HomeMy WebLinkAboutMansfield Best 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:.
JOSEPH DARAZI
Whose place of business is:
MANSFIELD BEST PIZZA
221 NORTH MAIN STREET
PERSON(S) IN CHARGE:
NAIM DARAZI, MANAGER
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-57
BOARD OF HEALTH
Michae(McC(ean, Chairman
FOR BOARD OF HEALTH USE ONLY
Date received: Date Inspected: Approved By: Permit # Issued
FOOD ESTABLISHMENT PERMIT APPLICATION
pp rcat n must be submitted at leastdays before the p nne opening a e
1) Establishment Name I`Vti RNSri i-.,.
2) Establishment Address t ok:T t OAA ,J s. f
3) Establishment Mailing Address (if different)
4) Establishment Telephone No ISt� 8 -- 3 3 7
5) Applicant Name & Title:
6) Applicant Address � i
7) Applicant Telephone No.: a S- 0jj 24 Hour Emergency No.:
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
10) Establishment Owned By:
11 An Association
KA Corporation
F-1 An Individual
A Partnership
❑ Other legal Entity
11) If a corporation or partnership, give name, title, and home address of officers
or partner.
Name Title Address
W)wSF,(---€o �cS-r- u..c_
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:
! (f} AZ t A PO4
Address:
t-i oe t Si' . s`✓ �J 7'37 9_- ii � r =�` 0'n� U � it � ��
Telephone No:
_
24 Hour Emergency No:
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E-mail
Alt E-Mail:
Q
c>
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: 3
17) DAYS/HOURS: ) (? Ay S ) C r= K , M ON rSAT t t m. i c> l)M . .S u,<tOI-y ' t L--_� t
18) Name of Person In Charge Certified in Food Protection Management: NA- rm
If more than 3 individuals are certified, complete list is on file.
Required as of 10/12001 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
❑ Caterer $25.00
Mobile Mobile Start Date:
Retail ( Sq. Ft)
❑ Milk & Cream $10.00
Moblie End Date:
[Food Service up to 100 or
❑ Mobile Food Consession
Mobile Comments:
up to 10' PHF display INCLUDING
NO PHF PREPARED ON SITE $75.00
FOOD TRUCKS $125.00
ElManufManufacture Frozen Desserts/ice Cream
21) Length of Permit:
XIAnnual
❑ Food Service up to 101 -200
to 25' PHF display $150.00
/freezer
or up
❑ Food Service up to 201 +
or 25'+ PHF display $275.00
❑Pushcart $25.00 # of Pushcarts:
❑ Residential Kitchen $100.00
Seasonal
Seasonal Dates:
❑ Food Service - Institution
(
❑ Retail Food $100.00
❑ Retail Snack Food $25.00
El Temporary
Temporary Start Date:
Meals/Day)
❑ Tobacco Products $25.00
Temporary End Date:
Temporary Time:
Rain Date:
23) Food Operations
Definitions:PHF- Potentially hazardous food(timeRemperature controls required)
(Check all that apply):
Nan-PHFs - non -potentially hazardous food(no time/temperetum controls required)
RTE- ready-toeat foods (Ex. sandwiches, salads, muffins, which need no fortherprocessing)
Sale of Commercially Pre -Packaged Non-PHFs
❑ PHFCooked To Order
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Sale of Commercially Pre -Packaged PHFs
❑ Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
❑ PHF and RTE Foods Prepared For Highly
❑ Delivery of Packaged PHFs
Susceptible Population Facility
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Reheating of Commercially
❑ Vacuum Packaging I Cook Chill
Processed Foods for Service Within 4 Hours
❑ Use of Process indi Variance
and/or HACCP Pllanan (including
uding bare hand
Customer Self -Service of Non PHF and Non-
El Customer Self -Service
Perishable Foods Only
_
contact alternative, time as a public health
control)
❑Ice Manufactured and Packaged for
Retail Sale
Preparation of Non-PHFs
Other Food Operations
_
❑ Juice Manufactured and Packaged for
❑ Offers Raw Or Undercooked Food Of
Retail Sale
Animal Origin
( 2''
❑ Prepares Food/Single Meals for
❑ Offers RTE PHF in Bulk Quantities
Catered Events or Institutional Food Service
_
El 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 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 la seen instructed by the
board of health on how to obtain conies of 105 CMR 590000 and the federal Food. ode. \
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec.49A, I certify unde a penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid state taxes required under law. ,,,rrr���
25) Social Security Number or Federal ID: ' 1 "' ' �'. j�2
26) Signature of Individual or Corporate Name: ^-'`
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.
or Corporate Na By: Corporate Officer (Mandatony if Applicable)
g3-1 3 Ll;719AA
'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.
CAUsers\sleite\Desktop\Scotes Documents\Food Establishments- Temp\TAX CERTIFICATION PORM.doe
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Ulf 600 Washington Street
Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeibly
Business/Organization Name: MAA7z; R C 13F5 -1— P r2 2,9 C4_C
Address
It/, M A I A) 5'7`
City/State/Zip: MA Phone #: j 0 Y 3 3 e( ST
Are you an employer? Check the appropriate box:
10 I am a employer with_ ^' employees (full and/
Business Type (required):
5. ❑ Retail
or part-time).*
2. ❑ I am a sole proprietor or partnership and have no
6. *estaurant/Bar/Eating Establishment
employees working for me in any capacity.
7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
[No workers' comp. insurance required]
8. ❑ 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]*
4. ❑ We are a non-profit organization, staffed by volunteers,
I LEI Health Care
with no employees. [No workers' comp. insurance real
12•0 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 providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
t� r
Insurer's Address: !,e- Q - \, 0 )( S L1 C) CD
City/State/Zip:
0 Z
Policy # or Self -ins. Lie. Expiration Date: Z [ s— ( .
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; a der the
provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town offuial
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
www.mass.gov/dia