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HomeMy WebLinkAboutQuan's Kitchen - 12/31/2020✓ � � � £ cam,. I / F FOR BOARD OF HEALTH USE ONLY Permit # Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening tlate� ti �- Establishment Name )LlCv 7 ° �� J A ` Establishment Address O Q� C j O26 xg f� wl Establishment Mailing Address (if different) S` 1 WesH � Establishment Telephone No %, 3� 5 g b 6 Applicant Name & Title: r, L t�CUn%n�S i"� „� n Applicant Address I, (�q�� `L 0�11 w �� cr��i�f 0 pp Applicant Telephone No.: -5©3- 24 Hour Emergency No.: Applicant Email W v""S(�L: Wa^4 lSU CST _ I 7777 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 A An Association partner. A Corporation Name Title Address An Individual El Partnership 1j_c:c'_�� 'Iy l A 41 iA40per( III Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: _704'YLQ4 )n��� tGLG1ri�--( ��p Address: C ��W7� I�e1 Y AAVvI LC+� rvV'�_ b q Telephone No: 1 3 g — �j 7 Z �j 24 Hour Emergency NO:: r- FAX: J�0 �lo� —~Igal ( q1 E-mail: �U"-5�� ( ^I(%Z� Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: I ,73 (� 2 7 O / 72-3 FAX: E-mail: Food Establishment Information WATER SOURCE: ESEWAGEDISIPOSAL:DEP Food Employees: Public Water Supply No: (If applicable) lR.`Of _ __... DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: 1 /l,l Name of Person(s) In Charge Certified in Allergen Awareness Training Name of pest control company routinely inspecting the premises for evidence of pests _A l 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. El Yes Does this establishment require a FOG permit? If yes, please attach the FOG permit application. Length of Permit: Establishment Type: nual ❑ Retail Food $125.00 I] Mobile Food Consession I-] Temporary � Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 Temporary Start Date: FOOD TRUCKS $175.00 ❑ Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date; Food Service up to 201 + $300.00 E] Pushcart $50.00 # of Pushcarts: Temporary Time: Supermarkets $400 ' E] Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 Q Caterer $35.00 Food Operations: Definitions:PHF - Potentially hazardous food(time/lemperalure controls required) (Check all that apply): Non-PHFs- non -potentially hazardous food(no time/lemperalure controls required) RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) [ Sale of Commercially Pre -Packaged Non-PHFs IA PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held [] Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ 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 ,❑' Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) of Non-PHFs Preparation Retail Sale p [] Offers Raw Or Undercooked Food Of E] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale E Vacuum Packaging / Cook Chill [] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for Retail Sale of Salvage, Out -Of -Dale Catered Events or Institutional Food Service 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.,9MR 590,000 and the federal. Food Code. Signature of Applicant:% - —r. /;-" Pursuant to MGL Ch.62C, sec. 49A, I certify under the penaltied"of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law. /rr pp Social Security Number or Federal ID: 0 2 O (� Signature of Individual or Corporate Name: hie � .V �.. \ I V1 C. Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGEPERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment ... Mailing Phone/Fax Number: Ema Contact Person/Title for Grease hQ- / 18 - 2 7831 Name of Company scheduled to pump internal grease trap(s) monthly: ✓(w / �� < SQ911( (Yl C— v �( Name of Company scheduled to pump external grease trap quarterly: Its 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 $50 container 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 information syhmitted in se documents is .ue, accurate a d complete. Signed Date Print 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): 7 Seating Capacity (Actual Count): I Normal Hours of Food Preparation/Service: Monday 13 3(i Tuesday Thursday �jD (� ' Friday s Sunday Uo — I I P""-- Wednesday Saturday 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 k 3 compartment sink Handwashing sink Commercial Dishwasher Bar sink Mop Sink Garbage Disposal Ice Making Machines Fryolators () Grills or Ovens Exhaust Hoods ( PJ(/ Floor drains Other: Wool SGVIa How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private Is dinnerware pre -rinsed before being washed? NA If yes, at what station/sink? N 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 1 Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes Where is the existing outdoor GRU located? No Size gallons 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: �U I — � V- '" Yellow Grease Waste Do you store yellow grease waste from fryolators? 4Z Where is the grease storage unit located? q-) 10 , flTME biZv�' 1 How often is this grease storage unit emptied? �_Z -- V� "-L5 Please list the vendor who removes the waste: Uua s- tc Gt i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Ulf Boston, MA 02111 wrvw.n;ass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Business/Organization Name: Are you an employer? Check the appropriate box: 1.❑✓ I am a employer with 2_ 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 employees. [No workers' comp. insurance req.] h L Phone #: t,'V Business Type (required): 5. ❑ Retail 6. ❑'Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (met. real estate, auto, etc.) 8. ❑Non-profit 9. ❑ Entertainment I0.❑ Manufacturing I L❑ Health Care l2.❑ Other *Any applicant that checks box # I must also till 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 # 1. I ant mt employer titrt! is provirlirU workers,' conrpeusation insnrrntce,for my employees. Below is Ibe policy information. Insurance Company Insurer's Address: City/State/Zip: Policy # or Self -ins. Lie. 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 a 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 D1A for insurance coverage verification. I (to hereby certify, under the pains anal penahies of petjuty that the information provider) apove 4 true and correct. Official use only. Do not write in this area, to be completer) by ch) or town ofrcinl. 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 Phone www.nuuss.gov/dia DATE(MMIDD/YYYY) Ac"RG7 CERTIFICATE OF LIABILITY INSURANCE 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 15 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: Eddie Mui Chan Insurance Agency, Inc. PHON o 617.451.6733 alc No: 617-451-6735 220 Harrison Avenue Boston, MA 02111 E-MAIL ADORess: service@chaninsurance.com INSURER(SIi AFFORDING COVERAGE NAIC# INSURER A: Travelers Insurance INSURED INSURER B: Guard Insurance Group INSURER C: Quan's Kitchen, Inc. 30 Chauncy Street Mansfield, MA 02048.1958 INSURER D INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION 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 NDDLiUBR INS❑ ❑ POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Es ..u.prel 300,000 MED ESP (My oneperson) $ 51000 1 PERSONAL B ADS INJURY $ 1,000,000 A 6004681136791642 10/17/19 10/17120 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICV[::] ECT �LOC PRODUCTS - COMP/OP AGO $ 2.000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par parson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS H BODILY INJURY (Per accident) $ PROPERTYDAMAGE PeracPdenl $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 1 $ 1 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatery In NH) N/A QUWCO22962 10/19119 10/19120 STATUTE !� ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 II yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Restaurant located at: 30 Chauncy Street, Mansfield, MA 02048 CERTIFICATE Town of Mansfield 6 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Frank C. Chan ACORD 25 (201(3163) The ACORD name and logo are registered marks of ACORD 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 (Mandatory, if Applicable) "Social Security No. (Voluntary) m 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:\UsersWeite\Desktop\ScotCs Documems\Food Establishments-Temp\TAX CERTIFICATION FORM.doc Nov z s 9: n., � y - � QD j0a \ G x¢ \/3[ �q/>2\06 y3ƒ \ Iy t�y> - � � = a ® 2 & ( % & \ e � _ � ® 9 a e (( \ § ( ( } ( \ OF Nov 21 19 11:02p PA PATRIOUSERVICES, INC. Your Grease Trap Pro & Drain Specialist P.O. Box 294 LIKE Bridgewater, MA 02324 US ON (508) 697-9565 1(800) 449-4480 (508) 759-0979 www.PatriotServicesMa.com Date of Service Invoice # Customer Name Phone # Address City Job Address (if different than customer) DESCRIPTION OF WORK Zip_ Apt, # I hereby authorize you to perform the above described services and I agree to pay the amounts indicated to the right. I certify that I am duly authorized to order and approve the work requested. Signature PARTS LABOR Terms: Cash OTHER PO # Bill Out TAX TOTAL This is to acknowledge completion of the above described work DISCOUNT which has been done to my complete satisfaction. TOTAL DUE Signature }, Date Customer Name Customer BMail Address Nov 21 1911:01 p p.1 Client: 195553 QUAN'S KITCHEN 871 WASHINGTON STREET Hanover, MA 02339 Customer Signature Technician Signature Customer is unavailable to sign Donald Brennan Order # Service Description 1550924 REGULAR PEST CONTROL SERVICE OUTSIDE RODENT CONTROL Integrated Pest Management Invoice/Service Report #1550924 Service Location: 195553 QUAN'S KITCHEN 30 CHAUNCY STREET Mansfield, MA 02048 L i c en ses.lCertiti cations 20874 Time In: 11!20/2019 6:66 AM Terms: NET 30 Time Out; 11/20i20197:09AW Quantity Unit Cost Amount 1.00 $55.00 $55.00 1.00 $15.00 $15.00 SubTotal: $70.00 Tax: $0.00 eta : Service Comments Tech Comment: Inspected and treated ih0 interior perimeter of the restaurant as pad of the PM I also checRed ilia exterior bait station and it was ok.if there are any issues please call the offce and thanks for choosing Al Exterminators Material Summary Material Applied Active Ingredient At % Finished Quantity Appliration Molhed Application Rate Ft EPA 4 Lot R Ai Concentration Undiluted Quantity Application Equipment OnSlaughl (S)cyano(3 ph. 0.4000 60.000 Fluid Ounce Crack & Crevice NIASql NIA noxyphsny0melh yl-(S) 4-chloro alpha. '021-IR15 NIA 0.0600 0.391 Fluid Ounce B&C NIA Totgat Pests: All Crawling Insects Severity Created Open Condit ions Responsib4ity 1-rat lnspaded NC Condfiens Added or Updated this Service. Severity Created Conditions Resolved This Visit RosponsiblIty Last Inspected None Noted. With Without Total Device Exceptions Pest Summary Quantity Device Summary Activity Activity Inspected Replaced Removed Skipped None Noted. None Noted. Additional pest findings may heve been observed. Please as conditions and comments tormore delefis Printed: 1112012010 Page; 1 r) t7l � 00* � � � � 0 Oil Ns f±i