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Home My WebLink AboutStefano's Pizza & Subs 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:. THOMAS BISSEN Whose place of business is: K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS 30 CHAUNCY STREET PERSON(S) IN CHARGE: THOMAS BISSEN, PRESIDENT Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-37 BOARD OF HEALTH MichaeCMcCCean, 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: THOMAS BISSEN having a place of business at: K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS 30 CHAUNCY 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-37 Board of Health michaeCMcCCean, Chai"nan POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred LFOR BOARD OF HEALTH USE ONLY Permit # Issued FSFS37 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name K D ENTERPRISES INC dba STEFANO'S PIZZA & SUBS 2) Establishment Address 30 CHAUNCY STREET 3) Establishment Mailing Address (if different) 30 CHAUNCY STREET No 2017 MANSFIELD, MA 02048 �- 4) Establishment Telephone No (508) 339-6111 5) Applicant Name & Title: THOMAS BISSEN, PRESIDENT 6) Applicant Address 50 HIGH STREET, BELLINGHAM, MA 02019 7) Applicant Telephone No.: (508) 966-5004 24 Hour Emergency No.: (508) 966-5004 8) Owners Name & Title THOMAS BISSEN 9) Owner Address (If different from applicant) 50 HIGH STREET, BELLINGHAM, MA 02019 Owner's telephone number (508) 966-5004 10) Establishment Owned By: 11) If a corporation or partnership, give name, title, and home address of officers I 1 An Association or partner. Ill A Corporation Name Title Address An Individual _ " (/7tdw✓}5._ijl5wv J�l=� Sc'_t��w`� LJ A Partnership -- fir, C 1 Other legal Entity__ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: THOMAS BISSEN, PRESIDENT Address: I50 HIGH STREET, BELLINGHAM, MA 02019 Telephone No: 1(508) 966-5004 FAX: E-mail: Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title. — Address: Telephone No: FAX: 24 Hour Emergency No: (508) 966-5004 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE: TOWN DEP Public Water Supply No: (If applicable) 17) DAYS/HOURS: MON-SUN 11:00 AM - 10:00 PM 15) SEWAGE DISPOSAL: TOWN 16) No. of Food Employees: 18 18) Name of Person In Charge Certified in Food Protection Management: PATRICK MCETTRICKtHOWARD If more than 3 individuals are certified, complete list is on file. WHITAKER Required as of 101112001 in accordance with 105 CMR 590.003(A) Please attach copy or THOMAS BISSEN certificate LISA MYSIUK-BIS 19) Person Trained in Anti -Choking Procedures (If 25 Seals or more): 20) Location: Permanent Location 22) Establishment Type [J Mobile Mobile Start Date: ❑ Retail ( Sq. Ft) Mobile End Date: Food Service up to 100 or Mobile Comments: up to 10' PHF display $125.00 21) Length of Permit: [VI, Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: ❑ Food Service up to 101 -200 or up to 25' PHF display $150.00 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 [„ I 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 ❑ 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 (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no timelemperature controls required) Check all that apply): RTE- ready -to -eat foods (Ex, sandwiches, salads, muffins which need no furtherprocessing) [ J Sale of Commercially Pre -Packaged Non-PHFs I Sale of Commercially Pre -Packaged PHFs ❑ Delivery of Packaged PHFs CJ Reheating of Commercially Processed Foods for Service Within 4 Hours _I Customer Self -Service of Non PHFand Non - Perishable Foods Only [J] Preparation of Non-PHFs Other Food Operations [i 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 I.-] Prepares Food/Single Meals for Catered Events or Institutional Food Service IJ 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 co ' s of 105 CMR 590.000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, se . 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 04-3245674 26) Signature of Individual or Corporate Name: V� . 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: K D ENTERPRISES INC dba STEFANC'S PIZZA & SUBS ADDRESS: 30 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-6111 FAX NUMBER: OWNER OF BUSINESS: THOMAS BISSEN TELEPHONE OF OWNER: (508) 966-5004 FEDERAL IDISS NUMBER: 04-3245674 FEE: $10.00 PERMIT NUMBER: FS-37 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. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) 4>9-3aysc-7 y "*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. RAH{ IthUane's DocumentsTERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PEP -NUTTING AUTHORITY. Applicant Information Please Print Le>?ibl Business/Organization Name: K' h, Cn Address: 3g C14 AU,%4 Cy ST City/State/Zip Vtd 3t7<G=in 17r4 c4A-4G Phone#: -;camg z�i'— toir/ Aree youanemployer? Check the appropriate box: I. N� 1 am a employer with �( _ employees (full and/ or part-8me).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp, insurance required] 1 ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required] 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] *Any applicant that checks box #] must also fill out the section below showing Business Type (required): 5. ❑ Retail 6, estaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl, real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 11. ❑ Health Care 12,❑ Other **If the corporate officers have exempted thcrosdves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box M. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance CompanyName:Aui J t— jT mst>o t-71 Insurer's Address; °�o ?��= 1-tC'.�. S�,N IS I�GG�A_l[_y % `L�7 ��+"f•r?� Y City/State/Zip; �a Policy # or Self -ins. Lic. # / L -> C 3G A-, Sa+ 3 Expiration Date: ` y�r IA I t/ 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. Cdo hereby certify, weer the pains andpenaldes of perjury that the information provided above is true and correct, .RicnAtilt � ilatr. //" L=a " / Phone cam" cg CjZ—* 2v3 r 4_/// Official use only, Do not write in this area, to be completed by city or town offetaL 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 64318245 Technology Insurance Company, Inc. A Stock Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Ncci Code: 39071 1. Insured KD ENTERPRISES, INC. DBA: STEFANO'S PIZZA & SUB SHOP 30 CHAUNCY STREET MANSFIELD, MA 02093-0000 Other workplaces not shown above: None Producer: AmTrust North America, Inc. c/o ZEMACK INSURANCE AGENCY 187 OAKS ROAD FRAMINGHAM, MA 01702 n •• 11 f Q INFORMATION PAGE Policy Number: TWC3621823 _Individual _Partnership X Corporation Federal Tax ID: 043245674 Risk Id: Renewal of: TWC3539285 2. The policy period is from 4/15/2017 to 4/15/2018.12:01 a.m. at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease $1,000,000 each accident $1,000,000 policy limit $1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OR, WA, WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: See Extension of Information Page 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM STATE ASSESSMENT TOTAL ESTIMATED COST Minimum Premium Deposit Premium Issue Date: 3/3/2017 Countersigned 5,479 292 5,771 500 839 9 c (U co N cu E O 1-4 on r �\ »»y: r y. r� r AWIYI� e 4W,• � e ep � r?I Al y �VN 31117, - / \ _I m■ ■ CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: r Oh1AB BIBBEN Certificate Number: 23137m Date of Completion: v 016 Date of Expiration: "m21 The above -named person is hereby issued this rerq)gimte for completing an allergen awareness training program recognized by the Massachusetts Department ofPnblicHealth in accordance with 105 CMR 590.009(G)(3)(a). This certificate will be valid forfrue (5) yemsfrom date oftompletion. Iaved By: NATIONAL RESTAURANT _ Masvchuaem ASSOCIATION, 800.765.2122 333 Turnpike Road, Suite 102 ww,vreataurontorg Southb0sough,MA 01772 508-303-9905 W 1TV.IIIaKS[0UIL6t89SOC.0(g CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: IJBA WSIUN.BIWEN Certificate Number: Mm24 Date of Completion: sava+B Date of Expiration: wmvi 0. . Inucd By: 7hr above -named person is hereby issued this certifirntr - L -campletingan allergen awareness trainingprogram NATIONAL RESTAURANT recognized by the Massachusetts Department of'Publir Health ��- ASSOCIATION in accordance with 105 CMR 590.009(G)(3)(a), Masmchusem Re.ta tAcsocistim 800.765.2122 333 Turnpike Road, Suite 102 wwtaashumntorg This certificate will he vafidfmjrve (5) years from date a(mmplrtion. Southborough, MA 01772 508-303-9905