HomeMy WebLinkAboutCheng Du - 12/31/2020FOR BOARD OF HEALTH USE ONLY Permit# issued
FOOD ESTABLISHMENT PERMIT APPLICA
(Application must be submitted at least 30 days before the planned opening
If gas < 1� 7/
Establishment Name Lll-1J6
Establishment Address A,' 5
Establishment Wiling Address (if different)
Establishment Telephone No
Applicant Nprr: .Title: 7i 713rVv
Applicant Aodress
Applicant Telephone No.: , _W - /J- e5e 7 24 Hour Emergency No.: fe e9 1?6 9
Applicant Email 1�3
Owner Name & Title (If different from applicant)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By:
If a corporation or partnership, give name, title, and home address of officers or
EJ An Association
partner.
M'A Corporation
Name Title Address
R An Individual
6 e-"': '�/
K A Partnership
N Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title: 7-1 ex
Address:
Telephone No: Z, 4ij-1 e 24 Hour Emergency No.
FAX: 7- i7el, T;%
E-mail:
Alt E-Mail: 7-Z � 0
District Or Regio ial Supervisor (if applicable)
Name & Title: 177ql,; er
Address: � 7
Telephone No: 24 Hour Emergency No:
FAX:
E-mail: CHI(�1-17-r'7
Food Establishment Information
WATER SOURCE:
SEWAGE DISPOSAL: v.
No. of Food Employees:
DEP Public Water Supply No: (If applicable) Fi7�i�/i ,. , ,, F._
DAYS/HOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
7-i (J ;» y .Tg1,6
N�a—m�-e' of/P/erson(s) In Charge Certified in Allergen Awareness Training
Name of pest control company routinely inspecting the premises for evidence of pests ?, Ey
If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times
food is being prepared. RYes
Does this establishment require a FOG permit? Z > If yes, please attach the FOG permit application.
Length of Permit:
Establishment Type:
EjiI/Annual
ApRetail Food $125.00
® Mobile Food Consesslon
E Temporary
Food Service up to 100 INCLUDING
NO PHF PREPARED ON SITE $100.00
FOOD TRUCKS $175.00
O Manufacture Frozen Desserts/Ice Cream
Temporary Start Date:
Food Service up to 101 -200 $250.00
$25.00/freezer
Temporary End Date:
c1 Food Service up to 201 + $300.00
I Pushcart $50.00 # of Pushcarts:
Temporary Time:
0 Supermarkets $400
I Residential Kitchen $100.00
Rain Date:
Milk &Cream $10.00
r'd Caterer $35.00
Food Operations: Definitions:PHF - Potentially hazardous food(fime/temperatum controls required)
Check all that a Non-PHFs - non -potentially hazardous food(no time/temperature controls required)
( PPY) RTE- ready -to -eat foods (Ex. sandwiches, salads, mums which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFs E] PHFCooked To Order
'Hot PHF Cooked and Cooled or Hot Held
ii Sale of Commercially Pre -Packaged PHFs 0 Praparation of PHFs For Hot And
for More Than a Single Meal Service
Delivery of Packaged PHFs Cold Holding For Single Meal Service
n PHF and RTE Foods Prepared For Hi lhly
Susceptible Population Facility
C❑a' Sale of Raw Animal Foods Intended
Reheating of Commercially to be Prepared by Consumer
Ed Use of Process Requiring A Variance
Processed Foods for Service Within 4 Hours
`Customer Self -Service
and/or HACCP Plan (including bare hl,nd
0 Customer Self -Service of Nan PHF and Non -
contact alternative, time as a public health
Perishable Foods Only [Eij Ice Manufactured and Packaged for
control)
Preparation of Non-PHFs Retail Sale
� Offers Raw Or Undercooked Food Of
0 Juice Manufactured and Packaged for
Animal Origin
Other Food Operations Retail Sale
Vacuum Packaging /Cook Chill
Offers RTE PHF in Bulk Quantities
0 Prepares Food/Single Meals for
F! Retail Sale of Salvage, Out -Of -Date
Catered Events or Institutional Food S;rvice
or Reconditioned Food
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.
Signature of Applicant:
Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns
and paid state taxes required under law.
Social Security Number or Federal ID:
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.
Signature of Individual or Corporate Name By: Corporate Officer (Manda{on/, 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.
C:\Users\sleite\Desktop\Scotts Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doe
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
t Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: il,,r' } f; ,«
��i7/7 5't C : /C,r'<S 7)r. .Erra.-zZ7 �
Address: r rv" I? t s-7
City/State/Zip:L Phone # ; W
Are you an employer? Check the appropriate box:
Business Type (required):
5. ❑ Retail
Ln
I am a employer with employees (full and/
or part-time).*
6. ®Restaurant/Bar/EatingEstablishment
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.
S. ❑ Non-profit
3.0
[No workers' comp. insurance required]
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]**11.❑
Health Care
4. ❑
We are a non-profit organization, staffed by volunteers,
12.0 Other
with no employees. [No workers' comp. insurance req.]
*Any applicant that checks box #I must also frll 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 #I.
I am an employer tleat is providing ivorkers' compensation insurance far my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip: C✓, �,/> a
c-
Policy # or Self -ins. Lie. #/ 4j! C CLta 6' b)e , - eF Expiration Date: >-lb J
Attach wcopy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure td 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, tinder the pains and penalties ofperjury that the information provided above is trite and correct.
Phone#: jr'&
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
www.mass.gov/dia
Phone
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT& FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment Name: 3Y b � -2 G,yck>z� '�
Address: Y f >j �L/ /o 3-7 k1
Mailing Add
Phone/Fax Number: % `l ,r% ✓ ✓ U �/ -1 r>
I
Email: C"'n m
Contact Person/Title for Grease Traps: %i t 1 �� �, r"k s= ti'7"
Name of Company scheduled to pump internal grease trap(s) monthly:
Name of Company scheduled to pump external grease trap quarterly:
Please attach the following documents to this application:
• Most recent waste hauler receipt or waste hauler manifest
• Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of
Mansfield)
Food Establishments Fee
Lse interceptors/traps or less and/or 1 yellow grease collection $50
iner
Each grease interceptor/trap over 3 $50 ($200 max)
I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND
GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCFOBER 4, 2018.
In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the information submitted in these documents is true, accurate and complete.
Siknedz f Date
Print Name %— C J' 170
Facility Operational Information
Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise
specified, please print or type.
Seating Capacity (per Fire Department Regulation): /
Seating Capacity (Actual Count): _ 70
Normal Hours of Food Preparation/Service:
Monday lr ,�� , - //) r, p P,nF Tuesday
Thursday rt , _ ;•,
Sunday l ,�> - r cf 'rr/
Friday /j _,; f - /t urn
i
Wednesday
SaturdayLr,
Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease
Removal Units (GRU/trap)
Number in
establishment
Attached to
GRU
0
r
� s
3 compartment sink
Handwashingsink
y
Commercial Dishwasher
i
Bar sink
Mop Sink
Garbage Disposal
j
Ice Making Machines
3
Fryolators
i
Grills or Ovens
/
Exhaust Hoods
Floor drains
Other:
How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company):
2
Is dinnerware pre -rinsed before being washed? t ' Yes
If yes, at what station/sink? ✓itS-M-1 e ' ; "e - "�� n-7-C:�
2
No
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
Please list fixtures attached to each grease trap
Grease Trap l
�,�,.,-,,ice;,
Grease Trap l
Grease Trap 3
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
f Yes No Size J , , gallons
Where is the existing outdoor GRU located? 1< . ' _ /,
If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of
the property owner below:
Property Owner's Name:
Property Owner's Address:
Property Owner's Telephone Number:
Yellow Grease Waste
Do you store yellow grease waste from fryolators? ;' E S
Where is the grease storage unit located? L)
How often is this grease storage unit emptied? /y,,,,f<,iy' ,9s A tg rl5 --,>
Please list the vendor who removes the waste: .:5"dim-rr'.r , f-/(-Y
A
Baker Commodities Inc.
Recycling for Life
134Rear Billerica Avenue
North Billerica, MA 01862
Service Address
ChengDu L/T
249 North Main St
Mansfield, MA 02048
CURRENT PERIOD ACnVITY
Date Description Reference
09/16/2019 2103-Grease a
Check Number: 1500392
Account Number: �2U74--00
Check Date: 10/10/2019
(/' city \UOM
\ 1,460 j LB
Price Tax Amount
—_. _—____._
Endorsing this check Indicates that you agree to the "UCO Terms and conditions" published on Baker's webslte and on the back of this check stub to support our
commitment to our "Green Initlative" to produce sustainable products.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
,
Original Printing Issued September 3, 2019 Standard
NCCI Carrier Code:28576
Type : Stock
Markel American Insurance Company
4521 Highwoods Parkway
Glen Allen, VA 23060
1. The Insured's Name and Mailing address:
Tang SZ Corp.
249 N Main St
Mansfield MA 02048-2214
5084516387
Policy Number
JAWC0006265-02
Renewal of Policy:
AWC0006265-01
Rewrite of Policy:
Fein # J Risk ID #:
042655616/0100399
DBA Name: Cheng-Du Restaurant
SIC CODE:
Other work place not shown above:See Attached Location Schedule Type of Corporation
entity:
2. The policy period is from 09/1012019 to 09/10/2020 [12.01 AM Standard Time] at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers
Compensation Law of the states listed here: MASSACHUSETTS
B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A.
The limits of our liability under Part Two are:
Bodily Injury by Accident: $100,000 each accident
Bodily Injury by Disease: $500,000 policy limit
Bodily Injury by Disease: $100,000 each employee
C. Other Stales Insurance: Part Three of this policy applies to the states, if any, listed here
NO COVERAGE AFFORDED FOR OTHER STATES
D. California Endorsements and Schedules
Other State Endorsements and Schedules:
MDWCIOOI, MWC 1201, WCOOOOOOC, WC000308, WC000406A, WC000414, WC000414A, WC000422B, WC000425, WC 20 03 01, WC 2003
02 A, WC 20 03 03 D, WC 20 04 01, WC 20 04 05, WC 20 06 01 A, WC 20 06 04, MJ WCl000, MIL 1214, MPIL 1083, MPIL 1007
4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans, All Information required is subject
to verification and change by audit.
Minimum Premium: 195.00 Deposit Premium: Total Estimated Annual Premium:$1,144.00
Pay plan: Payroll Reporting- 0%
Producer:Pittsburgh - Automatic Data Processing Ins Agency Inc Countersigned By:
1000 GSK Drive, Suite 22g0 412-397-9400
Coraopoli$ PA 15108 Date: 09/03/2019
Servicing office: Markel Service, Inc., (888) 500-3344
Central Park Plaza, 222 South 15th Street, Suite 150ON
Omaha, NE 68102-1680
(See extension of information page for class code, rate and premium detail)
THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND
ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY
MDWC 1001 05 10
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008012-01348745870473-09032019 AWC0006265-02.
IN
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