HomeMy WebLinkAboutKyoto Japanese Steak House - 12/31/2020# 15 �1 /�o
FOR BOARD OF HEALTH USE ONLY Permit#lssued
FOOD ESTABLISHMENT PERMIT APPLICATION 00
(Application must be submitted at least 30 days before the planned opening date)
2V
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Establishment Name
Establishment Address A" 0)_ 'q 4
Establishment Mailing Address (if different)
Establishment Telephone No C Ci
Applicant Name & Title: Lo o L10 t)Wne'(.
Applicant Address 2hof W�
Applicant Telephone No.: > ,j10 611 o 2-1 24 Hour Emergency No.:
Applicant Email
Owner Name & Title (If different from applicant) LOq� x%'q UI)
Owner Address
Owner telephone number
Owner email:
Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or
El An Association partner.
2'A corporation Name Title Address
El An Individual
El A Partnership
11 Other legal Entity
Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.)
Name & Title:L,()
Address: 11k2 x
6 CLLLVI C k S-A lAct-V14 -A jv�� ca 0'q
Telephone No( C 1( 6) �su Z - 24 Hour Emergency No: (r-) 11) 6 77 - o'l t i)
FAX:
E-mail: JCLS()i\_ Liv) (q%_l [C(0(k6(.CC�VVj kJOU) P)aYIS4,0A a VeAco. Coo,,
Alt E -Mail: V&(). Corn I CQ_)Jq 62o 0 qmc"i 1, cm
District Or Regional Supervisor (if applicable)
Name & Title: Y)
Address: 'DAkLV\(_jjj Awls'fel A , AA 02o R
Telephone No: (0+G) 60S — 09'Ca 24 Hour Emergency No: 70 01 - r) 2 / 0
FAX: 15t)8 ) :539 - 2 a 2 )')
E-mail: li<jo-vo r110�,Al'tP_j it oo . Co (In
Food Establishment Information
WATER SOURCE: SEWAGE DISPOSAL: T u7 �
DEP Public Water Supply No: (If applicable) No. of Food Employees , `I -
DAYSlHOURS:
Name of Person(s) In Charge Certified in Food Protection Management:
)G\1 L`
Name of Person(s) In Charge Certified in Allergen Awareness Training
Long x�n w L, 0
Name of pest control company routinely inspecting the premises for evidence of pestsV- I 'N IV ) ' I
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 Ch Yes
Does this establishment require a FOG permit? — If yes, please attach the FOG permit application.
Length of Permit:
/Annual
F] Temporary
Temporary Start Date:
Temporary End Date:
Temporary Time:
Rain Date:
Establishment Type:
Retail Food $125.00
Food Service up to 100 INCLUDING
FOOD TRUCKS $175.00
L] Food Service up to 101 -200 $250.00
Food Service up to 201 + $300.00
Supermarkets $400
ZMilk & Cream $10.00
Mobile Food Consession
NO PHF PREPARED ON SITE $100.00
Manufacture Frozen Desserts/Ice Cream
$25.00/freezer
Pushcart $50.00 # of Pushcarts:
Residential Kitchen $100.00
Caterer $35.00
Food Operations: Definitions:PHF- Potentially hazardous food (timeltemperafure controls required)
Check all that a I Non-PHFS - non -potentially hazardous lood(no time/lemperature controls required)
( Pp Y)' RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing)
Sale of Commercially Pre -Packaged Non-PHFS KPHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held
I M Is
Sale of Commercially Pre -Packaged PRFs
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
Preparation of PRFs For Hot And
Cold Holding For Single Meal Service
Q Sale of Raw Animal Foods Intended
to be Prepared by Consumer
Customer Self -Service
[J Ice Manufactured and Packaged for
Retail Sale
Juice Manufactured and Packaged for
Retail Sale
L] Offers RTE PHF in Bulk Quantities
Retail Sale of Salvage, Out -Of -Date
or Reconditioned Food
for More Than a Sing a as ervice
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
[Ase of Process Requiring A Variance
and/or HACCP Plan (including bare hand
contact alternative, time as a public health
control)
[� Offers Raw Or Undercooked Food Of
Animal Origin
Vacuum Packaging / Cook Chill
Prepares Food/Single Meals for
Catered Events or Institutional Food Service
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 On er the
and paid state taxes required under law.
Social Security Number or Federal ID:
Signature of Individual or Corporate Name: LR
of perjury that I, to my best knowledge and belief, have filed all state tax returns
01
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 InclMdual or Corporate Name By: Corporate Officer ( andatory, 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\sleile\Desktop\Scott's Docmnonls\Food Esla6lishtncnls- Temp\TAX CERTIFICATION FORM.doc
The Commonwealth oj'Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
d Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization
Address:
City/State/Zip:
Are you an employer? Check the ap r 'ate box: Business Type (required):
1. ® I am a employer with __employees (full and/ 5. E] Retail
or part-time).* \\ 6.Zestaurant/Bar/Eating Establishment
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 it any capacity.
[No workers' comp. insurance required] g• ❑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]* 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box NI 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 turd such an
organization should check box 111.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Compar
Insurer's Address:
City/State/Zip:
101Ikx Rnf0?. % 1� M 5k [0 UO LO
Policy # or Self -his. Lie. # 1 R 00 IS!R 3 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
g.2-2
ofpeijury that the information provided abovg is "e and correct.
Official use only. Do not sprite 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.ntass.gov/dia
Phone
Information and Instructions
Massachusetts General Laws cha=nter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written"
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter t52, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the per fonmance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Lmnited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to die Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license mmriber on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitilicense number which will be used as a reference number. In addition, an applicant that
must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for fibre permits or licenses. A new affidavit
must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Form Revised 5-26-05
Town of Mansfield Health Department
APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT
RESTAURANT & FOOD PREPARATION ESTABLISHMENTS
Business/ Food Establishment
Mailing
Phone/I
Email:
Contact Person/Title for Grease
1 - r
Name of Company scheduled to pump internal grease trap(s) monthly: ILS,,\ e ipuc ft ak ip S
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
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 consideration of the granting of the permit, the undersigned agrees to the conditions of the permit
and acknowledges that the
submitted in these documents is true, accurate and complete.
Date 0
1 ', 1 �
Print Name )/ I u CSI � I � n
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):
Normal Hours of Food Pre paratio n/S(ervice:
Monday
Thursday '_?70 C =3d
Sunday IT'bQ .q-�>0.
Tuesday `` _ ?� Wednesday_:, .
Friday ,)0 Saturday it ,jb
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 compartment sink
Handwashing sink
Commercial Dishwasher
Bar sink
Mop Sink
Garbage Disposal
Ice Making Machines
Fryolators
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):
Is dinnerware pre -rinsed before being
If yes, at what station/sink?
P.
Grease Trans and Grease Removal
Internal Grease Traps
How many indoor Grease Removal Units (GRU/trap) are on site?
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes No Size IA gallons
Where is the existing outdoor GRU located? If1LiIV
If the owner is responsible for external trap pumping, provide the Name, Address and TJphone Number of
the property owner below:
Property Owner's Name:
Property Owner's Addres
Property Owner's Teleph
Do you store yellow grease waste from i
Where is the grease storage unit locate(
How often is this grease storage unit err
Please list the vendor who removes the
Yellow Grease Waste
Please list fixtures attached to each grease trap
Grease Trap 1
ES'
1
`tiY12>1fi r(1
Grease Trap 2
- d
Grease Trap 3'4\
FJ
Grease Trap 4
Grease Trap 5
External Grease Traps
Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)?
Yes No Size IA gallons
Where is the existing outdoor GRU located? If1LiIV
If the owner is responsible for external trap pumping, provide the Name, Address and TJphone Number of
the property owner below:
Property Owner's Name:
Property Owner's Addres
Property Owner's Teleph
Do you store yellow grease waste from i
Where is the grease storage unit locate(
How often is this grease storage unit err
Please list the vendor who removes the
Yellow Grease Waste
Paraphrased from the FDA Food Code for Health Practitioner's Reference
From Subparagraph 2-201.11(A)(2) Organisms of Concern:
Any foodborne pathogen, with special emphasis on these 56 organisms:
1. Norovirus 2. S. Typhi 3. Shigella spp. 4. E. coli 0157:H7 (or other STEC) 5. Hepatitis A virus 6.
Nontyphoidal Salmonella
From Subparagraph 2-201.11(A)(1)
Have any of the following symptoms:
Diarrhea Vomiting Jaundice
From Subparagraph 2-201.11(A)(4)-(5)
Symptoms:
Sore throat with fever
Conditions of Exposure of Concern:
(1) Suspected of causing a foodborne outbreak or being exposed to an outbreak caused by Norovirus, S.
Typhi, Shigella spp., E. coli o157:H7 (or other STEC), Hepatitis A virus , at an event such as a family
meal, church supper, or festival because the person:
Prepared or consumed an implicated food;
or consumed food prepared by a person who is infected or ill with the organism that caused the
outbreak or who is suspected of being a carrier;
(2) Lives with, and has knowledge about, a person who is diagnosed with illness caused by Norovirus, S.
Typhi, Shigella spp., E. coli ol57:H7 (or other STEC), Hepatitis A virus ; or
(3) Lives with, and has knowledge about, a person who works where there is an outbreak caused by
Norovirus, S. Typhi, Shigella spp., E. coli ol57:H7 (or other STEC), Hepatitis A virus -
From Subparagraph 2-201.12
Exclusion and Restriction:
Decisions to exclude or restrict a food employee are made considering the available evidence about the
person=s role in actual or potential foodborne illness transmission. Evidence includes:
Symptoms Diagnosis Past illnesses Stoollblood tests
In facilities serving highly susceptible populations such as day care centers and health care facilities, a person
for whom there is evidence of foodborne illness is almost always excluded from the food establishment.
In other establishments such as restaurants and retail food stored, that offer food to typicaliy healthy consumers,
a person might only be restricted from certain duties, based on the evidence of foodborne illness.
Exclusion from any food establishment is required when the person is:
• Exhibiting or reporting diarrhea or vomiting;
Diagnosed with illness caused by S. Typhi; or
Jaundiced within the last 7 days.
For Shigella spp. or Escherichia coli 0157:1-17 or other STEC infections, the person's stools must be negative
for 2 consecutive cultures taken no earlier than 48 hours after antibiotics are discontinued, and at least 24 hours
apart or the infected individual must have resolution of symptoms for more than 7 days or at least 7 days have
passed since the employee was diagnosed.
Vomit and Diarrhea Clean -Up Procedure
WHY DO WE HAVE THIS PROCEDURE?
Vomiting and diarrhea can be symptoms of several very contagious diseases and it is the
responsibility of food service management to protect both employees and customers frorr
transmission of these diseases. The most important ways of accomplishing
this task are:
1) ensure that employees understand the importance of frequent
handwashing and that they know where and how to wash their hands;
2) ensure that employees understand their responsibility to report
all disease symptoms, such as vomiting, diarrhea, jaundice,
fever and sore throat; diagnosis of diseases; and exposure to
others who are sick to the Person in Charge;
3) ensure that employees are trained and do not handle food that
is ready to eat with their bare hands;
4) ensure that employees understand the importance of following
all regular cleaning and sanitizing procedures on a daily
basis and special cleaning and sanitizing procedures such as this one.
New employees will be trained in all of the above-mentioned procedures within the first week of
hiring. Reminder trainings will be done for all food service staff on an ANNUAL basis.
VOMIT/DIARRHEA CLEAN-UP KIT
A vomit/diarrhea clean-up kit is stored in a labeled bin in Contents of Clean-up Kit:
1) Personal Protective Equipment (PPE)
disposable gloves, nitrile or non -latex
face and eye shields (clean and sanitize after use)
disposable shoe covers
disposable aprons
masks
hair covers
2) Paper towels
3) Absorbent material: baking soda, Red Z powder, or kitty litter
4) Scoop or scraper, preferably disposable
5) Large plastic bags with twist ties
6) Caution tape for closing off areas
Buckets, wiping cloths, detergent and sanitizers will also be needed and are available in various
locations throughout the food service area. The Person -in -Charge is responsible for refilling the
clean-up kit after use. Extra supplies will be on hand. All supplies will be purchased or ordered at the
time of the incident so that the kit is ready for use as soon as possible after the incident.
WHEN A VOMITING OR DIARRHEA INCIDENT OCCURS
1) Remove the following from the area if no contact with vomit or diarrhea:
a) employees and/or customers
b) packaged food or food in closed containers
c) portable equipment, linens and open single -use and single -service articles.
For diarrhea, the immediate area that is visibly soiled should be the area of clean-up
concentration. For vomiting, since particles can be in the air, an area of 25 feet in all directions
should be considered the clean-up area. This is very important when considering which
employees or customers need to be removed; the food; and open single -use and single -
service articles that need to be discarded; the linens that will need to be washed; and the
equipment that will need to be cleaned and sanitized.
2) If vomiting occurred, completely close off area around the spill for 25 feet in all directions. Use
caution tape from the C!ean-up Kit.
Some small food service establishments will have to close during the clean-up of a vomiting
incident either by an employee or a customer. In the case of closure, the Regulatory Authority
should be called immediately to report the incident. A sign can be put at the entrance stating
that the food service establishment will be closed until a time judged to be sufficient to
accomplish the required clean-up.
a) bU�l�ue to its small size, will close after a vomiting
incident until clean- p is finished.
b) �4(�O �rj oc eek- 4&L ii $( ill. determine what areas will need to be
cleaned And sanitiz d, but will remain open with limited service, unless the incident occurs in
the only food prep area.
3) A trained employee should put on Personal Protective Equipment, gloves last.
All employees are trained in this clean-up procedure. If staffing allows, cooks should not be
the first choice for carrying out the clean-up.
4) Sprinkle � �.. �--�U�. � Soil ��n v vomit/fecal matter to soak up liquid. Using the
scraper or scoop from the Clean-up Kit, and paper towels, carefully wipe up vomit/fecal matter
and discard in a plastic trash bag. Then remove and discard gloves.
If staffing allows, a separate employee, wearing gloves and a mask, can hold the trash bag
open by folding the top back over their hands so that the top of the bag is not contaminated in
the process of discarding the paper towels, gloves, etc.
5) Wash hands and put on new disposable gloves and wash the area involved with detergent and
warm water.
All surfaces within the incident area, plus all doorknobs, railings, wall corners or other places
that you know are frequently touched should then be washed with soap and water. All
restrooms should be cleaned also, even if they were not known to be affected by the incident.
They are often used by employees and customers when they are not feeling well and the
infectious germs will be there even if they cannot be seen.
All areas washed as described above will then be sanitized.
6) Sanitize hard or porouG surfaces with chlorine bleach solution allowing the
area to remain wet for no less than 5 minutes; follow policy directions for
other surfaces or when using other sanitizers.
Bleach concentrations:
5.25% Sodium Hypochlorite 1 2/3 cup bleach per gallon of water 5000 PPM
or 6% dish machine sanitizer (1 part bleach to 10 parts water)
8.25% concentrated Sodium 1 cup bleach per gallon of water 5000 PPM
Hypochlorite (1 part bleach to 16 parts water)
Sanitizer to be used in this establishment will be l 4 �2 �t�
and will be left wet on hard surfaces for ��_ minutes before drying with papers
towels.
Ammonium chloride sanitizers are ineffective against Norovirus so if those are the standard sanitizers
used in a food service establishment, then chlorine bleach (or some other commercial product
approved by the EPA to kill Norovirus) must be kept on hand for use during a vomit/diarrhea incident.
Bleach is available in several different concentrations so food service establishments need to be
aware of the concentration they have available. Once opened, a bottle of bleach maintains its
strength for 30 days so PUT THE DATE ON THE BOTTLE WHEN YOU OPEN IT. Discard it after 30
days.
Remember that bleach will discolor many items such as carpets, flooring, etc. Test a small area if
there is any reason to believe that there will be a problem. Steam cleaning of carpets and upholstery
is recommended once the vomit/diarrhea has been removed. Linens should be washed in hot water
and dried in a hot dryer.
Open windows or increase ventilation as much as possible during the clean-up.
Make sure that all high -touch areas and restrooms are sanitized before areas are re -opened.
7) When totally finished cleaning up, dispose of all paper towels
and PPE in the plastic bag. Tie the bag closed and double
bag it before putting it in your regular trash.
8) Rinse food contact surfaces with clean water to remove chlorine residue left on the
surface because you used 5000 PPM to kill the infectious agents and re -sanitize
with your usual 100 ppm sanitizer.
RE -OPENING ESTABLISHMENT OR CLEANED AREAS
When the above-described clean-up procedure has been completed, the areas may be re -opened.
Establishments that closed for clean-up should call the Regulatory Authority and report that they are
ready to re -open. The Regulatory Authority may, or may not, want to actually visit the establishment
prior to re -opening.
Establishments should anticipate that some customers may request some kind of compensation.
Management should discuss that with employees as part of the training on this procedure. The
decision concerning compensation is entirely up to the establishment management.
MONITORING EMPLOYEES FOR ILLNESS
After incidents involving diarrhea and particularly vomiting, all employees, but particularly those
involved in the clean-up, will be monitored for signs of illness for several days. 'The Person -in -Charge
will remind employees to report symptoms of any illness.
INCIDENT REPORT
It is advisable for the Person -in -Charge to complete an incident report describing the date and time of
the incident; which employees were in charge of the clean-up; an overall description of the area of the
incident; how it was cleaned and sanitized; and the other areas of the establishment cleaned and
sanitized. It should also state what food was discarded. This report should be kept in the
establishment files in case there are any future questions about the incident.
REFERENCES:
"Clean-up and Disinfection for Norovirus ("Stomach Bug") Poster from disinfect-for-health.org.
Food Code U.S. Public Health Service, FDA, 2013, Annex 3, Public Health Reasons/Administrative
Guidelines, pages 395-397.
"Food Safety Sample SOP," NFSMI and USDA, Revised 2013.
"Guidelines for Responding to Vomiting and Diarrhea in Food Establishments," Rhode Island
Department of Health, Yankee Conference Presentation by Cathy Feeney and Lydia Brown,
September 22, 2016.
"Norovirus Information Guide," from SafeMark Best Practices, the Food Marketing Institute and
Ecolab, July 2010.
"White Paper: Guidelines for Response to Vomiting and Diarrheal Incidents in Food Service
Establishments," prepared by Paula Herald, PH.D., CP -FS, Technical Consultant, The Steritech
Group, Inc., www.steritech.com.
Updated January 27, 2017
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Nhen filing, tax doc:a9ents, psymentff", and related correapondegce, it 1s very:importaat
Chap: you Aid `-6c name.and"address exactly a9 shown above. Any variation
mhy`c µsella.:del ag.in.'proceaeing,-result'in.lnSPiFe�t_i. foxmP igxi.jA YQ! .aFcounk..nr_.evan_.;..
"; cause'yoq to
Al 11(oYe tiwnoDe liIti I the'inforriiatlo[n is`•not correeC. as shown '
,.. !above, .pleaeemake the correction'"using the attached tear 'off stuA and,return it,to us.
...
'Based on the information received:;fXam:you,or your representative,:;you:m0et file
`the follow}ag
form (q) by ;the date(s):ehown,
.09/30/2013
.. . _. .. "::..
Form _940.... ". '. O1/31/`L014 -. '.....
... ,. _ -
.....s:
-.•,.:. "� ,.:_ ' .":`:1 Fbrnt4'.12D.,:..-_...._..., -... ` - ... .
.... D3/15/2013.." ..
,I€-you:have questions about the foxm(s)'orahe due;date(s) '9hown,y0u can :call us at
,phone.: number or write to va at the. it sea,isho7xnrAt. the top of -this -notice... 'If you
�.ne�d'help`in @eterm(nitx)-your annual-aceounting.:pe;iod (tax year), see Publication 53s,
' ;,7).acwunting;8ez•iads :and. lyethods. ,.._ '
,. ....we"assignedyou.:'a;;tax"olaA0ificat;... 9ed:on infoxmation obtained from 'you'or'.your..._..'.
"';representatiQe:"It pis.inota_;]:egaldee=mination`of your tax classification, and is not
binding :the. -IRS. If'You S4a...... .'legal :detexu0mation of your tax classification, you may.
' "..;request- a"prtvate:letter rulii'-:fion.the IR.S under the.:guidelines: irk'
. 30oa'-i,,:::¢OQ4.rid .R.B..;I.:•;(o;:a0per. edi,ng.;Revenue PmcedUFe_;tfor,?the..-.ye NOte:."
`'" --.,, ', Certain -tax c�lasification•electiana Can ba; segueatgd by;fil3ng �g7$a"'.,e,932, .:sntdty
Classificatiai.;Election._...._see.Fprm..s8 t'.its'instxuctioxis"£or additional infosrtation.
..,c......,...........: :.m:....... ::...
INP'ORIsI,TION�:$OR'S'CORPORIITION SG6CPION':::-' .
\ -.... .
If you. in631d:10."elect to file your .. return -as ,'a::amall,)wsinesa agzporation, an_..,.
-.... •. eleetioq`t0,fiie.a-.Fc�xm:1120-5 must be made within�certain.�timeframes_and they
\.
corporation?",must ;meet eertai.n testa. 'All. of this 'infoxmation,aa.included in"the
instrucfian `fpr:Foxta" 2553, .SIectton.by a.:Small'@usiness. Qoipotation_ ,
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NOTICE
TO
EMPLOYEES
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DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As requjired by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
NorGUARD Insurance
NAME OF INSURANCE COMPANY
P.O. Box A -H, 16 S. River Street, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
POLICY NUMBER 220 Harrison Avenue EFFECTIVE DATES
CHAN INSURANCE AGENCY Boston, MA 02111 617-451-6733
NAME OF INSURANCE AGENT ADDRESS PHUNh #
LR Kvoto Inc. 242 Chauncy St. Ste 1 Mansfield, MA 02048
EMPLOYER ADDRESS
i 12/27/2018
EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers° Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby!, notified that the insurer has arranged for such attention at the
OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
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