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HomeMy WebLinkAboutQuan's Kitchen - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Permit to Operate a Food Service Establishment Type: FOOD SERVICE ESTABLISHMENT 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:. ERIC Y. QUAN, PRESIDENT Whose place of business is: QUAN'S KITCHEN, INC. 30 CHAUNCY STREET, MANSFIELD, MA 02048 PERSON(S) IN CHARGE: JULIE QUANIJAMES QUAN Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-65 BOARD OF HEALTH Michae(Heatey, Chairman x FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned ope date)_--____._ __-, Establishment Name: l9 ""Yn t�'s kL I t� S h L Establishment Address: ri -ka-\, YL t� Establishment Mailing Address(if�diiffferentl): O I l WaSWJ' Dv1 Establishment Telephone No,: _ Applicant Name & Title: CK I C j pp p i�l�nns.� r LAC c>Z� 5rl Applicant Address: 1 1 i l-Ltll� t�. Ll x Applicant Telephone No,: ct1 - 3 7 3 % 23 24 Hour Emergency No.: Applicant E-mail: Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. A Corporation Name Title I Address An Individual 173 A Partnership Other legal Entity ---—-------------- 111 ... Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: al t S c,�r�V.Ck)AA + Address: ( L( V�CSR d1.M1� 2- Telephone No: 3123 24 Hour Emergency No: t� l - �7 - �j 2-3 FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: rI'm Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) of Food Employees: qqNo. DAYS/HOURS: r U , W �� Pro Name of Person In Charge Ce Ified in Food Protection Management If more than 3 ipdIviduals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): [] Location: Permanent Location Establishment Type Q Caterer $35.00 []Mobile Mobile Start Dale: f, Retail ( ( 880v Sq. Ft) Gu Milk & Cream $10.00 Mobile End Date: [1] Food Service up to 100 INCLUDING }ra Mobile Food Consession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 [] Food Service up to 101 -200 $250.00 E] Food Service up to 201 + $300.00 [] Supermarkets $400 0 Manufacture Frozen Desserts/Ice Cream $25.00/freezer 0 Pushcart $50.00 # of Pushcarts: ❑-- Residential Kitchen $100.00 Q Retail Food $125.00 0 Retail Snack Food $50.00 Lengtof Permit: h Length K Annual — — Eg Seasonal Seasonal Dates: H Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations (Check all that apply): Definitions: PHF- Potentially hazardous food (limedemperature controls required) Non-PHFs - non -potentially hazardous lood(no time/temperature controls required) RTE -ready-to-eat foods (Ex. sandwiches, salads, muffins which needno lurtherprocessing) [] Sale of Commercially Pre -Packaged Non-PHFs 16KPHFCooked To Order 9] Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Q Sale of Commercially Pre -Packaged PHFs Preparation of PHFs For Hot And Cold Holding For Single Meal Service A-! PHF and RTE Foods Prepared For Highly Susceptible Population Facility Q Delivery of Packaged PHFs rv1 Sale of Raw Animal Foods Intended to be Prepared by Consumer Reheating of Commercially Processed Foods for Service Within 4 Hours Q Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health control) Customer Self -Service of Non PHF and Non- Perishable Foods Only Q Customer Self -Service -❑� Ice Manufactured and Packaged for Retail Sale [] Preparation of Non-PHFs Other Food Operations i] Juice Manufactured and Packaged for Retail Sale E] Offers Raw Or Undercooked Food Of Animal Origin Prepares Food/Single Meals for Catered Events or Institutional Food Service Offers RTE PHF in Bulk Quantities Retail Sale of Salvage, Out -Of -Date or Reconditioned Food To be completed by the Board of Health Total Permit Fee: Payment is due with application ® 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 590.9p0-and' 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 filed all state tax returns and paid state taxes required under law. Signature of Individual or Corporate Name: -_- Social Security Number or Federal ID: �) _ 7 i i Z- 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. (tCAP4 1 11G I-r- (kaz�__ Signature of Individual or Corporate Name By: Corporate Officer ( andato y, if Applicable) 6q-3- A- SS20 *"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. CAUsers\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wwtv.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses nnlicant Information Please Business/Organization Name: Eta Ktw Arou an employer? Check the appropriate box: Business Type (required): I . I am a employer with 20 employees (full and/ 5. Ej Retail or part-time).* 6. ❑ Restaurant/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 in any capacity. [No workers' comp. insurance required] 8. ❑ 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 #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 # 1. I am an employer that is providing workers' Insurance Company Name: L Insurer's Address: Us City/State/Zip: Policy # or Self -ins. Lie. # insurance f rimy employees. Below is the policy information. o 7(1) 8 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. do hereby certify, under the pains and penalties o[pe� that the information provided above isrtnre and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 0 Ntg 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.mass.gov/dia ACORV CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DO YYVI 1 L ./ 11/1912018 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 IS 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 Frank C. Chan NAMPHONE Chan Insurance Agency, Inc. _ INC No E (617)451.6733 Fn c No: (617)451.6735 220 Harrison Ave E-MAIL ADDRESS: fchan@chaninsurance.com Boston, MA 02111 License #: 1781623 INSURERS AFFORDING COVERAGE NAICN INSURERA: Travelers Insurance Company 25623 INSURED INSURER8: Guard Insurance Group 31470 INSURER C: Quan's Kitchen, Inc. INSURER D: 30 Chauncy St INSURER E: Mansfield, MA 02048 INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 1 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 rypE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY E%P MMIDDIVYYV LIMITS A X COMMERCIAL GENERAL LIABILITY 6804681B679 10/17/2018 10/17/2019 EACH OCCURRENCE $ 1000000 CLAIM&MADE WOCCUR EM SES E ToEeEwa ad. $ ------- -PR MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1 OOOOOO AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000 GEN'L X — _ POLICY PRO- 1:1❑ LOG JECT PRODUCTS-COMP/OPAGG _ _ $ 2 OOO OOO OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY I NJURY(Per person) $ ANYAUTO OWNED ASCHEDULED AUTOSONLY UTOB BODILY INJURY (Per accidenQ S PROPERTY DAMAGE Per acddenl $ HIRED NON -OWNED AUTOSONLY AUTOSONLV UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMSMADE DED RETENTION$ $ B WORKERS COMPENSATION QUWC936672 10/19/2018 10/19/2019:: X STATUTE I PRH AND EMPLOYERS' LIABILITY YIN EL EACH ACCIDENT $ 600,000 ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory .... H) NIA EL DISEASE - EA EMPLOYE S 500,000 DEda"ribe under SCRIPTION OF OPERATIONS beIa.V E.L. DISEASE - POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Chinese Restaurant located at: 30 Chauncy St. Mansfield, MA 02048 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Mansfield THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 6 Park Row Mansfield, MA 02048 AUTHORIZED REPRESENTATIVE FCC ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by FCC on November 19, 2018 at 11:39AM NATIONAL REGISTRY OF FOOD SAFETY PROFESSIONALS® CERTIFIES JULIE W QUAN HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR THE FOOD SAFETY MANAGER UNDERTHE CONFERENCE FOR FOOD PROTECTION STANDARDS PRESIDENT: Ag:- ISSUE DATE: APRIL 22, 2014 EXPIRATION DATE: APRIL 22, 2019 CERTIFICATE No: 20970986 TEST FORM: EZC 12 T lb.. flue yenrr fromellete diev ie. U w W U lJ r� N Y O G` u O 6 N O C 7 E Y E v 0 a m� •� N V m Cy w d�E •� 4.S 4 6 a 1 I 3 1 v d ~ l u c rA coox a " qF 9 c m iz s Fy � V u o r `pq ti w 3 E g `o n0 0 12 U n