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Home My WebLink AboutCousin's Pizza - 6/1/2010G@ Commonwealth 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 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:. FRANK MYLONAS Whose place of business is: COUSIN'S PIZZA & SUBS, INC. 660 EAST STREET PERSON(S) IN CHARGE: FRANK MYLONAS Permit Expires: June 01, 2010 License Number: FS-13 Food Fee: $75.00 Milk & Cream S?J BOARD OF HEALTH Dr. Raymond Martin, Chairman FOR BOARD OF HEALTH USE ONLY Date received: Date Inspected: Approved By: Permit # Issued FS-13 FOOD ESTABLISHMENT PERMIT APPLICATION (Aaolication must be submitted at least 30 days before the planned opening date) 1) Establishment Name: COUSIN'S PIZZA & SUBS, INC. 2) Establishment Address 660 EAST STREET 3) Establishment Mailing Address (if different) 660 EAST STREET MANSFIELD, MA 02048 4) Establishment Telephone No: (508) 339-6243 5) Applicant Name & Title: FRANK MYLONAS 6) Applicant Address 6 CROSSWOODS PATH, WALPOLE, MA 02081 7) Applicant Telephone No.: (508) 668-8982 24 Hour Emergency No.: (617) 686-0206 8) Owners Name & Title FRANK MYLONAS 9) Owner Address (If different from applicant): 6 CROSSWOODS PATH, WALPOLE, MA 02081 10) Establishment Owned By: ❑ An Association V A Corporation ❑ An Individual ❑ A Partnership ❑ Other legal Entity 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 12) Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: .0 (I/ �I�(1 �u(U I Address:�j J "wwl-l t rl(I O Telephone No: 2 24 Hour Emergency No: FAX: 13) District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: 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 June 1 st of each year. NAME OF BUSINESS: COUSIN'S PIZZA & SUBS, INC. ADDRESS: 660 EAST STREET TELEPHONE AT LOCATION: (508) 339-6243 FAX NUMBER: OWNER OF BUSINESS: FRANK MYLONAS TELEPHONE OF OWNER: (508) 668-8982 FEDERAL ID/SS NUMBER: 04-275-7180 FEE: $2.00 PERMIT NUMBER: FS-13 SIGNATURE: 17 P f DATE: s � 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: FRANK MYLONAS having a place of business at: COUSIN'S PIZZA & SUBS, INC. 660 EAST 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 June 01, 2010, unless previous to that time is suspended or revoked. Expires: June 01, 2010 License No.: FS-13 POST THIS LICENSE IN A CONSPICUOUS PLACE This license shall not be sold, assigned or transferred 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. * ignature of Ind' idual or Corporate Name (Mandatory) By: Corporate Officer (Mandatory, if applicable) ** Social Security Number (Voluntary) or Federal Identification Number * This license will not be issued unless the 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 Mass. General Laws, Chapter 62C, Section 49A. 14) WATER SOURCE: TOWN Food Establishment Information 15) SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) 16) No. of Food Employees: 5 17) DAYS/HOURS: 7 DAYS 10:30 AM - 10:30 PM 18) Name of Person In Charge Certified in Food Protection Management: ELIZABETH TSIANAKAS If more than 3 individuals are certified, complete list is on file. 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: W Permanent Location ❑ Mobile Mobile Start Date: Mobile End Date: Moblie Comments: 21) Length of Permit: Annual ❑ Seasonal Seasonal Dates: ❑ Temporary Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: 22) Establishment Type ❑ Retail ( Sq. Ft) ❑./ Food Service up to 100 or up to 10' PHF display $75 ❑ Food Service up to 101 -200 or up to 25' PHF display $100 ❑ Food Service up to 201 + or 25'+ PHF display $125 ❑ Food Service - Institution ( Meals/Day) ❑ Bakery $25 ❑ Caterer $25 ❑ Food Delivery $25 ❑� Milk & Cream $2 ❑ Mobile Food & Consession $50 ❑ Mobile Food Temporary $25 ❑ Manufacture Frozen Desserts/Ice Cream $5/freezer ❑ Pushcart $25 If of Pushcarts: ❑ Residential Kitchen $25 ❑ Retail Food $50 ❑ Retail Snack Food $10 ❑ Tobacco Products No Fee 23) Food Operations Dentitions: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) ❑ Sale of Commercially Pre -Packaged Non-PFHs ❑d PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service ❑ Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly ❑ Delivery of Packaged PHFs Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Vacuum Packaging / Cook Chill Processed Foods for Service Within 4 Hours ] Customer Self -Service of Non PHF and Non- ❑ Customer Self -Service ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only ❑ Ice Manufactured and Packaged for contact alternative, time as a public health ] Preparation of Non-PHFs Retail Sale control) Other Food Operations ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Retail Sale Animal Origin ❑ Offers RTE PHF in Bulk Quantities ❑ Prepares Food/Single Meals for Catered Events or Institutional Food Service ❑ Retail Sale of Salvage, Out -Of -Date or Reconditioned Food Board of Health =Permit$75.00 plication ❑ 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.620, sec. 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: 04-275-7180 26) Signature of Individual or Corporate Name: V1 orkers' Compensation and Employer's Liability PolicyGUARD1� tGROUP AmGUARD Insurance Company - A Stock Company INSURANCE Policy Number COWC916425 Renewal of NEW NCCI No.[21873] Policy Information Page MEN sured and Mailing Address Agency IR IZZA & SUBS INC. C &SINS. AGY., INC. ods Path C & Chauncy St. A 02081 PO Box 406 7Fedreral Mansfield, MA 02048 Agency Code: MACSINIO mployer's ID 04-2757180 Insured is Corporation Risk ID Number 316846 Locations on Policy (1-2) 660 East St. , Mansfield, MA 02048 (08/01/2008 - 08/01/2009) [2] Policy Period From August 01, 2008 to August 01, 2009, 12:01 AM, standard time at the Insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to by - verification and change audit. (Continued on another page) Total Estimated Policy Premium $ 5,921 Total Surcharges/Assessments $ 92 Total Estimated Cost $ 6,312 91 INTERNAL USE TK Page - 1 - MGA : COWC916425 Information Page Date ; 07/22/2008 WC 000001A MANOTE 16 South River Street. P.O. Box A-H• Wilkes-Barre, PA 18703-0020.www.guard.com JQX 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 Business/Organization City/State/Zip: Are y it employer? Check the appropriate box: 1. ED I am a employer with _ employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ 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 emulovees. fNo workers' Como. insurance real Phone Business Type (required): 5. ❑ Retail 6. [1 *`staurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing 1 I.❑ Health Care 12.❑ Other *Any applicant that checks box Nl 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 H 1. I ant an employer that is Insurance Company Nan Insurer's City/State/Zip: Policy # or Self -ins. Lic. my employees. Below Is the policy information. Expiration 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, under the pains and penalties ofperlury that the Information provided above is true and correct Offecial 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 www.mass.gov/dia Phone