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HomeMy WebLinkAboutTahana Restaurant - 12/31/202000 25 - t0 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) ?3 " fly Establishment Name TA H AN A KESTAU KAN'j Establishment Address 60 OLrKL,AtiI'P S>T• MA%15E(C0) M4 ©2-01kgr Establishment Mailing Address (if different) !SAME Establishment Telephone NoQ Applicant Name & Title: I cT E f:� CHAN A-W) ` A (} E K Applicant Address 10� (ni IN T IZl7r �� �O�_IL_f /q E M71 O 2 q-y-� Applicant Telephone No.: 61 r7- 73 S-- �%3 24 Hour Emergency No.: SDI- yS 2 91 U (CCU - /O/'S� Applicant Email W(LL Cf}AN 99- lk SOT Mi}IL CONI G� I ?7672- Cc6LO Owner Name & Title (If different from applicant) Owner Address S A M Owner telephone number Owner email: IVA Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. Corporation Name Title Address El An Individual fETLQ CHAN PTffS �/� Ili] RKOC :�tw& 4 APartnership V0-MIN ` ;ZEASUIZEK :516tMC Other legal Entity I LU AM C'ff N CLCKK -�->AlgC Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: fETE2 C44AN %i RNA CrE2 Address: 107 WIIqFNKor P-D RUOgLIN& M71 02,,4 S Telephone No: 6 1 % - 7 3k - Ort - 3 24 Hour Emergency No: FAX: E-mail: a+ Alt E-Mail: N I LL CHAN 89 �^ i IOTMAIL , 0-0 M District Or Regional Supervisor (if applicable) Name & Title: Address: I Telephone No: t 1 24 Hour Emergency No: FAX: E-mail: 3 Food Establishment Information T/fiffAN fi WATERSOURCE: PrnQLIC SEWAGEDISPOSAL: �cC13LIG DEP Public Water Supply No: (If applicable) No. of Food Employees: 3 DAYS/HOURS: R(AS INESS 44OUK ;-'0 0PA I — I =OO AAJ �T>A I L i Name of Person(s) In Charge Certified in Food Protection Management: ln/I L-L, t A M C4+A N Name of Person(s) In Charge Certified in Allergen Awareness Training WI LOAM CNAN Name of pest control company routinely inspecting the premises for evidence of pests F `f w (�L� T CONTIZOL 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. 0 Yes Does this establishment require a FOG permit? JeS If yes, please attach the FOG permit application. of Permit: Establishment Type: ,Leength LJV Annual [] Retail Food $125.00 Mobile Food Consession Ej Temporary Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 O Manufacture Frozen Desserts/Ice Cream $25.00/freezer Food Service up to 101 -200 $250.00 Temporary End Date: ❑Food Service up to 201 + $300.00 Pushcart $50.00 If of Pushcarts: Temporary Time: Supermarkets $400 n Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 [] Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/temperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous tood(no timetemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Q Sale of Commercially Pre -Packaged Non-PHFs 1y PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs 0 Preparation of PHFs For Hot And for More Than a Single Meal Service E] Delivery of Packaged PHFs Cold Holding For Single Meal Service Q PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility �] Reheating of Commercially to be Prepared by Consumer Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand Q Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only Ice Manufactured and Packaged for control) Lj Preparation of Non-PHFs Retail Sale Offers Raw Or Undercooked Food Of Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale Vacuum Packaging /Cook Chili Offers RTE PHF in Bulk Quantities 0 Prepares Food/Single Meals for 0 Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food I, the undersigned, attest to the a e6raoy of the information provided in this application and affirm that the food establishment operation will com�lyyw th 105 CMR 590 000 and all of r pppficable law. I have been instructed by the board of health on how to obt r b"opies of,105 CM 590,000 and the,�c(eral Food Code. Signature of Applicant: Z�'s`z...- Pursuant to MGL Ch.62C, s9 c. 49A, I certify under the p, nalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: �( G Lf w� a_ CO X U7 y j D CO n' r^ O 3: CTt 4 N) C) m p x � A C Q m Z A VyaO / t „ ® s*\\ ƒ \!: \)\{\ \( . � \ \ \ \ \ \ \ \ I '\ W � I I I I k « 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 Finder law. TAl+A/q Fr TN C Signature of Individual or Corporate Name 0q_zyo5 Z4`t '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\slcite\DesktoIMcolrs Documents\Food Establishments-'FempVFAX CERTIFICATION FORM.doc 5 X The Commonwealth of Massachusetts -rAIMN A Department of Industrial Accidents Office qf Investigations 600 YVashington Sheet u,p Boston, MA 02111 W iviv. mass.gorldia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: TARANA KE;TX UF, �I 1N BOO 0AKL-1-1r14lD sT City/State/Zip: MANSB&0) NA 020 4k Phone #: 5p� — 3 3 % — 0 Are yo( an employer? Check the appropriate box: Business Type (required): 1. I ,an a employer with employees5. (Cull and/ ❑ Retail or part-time).(` 6. Q RestaurantBar/Eating Establislunent 2. ❑ I all a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl, real estate, auto, etc.) employees working for nie in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertaimnent their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' eonip. insurance required]" 4. ❑ We are a non-profit organization, staffed by volunteers, I I.❑ 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 01. I ant (ai employer ihat is providing workers' coatpenrs'ation insiavntee.for ray enployees. Beloit, is the poliel, information. Insurance Company Name: 6 `cR KSff (Kc �JAR4 WA K GU/,V � Ll`iS U RftNCE- CO . Insurer's Address: P. n R�)( / r —H 1 &5 RIVER S City/State/Lip: Wf LKt-S — BAKR� FA 703 00;Z6 Policy # or Self -has. Lie. #TAW C oq 9 5 b Expiration Date: 3 ed Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (late). 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 iniprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a tine orup to $250.00 a dainst file violator. Be advised that a copy of this statement pray be forwarded to the Office of brvestigatita of tlz I)� A for insurance coverage verification. I (to hereby cer01111auler thelights and penaltic"fpeijury thai the ittfoi•nirdioti provhled above is true and correct. 1(-- 1-2-019 !�j7—SCOO Official use on(V. Do not write in this area, to he completed /fir eill, or lawn 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.npass.gov/din C A / '.v!Berkshire Hathaway insurance 41fW G U BARD Companies Worker's Comoensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Co. Policy Number TAWC049562 Renewal of TAWC989942 NCCI No. [25844] Policy Information Page [1]Named Insured and Mailing Address Tahana Inr DBA/TA Tahana Chinese Restaurant 60 Oakland St Mansfield, NA 02048 Federal Employer's ID 04-2905244 Risk ID Number 78891 Additional Names of Insured (N2) Tahana Chinese Restaurant Agency RICHARD SOO HOO INSURANCE. AGENCY, INC. 1148 Washington Street Boston, MA 02118 Agency Code: MARIS010 Insured is Corporation [2] Policy Period From March 25, 2019 to March 25, 2020, 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 '-aw of the following states: Massachusetts B.=mployer's Liability Insurance - Part Two of this policy applies to work in each of the states listed n 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 [31A. 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 [q Premium Tte 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 verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 871 Total Surcharges/Assessments $ 21.00 Total Estimated Cost $ 892.00 INTERNAL USE Xx Page - 1 - Information Page MGA :VMC049562 WC 000001A Date : 02/18/2019 MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 • www.guard.com Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: TR+tANA P&� I AGKAI N 1 Address: 60 Q KLHN > ST MPrNSF-(&(-'P MA Mailing Address: SAM Phone/Fax Number: 7 —5-�00 i C EP00 Email: LL CRAN gga HOT MA fL , C- OM Contact Person/Title for Grease Traps: (�LUMbC� >,��"ao3z6 Name of Company scheduled to pump internal grease trap(s) monthly: F-'KRNC(S��LO3 zh Name of Company scheduled to pump external grease trap quarterly: NIA 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 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 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 OCTOBER 4, 2018. In consideratio of L granting of the permit, the undersigned agrees to the conditions of the permit and acknowledg s that the in ormation subfitted in these documents is true, accurate and complete. Signed '( r�.f ti'Z� �[� �(,%� � j�,y;=j9 Date 11 t —`l =1ii01FTiy 01 -rAtJA/' A Facility Onerational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. r7 Seating Capacity (per Fire Department Regulation): ! / / 0 Seating Capacity (Actual Count): / _r, _0 Normal Hours of Food Preparation/Service: Monday Tuesday Wednesday Thursday Friday Saturday Sunday O(� PAI —_ -00 A M 1>AIL 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 3 j 3 compartment sink C/ Handwashing sink Commercial Dishwasher c� V! Bar sink l Mop Sink I Garbage Disposal Ice Making Machines 2j Fryolators Grills or Ovens Exhaust Hoods 7 Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): By Fig f/Vc--, FizoF&;5 IONA-LL CO Tb 2)o (lq THE CLANr— ApTEe1 1 ON CLEAN I IBC, _�7 N c 61 - aW - 7-7 �k Is dinnerware pre -rinsed before being washed? ✓ Yes If yes, at what station/sink? 13 Y 50AK I N4 IN TI I C R QCK / OR -rAq BRA Grease Traps 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 1 J`(E%_ WOKS Grease Trap 2 U /PEK 2 COMPhk jV( ENT 51/\I K Grease Trap 3 N --D:E TF}E S (N K Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes `\/ No Size gallons Where is the existing outdoor GRU located? 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? 7 &S Where is the grease storage unit located?SACK, FAr K(�/U7 (-0 F How often is this grease storage unit emptied? TH C l ffAVE TffEfrZ o WAt SciE�>u LC - Please list the vendor who removes the waste: F3AKjE"K CO MMO,) ((I E-5 T/qG [®