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Home My WebLink AboutMansfield Best Pizza 12/31/2018 (2)r A J�\ FOR BOARD OF HEALTH USE ONLY Permit #Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name: rNl (/Y S f e ( S /� rk� MN,U°c (0- {Mr°t 02oIi8 Establishment Address: i PVJ Establishment Mailing Address(if different): Establishment Telephone No.: 5 0,% 3 3 Applicant Name & Title: a o$ e \f k D a. f/ Applicant Address: ci cz MT kA -z Q S 1 c W • �}) (L � j�� J2 ` rM (,� o -00 Applicant Telephone No.: S-Dlt �j i p ,3 i I 24 Hour Emergency No.: Applicant E-mail: ►\j M q 6 Z Z Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: 5 C� Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or Ed An Association partner. L L' L WA Corporation Name Title Address 0 An Individual 44 C_— d- ViO O A Partnership O Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: A ha i M Drh i L� � � Sa �✓• � f� L� � iwt a4 � ? G � Address: 0--to PA-r i� t Telephone No: 5� U ,3 K 24 Hour Emergency No: FAX: E-mail: \ Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: VJ\,V,L SEWAGE DISPOSAL: 'pJ�j,tY No. of Food Employees:- DEP Public Water Supply No: (If applicable) DAYS/HOURS: +p a, _ --,, �'� M e4 --> � Name of Person In Charge Certified in Food Protection Management` If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): E3 N Location: E Permanent Location Establishment Type Q Caterer $35.00 QMoblie Moblie Start Date: Q Retail ( Sq. Ft) Milk & Cream $10.00 Mobile End Date: (y'� Food Service up to 100 INCLUDINC Mobile Food Consession Mobile Comments: TT FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Food Service up to 101 -200 $250.00 n Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: Annual Food Service up to 201 + $300,00 Supermarkets $400 Ell Pushcart $50.00 # of Pushcarts: Residential Kitchen $100.00 ® Retail Food $125.00 Retail Snack Food $50.00 '}❑"<. Seasonal Seasonal Dates: ED Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations Definitions:PHF- Potentially hazardous food(fimerlemperature controls required) Non-PHFs - non-potenh'ally hazardous food(no time/temperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) R Sale of Commercially Pre -Packaged Non-PHFs RPHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑rl�-.-.- 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 Susceptible Population Facility Delivery of Packaged PHFs Ej Sale of Raw Animal Foods Intended to be Prepared by Consumer Q Customer Self -Service ':.. Reheating of Commercially Processed Foods for Service Within 4 Hours •,'�--7 Customer Self -Service of Non PHF and Non- Perishable Foods Only Vacuum Packaging /Cook Chill `,-.- Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale - Preparation of Non-PHFs Other Food Operations i] Juice Manufactured and Packaged for Retail Sale ij Offers Raw Or Undercooked Food Of Animal Origin Offers RTE PHF in Bulk Quantities iM Prepares FoodlSingle Meals for Catered Events or Institutional Food Service 0 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 E0 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 CC R 590.000ynd a oth r applicable la N _ instructed by the board of health on how to obtain copies o� MR 590, 00 and the deral Fo de. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49Fj/ - ertifynder the ties of rjury that I, to my best Viand belief, have fled all state tax returns and paid state taxes required und, aw. fir./ � Signature of Individual or Corporate Name: M /M i'�i c lt r d� t 1� ,' T (-. _c Social Security Number or Federal ID: 13 L4 % 0 L (.' 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. irn w. s F"4 /) n is 5 T 0 1" LoLk-- .Sew � � -Dur 2 atu vidual or orpo ame By: Cor� O fi er (Mandatonj, if Applicable) 3-f3(47d6� **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:\Users\sleiteVDesktop\Scotts Doe ments\Food Establishments- Temp\TAX CERTIFICATION FORM.doe The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le:ribly Business/Organization Name: Ip/V1 Address: (/\Arnt\C.k City/State/Zip: YVl � � f F, � /,� n i li g Phone #: 5 3 319 S F fl u Are you an employer? Check the appropriate box: Business Type (required): 1. Q I am a employer with _ employees (full and/ 5. ❑ Retail or part-time).* 6. 0 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. [No workers' comp. insurance required] $• ❑ 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, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ 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 41. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: T/ q 1f e m, ,lrn.4 s/ f A n.. e ✓-, C - Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. # k 14 ✓l� I l/; j z% 1 i Expiration Date: 0 _- IC 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, yWer the pa en es o penury 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 official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia ACC ,,, R CERTIFICATE OF LIABILITY INSURANCE ��' DATE/14/20VYYY) 11l14/2018 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 R A REINBOLD INSURANCE AGENCY INC 860 LANDRY AVENUE _ NORTH ATTLEBORO MA 02760 CONTACT NAME: Mellissa Cornell PHONN . Ext (508) 695-031.4 FAX . No): E-MAILmellissa@reinboldinsurance.com E-MAILADDRESS, @reinboldinsurance.com INSURERS) AFFORDING COVERAGE NAIC# INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED MANSFIELD BEST PIZZA LLC INSURER B: INSURERC: INSURER D: 890 MT HOPE ST INSURER E NORTH ATTLEBORO MA 02760 1 INSURER F: \ UVERAGES UaRIIFICAIE NHMRFR• 337FRQ REVICInN NUMB o. 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 im SUER D POLICY NUMBER POLICY EFF MMIODIYYYY POLICY EXP MM/OD/YYYY -'- LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE D OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MEDEXP(Any one person) $ — -- ... PERSONAL$ ADV INJURY $ N/A GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO POLICY JECT PRODUCTS - COMPIOP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED -- -- AUTOS AUTOS N/A BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY AGE Per accitlakenl -- $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE N/A DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN /� STATUTE EORH - E.L. EACH ACCIDENT '- - $ 100,000 A ANYPROPRETOR/PARTNEREXECUTIVE REXCLUOEOR NIA NIA NIA 6HUBIK54949118 08/16/2018 08/16/20.19 E.L. DISEASE -EA EMPLOYEE -- -- $ 100,000 (Mandatory In N Ifyes,dorybeund If yes, describe antler E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) '.. Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. 6 PARK ROW AUTHORIZED REPRESENTATIVE Mansfield MA 02048L,- Daniel M. CroWWey, CPCU, Vice President— Residual Market— WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD W* 0 6w � � u 0-4 W-4 0-10 � �w u (M� z �-o z I � � W z W4 �4 � � � Ale - & < y » « \ o / } 4»{¥ & » / & 04/10/2017 18:28 'FO 0002 SerVSafe e, NAIM DARAZI �0dw+v"6'4"h,nh fa 16 N019+ M19-ICali(iMw Expsindi., WIC'h i, ncaedifed W the Anwd.G Naiceel%wJmd,hale%V,N.9Kwfirenee her foal Ra*mm IefPl, 5159 EXAM FORM NUMRER 5114/2021 DATE OF EXPIRATION i`cwli(wwAw, ,�rvxmwM. [wmr..Mimd++,a VSW b6o,tlM L ISM, v�. LbMMw 5w3ilrc. ,