HomeMy WebLinkAboutGourmet Pizza & Grill 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:.
JAMALCHERAA
Whose place of business is:
INJ ENTERPRISES, INC. DBA GOURMET PIZZA AND GRILL
221 NORTH MAIN STREET
PERSON(S) IN CHARGE:
JAMAL CHERAA
Permit Expires: December 31, 2018
Food Fee: $125.00
License Number: FS-55
BOARD OF HEALTH
MichaeCMCCCean, Chairman
FOR BOARD OF HEALTH USE ONLY Permit# Issued FS-55
FOOD EST69USM
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name INJ ENTERPRISES, INC. DBA GOURMET PIZZA AND GRILL
2) Establishment Address 221 NORTH MAIN STREET
3) Establishment Mailing Address (if different) 221 NORHT MAIN STREET
MANSFIELD, MA 02048
4) Establishment Telephone No
339-5800
5) Applicant Name & Title: JAMAL CHERAA, OWNER
6) Applicant Address 17 ERICK ROAD, UNIT 27A, MANSFIELD, MA 02048
7) Applicant Telephone No.: (774) 266-1128
8) Owners Name & Title
9) Owner Address (If different from applicant)
Owner's telephone number
24 Hour Emergency No.: (508) 369-0480
JAMAL CHERAA
17 ERICK ROAD, UNIT 27A, MANSFIELD, MA 02048
7742661128
10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers
An Association or partner.
Ili A Corporation Name Title Address
I.!An Individual
I 1 A Partnership
12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: IJAMAL CHERAA
Address: 17 ERICK ROAD, UNIT 27A, MANSFIELD, MA 02048
Telephone No (774) 266-1128 24 Hour Emergency No: (508) 369-0480
FAX:
E-mail: IOMARCHEIKH4@GMAIL.COM
Alt E-Mail:
13) District Or Regional Supervisor (if applicable)
Name & Title !OMAR CHEIKH, OWNER
Address:
Telephone No:
FAX:
7 ERICK ROAD, UNIT 27A, MANSFIELD, MA 02048
508) 369-0480 24 Hour Emergency No: (508) 369.0480
E-mail: OMARCHE I KH4@G MAI L. COM
55_ ® DEC, 6 Ft40 ,
14) WATER SOURCE: TOWN
DEP Public Water Supply No: (If applicable)
17) DAYS/HOURS:
Food Establishment Information
15) SEWAGE DISPOSAL: TOWN
L 16) No. of Food Employees:
18) Name of Person In Charge Certified in Food Protection Management: JAMAL CHERAA
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: [y') Permanent Location
Mobile Mobile Start Date:
Mobile End Date:
Mobile Comments:
21) Length of Permit:
Annual
❑'i Seasonal
Seasonal Dates:
Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
22) Establishment Type
❑ Retail ( Sq. Ft)
[] 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 $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
El 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 (fime/temperature controls required)
Non PHF s - non -potentially hazardous food(no limeRemperature controls required)
Check all that apply): RTE - ready-to-eal foods (Ex sandwiches salads, muffins which need no further processing)
1, 1 Sale of Commercially Pre -Packaged Non-PHFs
!_1 Sale of Commercially Pre -Packaged PHFs
L ] Delivery of Packaged PHFs
] Reheating of Commercially
Processed Foods for Service Within 4 Hours
Customer Self Service of Non PHF and Non -
Perishable Foods Only
❑ Preparation of Non-PHFs
Other Food Operations
[] PHFCooked To Order
Preparation of PHFs For Hot And
Cold Holding For Single Meal Service
Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Ice Manufactured and Packaged for
Retail Sale
❑ Hot PHF Cooked and Cooled or Hot Held
for More Than a Single Meal Service
Susceptible Population Facility
❑ Vacuum Packaging / Cook Chill
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
Juice Manufactured and Packaged for I ❑ Offers Raw Or Undercooked Food Of
Retail Sale Animal Oriqin
Offers RTE PHF in Bulk Quantities ❑_ Prepares Food/Single Meals for
..__.__. _
Catered Events or Institutional Food Service
Salvage,
I 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 590.000 and all other applicable law. I have been instructed by the
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 un 7
and paid state taxes required under law.
25) Social Security Number or Federal ID: 81-51
26) Signature of Individual or Corporate Name: _
penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
(k
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.
N1 FmPCiJr, Tirt-
Signa e of Individual 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: Hn1thVane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I 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 Please Print Legjbly
Business/Organization
Address: =C Q N
Phone
339- 58 00
M
Are you an employer? Check the appropriate box:
Business Type (required):
1. ❑ I am a employer with _ employees (full and/
5. ❑ Retail
or port -time).*
6. []Restaurant(Bar/Fating Establishment
2. ❑ 1 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.
9. ❑ Non-profit -
[No workers' comp. insurance required]
3R 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 by
I
l l.❑ Health Care
are a non-profit organization, staffed volunteers,
❑
with no employees. [No workers' comp. insurance req.l
12. Other
*Any applicant that checks box #1 must also fill out the section below showing their worker:' compensation policy information.
**If the corporate officers have cxempted tbcwclves, 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
Insurer's
City/State
Policy # or Self -ins, Lick# °Y.L, V� C, �� %� Expiration Date: O 1 1 I Zo W
Attach a copy of the wor ers' 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, under the pains anal penalties of perjury that the information provided above is true and correct
N
Phone#' 2 J— ��Oo
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#:
www.mass.gowma