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HomeMy WebLinkAboutMansfield House of Pizza 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:. EZZAT A. ZAKHARY Whose place of business is: MANSFIELD HOUSE OF PIZZA, INC 175 NORTH MAIN STREET PERSON(S) IN CHARGE: EZZAT A. ZAKHARY Permit Expires: December 31, 2018 Food Fee: $125.00 License Number: FS-45 BOARD OF HEALTH a lichae(-MCCCean, Chairman Milk & Cream CI 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: EZZAT A. ZAKHARY having a place of business at: MANSFIELD HOUSE OF PIZZA, INC 175 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-45 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 45 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name MANSFIELD HOUSE OF PIZZA, INC 1 2) Establishment Address 175 NORTH MAIN STREET 3) Establishment Mailing Address (if different) 175 NORTH MAIN STREET ;= rr MANSFIELD, MA 02048 NOV 101 -- -- 4) Establishment Telephone No (508) 339-6400 5) Applicant Name & Title: EZZAT A. ZAKHARY, PRESIDENT 6) Applicant Address 24 LANCASHIRE DRIVE, MANSFIELD, MA 02048 7) Applicant Telephone No.: (508) 269-4133 24 Hour Emergency No.: (508) 2694133 (508) 339-7768 8) Owners Name & Title EZZAT A. ZAKHARY 9) Owner Address (If different from applicant) 24 LANCASHIRE DRIVE, MANSFIELD, MA 02048 Owner's telephone number (508) 269-4133 10) Establishment Owned By: 11) If a corporation or partnership give name, title, and home address of officers ❑ An Association or partner. IV] A Corporation Name Title Address ❑ An Individual _ ❑ A Partnership ❑ Other legal _En: ity-___— 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title IEZZAT A ZAKHARY Address: 124 LANCASHIRE DRIVE, MANSFIELD MA 02048 Telephone No }1(508) 339-7768 24 Hour Emergency No: (508) 269-4133 (506) 339-7766 FAX: E-mail: Alt E-Mail: 13) District Or Regional Supervisor (if applicable) Name & Title Address: Telephone No: FAX: I E-mail: 24 Hour Emergency No: Food Establishment Information 14) WATER SOURCE TOWN 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No. (If applicable) 16) No. of Food Employees: 2 17) DAYS/HOURS: MON-SUN 11:00 AM - 11:00 PM 18) Name of Person In Charge Certified in Food Protection Management: EZZAT A, ZAKHARY 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) I ] 20) Location: ❑d Permanent Location ❑ Mobile Moblie Start Date: Mobile End Date: Mobile Comments: 21) Length of Permit: 1yi Annual [j Seasonal Seasonal Dates: [_J Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) W 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 ❑ Food Service up to 201 + or 25'+ PHF display $275.00 I ] Food Service - Institution Meals/Day) ❑ Caterer $25.00 ❑J 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(time/temperature controls required) Non-PHFs non -potentially hazardous food(no time/temperature controls required) (Check all that apply): RTE - ready -to eat foods (Ex sandwiches, salads, muffins which need no further processing) [-I Sale of Commercially Pre Packaged Non-PHFs I E] PHFCooked To Order ❑J Hot PHF Cooked and Cooled or Hot Held I -- H - -ra -- for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs �dl Preparation of PHFs For Hot And 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 Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Ice Manufa, Retail Sale I_I PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Vacuum Packaging /Cook Chill ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin RTE PHF in Bulk Quantities I_..] Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date ------- ---! lt -- or Reconditioned Food To be complee ted by the Board of Health — _ — Total Permit Fee: $125 00 Payment is due with application i 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 apd all other applicable law. I have been instructed by the board of health on how to obtain copies, 105 CMR 590.O;%,nd the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 9A, I certify and paid state taxes required under law. penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 25) Social Security Number or Federal ID: 04-3291697 ,, 26) Signature of Individual or Corporate Name: (A hSr) 81 1&U5;2_. %-- b-7_0 1'n C_� 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: MANSFIELD HOUSE OF PIZZA, INC ADDRESS: 175 NORTH MAIN STREET TELEPHONE AT LOCATION: (508) 339-6400 FAX NUMBER: OWNER OF BUSINESS: EZZAT A. ZAKHARY TELEPHONE OF OWNER: (508) 269-4133 FEDERAL ID/SS NUMBER: 04-3291697 FEE, $10.00 PERMIT NUMBER: FS-45 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 ame By: Corpor t ficer (Mandator if Applicable) *"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. R:\HmlthVa es Docu eats\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02II4-20I7 www.mass.gov/dia Workers' Compensation insurance Affidavit: General Businesses. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information PIease Print Legibly Business/Organization Name:MAds 'l C'LD H©t, z o1 - ?,17Z)7 11ar Address: #:.wog-33q- LQ,I00 Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with 3 employees (full and/ 5. ❑ Retail orpart-tune).* 6. Restaurant/Bar/EatingEstablishment 2. ❑ lam 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. 8• ❑ 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]* I1.❑Health Cate4. ❑ We are a non-profit organization, staffed by volunteers, 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 cxcmptcd themselves, but the corporation has other employees, a worktm' compensation policy is required and such an organization should check box #1. am an employer that is providing workers' compensation insurance for my employees. Below is the policy informa$on. [nsurance [usurer's Address: 42:9 p m N-S 5 "1 r�e 1AA" City/State/zip: of i p1 s ram . ('2 r __Q ,.? U Policy # or Self -ins, Lic. # W) I 6 ,_&, Expiration Bate: J 1 —' 1;y Attach a copy of the workers' compensation policy declaration page (sho)iing 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify, under theppains anadppenala ' afperjuty that the information provided above is true and correct LC% 70 I7atw F lY 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#: r WORKERS COMPENSATION AND EMPLOYERS" LIABILTY INSURANCE POLICY ---• INFORMATION PAGE r INSURER: POLICY NO: WE172629A , ;NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY 222 AMES STREET NEW BUSINESS DEDHAM, MA 02026 NCCI Company No: ` 21059 Account No: FEIN: 04-3291697 ITEM 1. NAMED INSURED AND MAILING ADDRESS: AGENT NAME AND ADDRESS: MANSFIELD HOSE OF PIZZA INC 175 N MAIN STREET SALHANEY INSURANCE AGENCY MANSFIELD, MA 02048 5264 WASHINGTON.STWEST ROXBURY,'MA 021.32 AGENT NO.: 20121060 LEGAL ENTITY: CORPORATION OTHER WORKPLACES NOT SHOWN ABOVE: (See Workers Compensation Classification•Schedule} ITEM2. POLICY PERIOD: From: 11/05/2017 To: 11/05/2018 Effective 12:01 A.M. Standard Time at the Insured's mailing address. ITEM 3. COVERAGE: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident: $ 500,000 each accident Bodily Injury by Disease: $ 600,006, ` policy limit Bodily Injury by Disease: $' Soo 000 each employee C. Other States Insurance: Part Three of the, policy applies to the states, if any, listed here> SEE ENDORSEMENT WC 20 03 06 B' D. This Policy includes these Endorsements and Schedules See Schedule of Forms and Endorsements. ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. AI information required on the Workers Compensation Classification Schedule is subject to verification and change by audit. Total Estimated Minimum Premium: $ 217: Annual Premium:" $ 1, 041, Audit Period: ANNUAL Additional t Return Premium: Comments,: Issued At: Date: 11/06/2017 Countersigned, by WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance (NSURED COPY N m O N N v m 0 0 Z z W H u 0 c� U. G r C 2' X w W u 4 0 Y E LL w � o o •� Y 4= o @ v o yo LL @ `o o @ C Y � u a o z �. i m :G G �C�pp @ U ya fl. A 'O N N -: L.'j `y u w. @ 3 L. w u ;5 1 n = m a v 0 N V H w to �- a r N 40 W CAa a r r N � � z 4 z 0 *.a 0 0 w000 W 0 W4 V C O v a c w.swa y Q N d � y u l�l 40 Op ti