Held i Sale of Commercially Pre -Packaged PHFs j ve Preparation of PHFs For Hot And for More Than a Single Meal Service Deliver of Packaged PHFs - i Y 9 Cold Holding For Single Meal Service ', PHF and RTE Foods Prepared For Highly - - -- -- Sale of Raw Animal Foods Intended Susceptible Population Facility 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 E i Customer Self Service of Non PHF and Non- L 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 i Preparation of Non-PHFs Retail Sale - control) Other Food Operations i_. Juice Manufactured and Packaged for I ❑d 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 Retail Sale of Salvage Out -Of -Date 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 690.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 59„Q.000 and the federal Food Code. 24) Signature of Applicant: s /% Pursuant to MGL Ch.62C, sec. 49A, I certify under t " enalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law. 25) Social Security Number or Federal ID: 043-461-876 26) Signature of Individual or Corporate Name: 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: TRATTORIA LA CUCINI DELLA NONNA ADDRESS: 160 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-5432 FAX NUMBER: (508) 339-4680 OWNER OF BUSINESS: KENNY M. DEFAZIO TELEPHONE OF OWNER: (508) 725-3649 FEDERAL ID/SS NUMBER: 043-461-876 FEE: $10.00 PERMIT NUMBER: FS-94 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. Sign e of 1ndivid/wf or Corporate Name **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.MmItWane's Doc=ents\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 PERMITTING AUTHORITY. Applicant Information � PIease Print Legibly Business/Organization Name: \C S, �i\ C" . c > mac. Address: ��i� ��.c��` Are you an employer? Check the appropriate box: Business Type (required): I. 15� I am a employer with ' employees (full and/ 5. ❑ Retail or part-time).* 6. Ig Restaurant(Bar/Eating Establishment 2. ❑ 1 am a sole proprietor or partnership and have no ?, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 9. ❑ 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]* l 1. ❑ Health Care 4. El We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurancereq] 12,❑ Other *Any applicant that checks box #1 must also fill out the section below showing theirworkers' 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 providing workers' compensation insurance for my employees. Below is the policy infarmatioir. Insurance Company NameC \lxki.e �r�..*-.` \v, � a'�'- � '0, t Insurer's Address: ` ` Policy # or Self -ins, Lie, #-�.�'�'\�.� `.�,�,61C1� �� Expiration Date: i, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expira on 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town office¢[ City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Pbon A� Ro® CERTIFICATE OF LIABILITY INSURANCE OD/YYVY) DAv1-512on 1 ts/z THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER AUTOMATIC DATA PROCESSING INSURANCE AGCY INC CONTACT NAME: A/CNNa, Ext: 877677-042e _FAX He): 877 677-0430 1 ADP BLVD MS 625 ROSELAND, NJ 07068 (877)677-0428 E-MAIL ADDRESS: s .bic.d bmmI0m.com INSURER($) AFFORDING COVERAGE NAIC# INSURER A: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT INSURED INSURER B DEFAZIO, KENNETH MITCHELL DBA: TRATTORIA DELLA NONNA INSURER C: INSURER D: 160 N MAIN ST INSURER E: MANSFIELD, MA 02048 INSURER F: COVERAGES CERTIFICATE NUMBER: 517171930151913 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. INSR LTR TYPE OF INSURANCE ADDL INSO SUER WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Es occurr-eence) $ MED EXP (Any_oneperson) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY ❑PRO- ❑LOG JECT OTHER: GENERALAGGREGATE $ PRODUCTS - COMP/OP AGO $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY I NJURY(Per person) $ 6001LV INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA UB-9J286951-17 09/08/2017 09/08/2018 X PER ORH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) BOARD OF SELECTMAN TOWN OF MANSFIELD SIX PARK ROW MANSFIELD, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE •� J © 1988-2014 ACORD CORPORA LION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD § 5 � � W � � z z � � t { � }7 S» / LO �\ � \ : § \ \ \ \ \ \ : § t ® CIS 0 \ \ / \ 0 / / 2 / \ / pq � % §�\7 �)\~( )\\ )° \\\\ \ !!/ \ §\»\ } & R i," for successfully completing the stwdards.I forth for the ServS.V Food Proto m Munogoe Codification ExamincSion, which is accredited 6y the Amedcan National 51andards Institute (ANSIi-Caa(mf %kv Foed Protxlion (CFPI. 5110 EXAM FORM NUMRIER 11/1612020 DATE OF EXPIRATION re:vlifimlion requirements. Ctfiiles�':'{, GYiv'ndiN l]SY+ltii'iJ�r4'�.Sbl$'Jn.CF.;yj]�R.F^�{,OdciSw.dTe$�14UJv7rar4U- Name of Recipient: OEVIN SNENMS Certificate Number: 2147353 Date of Completion: 12e¢015 Date of Expiration: 'an 020 77ie akovt nanvd person ribereltio issnnl this;er / finale foe rontpieling an al/ngen awareness tredning program recognized ky the D•lassadjuseln Departne•nt of Puklir Health in arrordnnre ¢citk 105 CdIR 590.009(C)(7)(a). 71ris rerlifiatte willbe valid 1Z, jive (S)pears from date ofrontpleliou. Issued Bv: �•I 1`, tilnll[t NI' t\\ YIOIN' Nh,,dnisnss Restaurmt As.O.rlmt 800.765.2.121 333 Turnpike Road, Snits 102 uwtv.rcstnamuentg Southhurm:gh, MA 01772 508-303-9905 mvo•.mntesrmnnwssoc.mg :A CUCDA'A Jlei,),IHA 1 N ST 043-401—i76 IDrN'nHCA'"0N NUMBER 0 3 ) —1 7 / J 0 ISSUE DATE A. LASkLY This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE PEEL HERE y PEEL HERE Hel��arttsaver® American C f R. A E D Heart Association..' KENNY DIFAZIO This cam cedilla s that the shave InQhddual has suwessmlly completed the phlectives and skills evaluattons in accrrdmme vdth the cumwthm of the ARA Neadsaver CPR Am Pmgmm. O110onal completed modules am those Or marked out Child CPR AED lariat CPR Written led 02/20/16 02/2018 Issue Date Recommended Renewal Data Strike through the modules NOT completed. This card contains unique security features to protect against forgery. Heartsaver® American CPR A E D Heart Associations YVONNE DEFAZIO This cam ceNRes thatthe ahave individual has success illy completed the objectives and skills anduatlons In accomance, with the cumtculum of the AM Headsaver CPRAED Pmgmm. Optiunal comple@d.moduln we Nose NUr marked out Child CPR AED Infant CPR Written test 02/20/2016 02/2018 Issue Dale Recommended neaewal Data Strike through the modules NOT completed. _ This card contains unique security features to protect against forgery. Training TC D 4 - Center Name SOUTHEASTERN NEW EI�GLAND TC Info City, A.3t LEBORO, MEp02703 (468)e236-7151 Course Location STURDY MEMORIAL, HOSPITAL Instructor Name DEBRA WALSH 11IOI�j318:149 Holder's OZmlPmalcan Movl AssarlaVan Tenpavg rvrN am cvtl mNaevfiappoaiaraq. Seine Tenting Center Name �t.SOUTHEASTERNNEWAND Tc ttMBBORO, MA 02703 (5 236-7151 Info City, $late ZIP Piloho e Course Location STURDY MEMORIAL HOSPITAL Location Instructor I st ID Name DEBRA WALSH 1II213O149 Holder's OZe1l Mnnlo„Head AVWaVan TampeMg aph and ¢NvidlaVo-dsWuveem 90.1ata 90-1813 3/11 90-1813 3/11 Heartsaver° American CPRPAED Heart f_ rl Association. PEEL HERE STACEY JARVIS —� This card ceniDes that he above Indvidual has successfully completed the objectives' and skills evaluations In accmdamm wih he curdculum of the ANA Neadsaver CPR AED Pmgmm. Optional completed modules are these NOT mmked"not Child CPR AED Intent CPR Wdllonlest 02/20/2016 02/2018 Issue Date Recommended Renewal Date PEEL HERE Strike through the modules NOT completed. This card contains unique security features to protect against forgery. Heartsaver® CPR AED Training Center Name SOUTHEASTERN NEW NUA"ND Info Gdy. AZiLEBORO, A%, 02703 .(S�$��36-7151• Course Location STURDY MEMORIAL HOSPITAL Location Nstructor ame DEBRA WALSH IIAT361149 Holders 02ml Amelem H.MA%acludw ISmp.ing cord aJvwdxglaaerih apPuvacv a0.m13 0 American CentergName SOUTHEASTERN NEW EMAND Heart Association. TC T Into CHI. >; KLEBORO, A %, 02703 (Y 8Jr236-7151 DEVINSHENKAR This card sermon hatthe ahom Individual has successfully completed he objectivm and skills evaluations In accordance with the cunimium of the AM Modicum CPRAED PmgnunAptional completed modules are hale NOT marked out Child CPO AED Imam CPR Written test 02/20/16 02/2018 Issue Dale Recommended Renewal Date Strike through the modules NOT completed. This card contains unique security features to protect against forgery. Course Location STURDY MEMORIAL HOSPITAL InstruNamector DEBRA WALSH 1I10i TA149 Holders Signature 02m1Nnedoa HeMAssadoena Tampemg wID gltsmdwNagerieappwrsatx 9LL1613 90-1813 3111 90-1813 3/11