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HomeMy WebLinkAboutMansfield Best Pizza 12/31/2018 (3)FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION App eca e�fbe su me e a east �before�e opening a e 1) Establishment Name Vt 2) Establishment Address ;q4 AjC)ATk VAa,n) Sr 3) Establishment Mailing Address (if different) 4) Establishment Telephone No 5- K - 3 3 `Y 11 5) Applicant Name &Title: Ptf OAF:Rzi 6) Applicant Address gel 0 ✓rt e uV7_ 1-(0f'Z a , Ns �4 TTi. Fd,i A'V, M l . 0,2 -a 7) Applicant Telephone No.: s,24 Hour Emergency No.: 8) Owners Name & Title 9) Owner Address (If different from applicant) -- ---------__._ ---_ __--- -...----------- Owner's telephone number 10) Establishment Owned By: El An Association KA Corporation El An Individual El A Partnership 1-1 Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address J Li-c_ 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: <YY, c%' m. i Hoe iu. S`t fi i77,C'gne4i✓ da',a L:> Telephone No: C' « 24 Hour Emergency No: r�� Et 9 y E-mail: Alt E-Mail: 1 IVjV, Q () 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: -V L ;,) 15) SEWAGE DISPOSAL: '\--C)t,, j,-J DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 13 17) DAYS/HOURS: AY,, e L i,= K_ 1 t CN - S AT y`2'vi . S u�VOi-r ' t-t_-9 18) Name of Person In Charge Certified in Food Protection Management: NA" c,kk o v9 A Z E If more than 3 individuals are certified, complete list is on file. Required as of 1011/2001 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: XPemnanent Location 22) Establishment Type ❑ Caterer $25.00 Mobile Moblie Start Date: Q Retail ( Sq. Ft) ❑ Milk & Cream $10.00 Mobile 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 Ei Manufacture Frozen Desserts/Ice Cream 21) Length of Permit:E] Annual Food Service up to 101 -200 to 25' PHF display $150.00 $25.00/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: Q Food Service -Institution ( El Retail Food $100.00 ❑Retail Snack Food $25.00 _ 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) Non-PHFs - non-polenfially hazardous food(no fima4amperature controls required) (Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches,salads, muffins which need no furtherprocessing) 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 Pm -Packaged PHF ❑Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Cold Holding For Single Meal Service Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially ❑ Vacuum Packaging / 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 Safe ❑ Preparation of Non-PHFs Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Prepares Food/Single Meals for ❑ Offers RTE PHF in Bulk Quantities❑ Catered Events or Institutional Food Service 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 E] waived 1, 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 en instructed by the board of health on how to obtain conies of 105 CMR 59(L00g and the federal Food ode. 24) Signature of Applicant: r-- -- Pursuant to MGL Ch.62C, sec. 9A, I certify unde a penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law. 25) Social Security Number or Federal ID: 3.7 � ` r ��t _ ',Vkq 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 Corpp6te7" By: Corporate Officer (Mandatoni, if Applicable) �?3-13 `Z.3M 'Social Security No. (Voluntanl) 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:\Usem\sleite\Desktop\Scotes Documents\Food Establishments- Temp\TAX CERTIFICATION FORM,doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations u,p 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: MA-(v% R Co j3C5 T" j9rG.-2A- LLLe A/, Al A I A) 5 "T City/State/Zip: M�FiJs�l t—t� MA uK— -., Phone #: , C O Y 3 3 ( .S TO Are you an employer? Check the appropriate box: Business Type (required): 1VV I am a employer with employees (full and/ 5. ❑ Retail _ or part-time).* 2. ❑ I 6. testaurant/Bar/Eating Establishment 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] 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, 1 i.❑ Health Care with no employees. [No workers' comp. insurance req.] 12. ❑ Other *My applicant that checks box # 1 must also fill out the section below showing their workers' comcensation nolicv infonnarien **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 r Insurer's Address:_ �2 i - a' ' 0 k Se� O p City/State/Zip: UZ Policy # or Self -ins. Lic. # ��' Z rJ L Expiration Date: 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceM , a der the pginsVKd pl Wdes ofperjury'lhat thejnformadon provided above is true and correct. Offkhd use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone #: www.mms.gov/dia NOTICE OF ASSIGNMENT EMPLOYER: ................._ .._.__ _ --. MBO 'I"). _, _ MANSFIELD HEST PIZZA LLC 890 'COi.b, . STATUS OF EMPLOYER ORTI1 TTLHOPE OR 001120243 Limited Liability Comp NORTH ATTLEBORO, MA 02760 COVERAGE GROUP 1IR4611 The Nazver of Our Right to RecOvOz From Others Endorsement is available on Pool policies, Contact your agent for details. AGENT R A REINHOLD INSURANCE AGENCY INC OR PRODUCER: MELLISSA-CORNELL 860 LANDRY AVENUE NORTH ATTLEBORO, MA 02760 AGENCY FEIN: 042731859 CLASSIFICATION OF OPERATION Coverage under this assignment applies to Massachusetts Operations Only. For coverage outside of Massachusetts, contact the appropriate Pool or Plan for that state. INSURANCE COMPANY: _..._.._ _....__.._._---..._�-., TRAVELERS EM TRAVELERS INRDMbNITY CO OF WERICA P 0 BOX 5600 HARTPORD, CT 06102-5600 (800) 443_4404 CLASS ESTIMATED RAZE CODE TOTAL ANNUAL REMUNERATION RESTAURANT NOC �------------ ---------` DRIVERS, CHAUFFEURS AND REL.PERS-NOC-CO9079 EMPLOYERS LIABILITY 100/100/500 MMERCIAL 7580 STANDARD PREMIUM 9845 EXPENSE CONSTANT TERRORISM CHARGE 0900 TOTAL POLICY MINIMUM PREMIUM 9740 TOTAL ESTIMATED PREMIUM DIA ASSESS, 3.83$ TOTAL EST, PREMIUM PLUS ASSESSMENT INSTALLMENT BASIS: Annual COMMENTS Coverage effective 12:01 AM on 09/16/18. ESTIMATED PREMIUM $29,000 1.03 $P99 $11,000 5.96 $656 $955 $250 $12 $479 $1,217 $37 $1,254 DEPOSIT PREMIUM: $1,254 THIS IS NOT A BILL CARRIER NOTE: Certain information on the electronic application was initial incorrectly or has changed, For the corrected information, this application included in oally reported Your application bu refer tO the attachments to ndle. DATE OF NOTICE: 08/ 20/ 18 PREPARED By; Sherry aones EXT Sib * w SERVICYNG CARRIER ASSIGNMENT w w LFTTERID: 5058333 The Workers' Compensation Rating and Inspection Bureau of Massachusetts 101 Arch Street • Boston, MA 02110 (617)439-9030 - FAX (617)439.0065 • www.wcribma.org /►co- CERTIFICATE OF LIABILITY INSURANCE �� � ­DATE11/14/2018 Y) 11/14/2018 ,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 CONTACT NAME: Melllssa Cornell PtiJCO.N E.Ext1. (508) 695-0314 AIC Nol. EMAIL llissa ADDRESS: me@felnbOdlnsUranCa,COm 860 LANDRY AVENUE INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 NORTH ATTLEB_ORO MA 02760 INSURED MANSFIELD BEST PIZZA LLC INSURER B INSURER C: INSURER D : 890 MT HOPE ST . INSURER E: NORTH ATTLEBORO MA 02760 INSURER F: COVERAGES CERTIFICATE NUMRFR- 337520 oclnelnnl NUMBER 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 INSDD SUBR POLICYNUMBER (MMIDDNYYY1 MMIDD/YYYY -- -"-"'- LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTEDPREMISES Eaoccurrence $ MED EXP (Any one person) $ .... _ PERSONALS ADV INJURY $ N/A _GEN'L AGGREGATE LIMIT APPLIES PER: POLICY E PRO- PRO LOC GENERALAGGREGATE $ PRODUCTS - COMP/OP AGO - $ --_ $AUTOMOBILE OTHER: LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY (Per accident) — $ HIRED AUTOS NON -OWNED AUTOS PROPERTYDAMAGE Per accitlent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE y EXCESS LIAB CLAIMS -MADE N/A AGGREGATE $ DED RETENTION$ _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) 1I yes, describe under NIA NIA 6HUB1K54949118 08/16/2018 08/16/2019 ""E.L. X/ PER OTH- ^ STATUTE ER E.L. EACH ACCIDENT - $ 100000 ,-- -- DISEASE - EA EMPLOYEE - $ 100,000 E.L. DISEASE -POLICY LIMIT - -- $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS / LOCATIONS / 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 02048 Danielel M. CroQby, CPCU, Vice President —Residual Market— WCRIBMA © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACQRO® Dnr¢ (NRAIDOmY1T CERTIFICATE OF LIABILITY INSURANCE Da.zs-zofs 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 have ADDITIONAL INSURED provisions or 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 CONTACT NAME: R A REINBOLD INS AGCY _ PHONE II -AC 860 LANDRY AVENUE NORTH AYiLE80R0, MA 02750 No Extl: xa EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICa INSURER A I THE TRAVELER8 IN DEMMW COMPANY OF AMERI INSURED INSURERS: MANSFIELD BEST PIZZA LLC 500 MT HOPE $T INSURER D: .__ INUURER D NORTH ATTLEBORO. MA 0275D INSURER E: INSURER F COVERAGES CERTIFICATE NI IMBER RFNRIAN NI IMIAFR• 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 INSD SUB WvD POLICY NUMBER POLICY EFP IMWDDIYYYY POLICY EXP MMIDO/YYVY LIMITS COMMERCIAL GENERAL LIABILITY CLAIM6-MAOE _ :: OCCUR — EACHOCCURRENCE $ =ACE TO RENTED PREMISES Eaocppeenpe S MEOEXP(A�ya+.,ewer) 8 PERSONAL a ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: PIXICY TJ PRO. r LOC _....—_ JECr OTHER: GENERAL AGGREGATE S PRODUCTS -COMMOP AGG e S AM DIADEM LIABILITY MBas�INECEMOLE LIMIT E MY AUean OWNED D LED AUTOS ECHEDU lnO6AUros ONLY BODILY INJURY (Per parson) 8 BODILY INJURY acddenp S HIRED NON -OWNED AUTOS ONLY .__ AUTOS ONLY ROPERTY gMAOE FG S S I UMBRELLA LIAR OccUR EACH OCCURRENCE S EXCESS LIAR , CLAJMS-MADE AGGREGATE 3 DEO RETENTIONS 6 WORKERS COMPENSATION AND EMPLOYERS'LIABIDW YIN AXECUTI EETOR/PAR7NER/ FYIN/A EXECUTIVE OFFICEARAEMSER EXCLUOEDT (Mendaloryln NH) 6HUB 1K549491 08-16-2018 > 08-16-201a PER 6TATUTE DTH. ER 6.L EACH ACCIDENT 8S10Q0DD E.L DISEASE. EA DMPLOYBE S$100,000 IFyes, dessdeaunder DE6CRIPTION OF OPERATIONS ado. E.L. OIBEA6E-POLIGY LIMIT$500,000 B DESCRIPTION OF OPERATIONS / LOCAYIGNS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe adaoheE Irmare apace la required] LOCATION: 221 N MAIN ST MANSFIELD, MA 02048 TOWN OF MANSFIELD 6 PARK ROW MANSFIELD,MA 02048 SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. qbV RV LD IZUIDIIAII I he ACORD name and 1090 are registered marks of ACORD