Loading...
HomeMy WebLinkAboutSake Steakhouse - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health 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:. GUANG K. SHI Whose place of business is: SAKE STEAKHOUSE, INC. DBA SAKE STEAKHOUSE 280 SCHOOL STREET PERSON(S) IN CHARGE: MICHELLE LI, MANAGER Permit Expires: December 31, 2019 Food Fee: $250.00 License Number: FS -66 BOARD OF HEALTH Milk & Cream MichaeCWeatey, Chairman FOR BOARD OF HEALTH USE ONLY Permit FOOD ESTABLISHMENT PERMIT APPLICATIC (Application must be submitted at least 30 days before the planned -7 Establishment Name a lga'15f � e(aQ 14 A o NV 0 8 2016 date) Establishment Address2 'a S G(l 49,9 C S L l 69 Establishment Mailing Address (if different) Establishment Telephone No o Z o Applicant Name &Title: q UgNq Applicant Address Applicant Telephone No.: Applicant Email Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: Cl An Association )CA Corporation An Individual I A Partnership I Other legal Entity / 'P> _o s (' oceot ,AVe . Mei IU12v\ 44A 24 Hour Emergency No.: / /, 6 _ q I0-6 �e'Zq If a corporation or partnership, give name, partner. Name Title Person Directly Responsible For Daily Operations (owner, person in charge, SL Name &Title: S Vvltin�y \ OLO8r- Address: Telephone No: S �� 3 �— p 24 Hour Emergency No: FAX: 3 �✓� Z Z O E-mail: Alt E -Mail: SGt�27�eGit`t�t�VSC _ (�A District Or Regional Supervisor (if applicable) Name & Title: Address: 41z-s,H- 4 Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: DEP Public Water Supply No: (If applicable) I NO of Food Employees _. DAYS/HOURS: Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (If 25 Seats or more): 1K Location: Permanent Location Establishment Type: Moblie Mobile Start Date: 1_] Retail ( Sq. Ft) Mobile End Date: t j Food Service up to 100 INCLUDING . Mobile Comments: FOOD TRUCKS $175.00 Length of Permit: Annual Seasonal Seasonal Dates: _i Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: i Food Service up to 101 -200 $250.00 -- - -- --- - Food Service up to 201 + $300.00 Supermarkets $400 Caterer $35.00 fX Milk & Cream $10.00 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream -- $25.00/freezer L I Pushcart $50.00 # of Pushcarts: F; ) Residential Kitchen $100.00 Retail Food $125.00 Retail Snack Food $50.00 U Tobacco Products $150.00 Food Operations: Definitions: PHF- Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time/temperature controls required) Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) -1 Sale of Commercially Pre -Packaged Non-PHFs Sale of Commercially Pre -Packaged PHFs -', 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 PHFCooked To Order Preparation of PHFs For Hot And Cold Holding For Single Meal Service Sale of Raw Animal Foods Intended to be Prepared by Consumer i J Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Vacuum Packaging / Cook Chill ------- ---- IV Use of Process Requiring A Variance Customer Self -Service and/or HACCP Plan (including bare hand tJ Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale Icontrol) ❑ Juice Manufactured and Packaged for ] ] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Retail Sale of Salvage, Out -Of -Date or Reconditioned Food [.] Prepares Food/Single Meals for Catered Events or Institutional Food Service To be completed by the Board of Health Total Permit Fee: ! Payment is due with application i ] 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 9YR 590.000 and the fedeAl Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: index the pei -Z� — Z aids of perjury that I, to my best knowledge and belief, have filed all state tax returns 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 "Social Security No. (Voluntary) or Federal Identification Number 6y_�J, By: Corporate Officer (Mandator, if Applicable) *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. R:\Health\Jane's Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc \ The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I F P1 Business/Organization Name: 5tectk ot)sC_ e llrP��• 2 �0 SC L 0JL 6E, —S 10 0 City/State/Zip: �o9 -331--23 Are you an employer? Check the appropriate box: Business Type (required): I. I am a employer with employees (full and/ 5. 0 Retail or part-time).* 6. �Restaurant(Bar/Eating Establishment 2. 1 am a sole proprietor or partnership and have no ?. 0 Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. $ 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 10.0 Manufacturing no employees. [No workers' comp, insurance required]* 11.0 Health Care 4. E]We are a non-profit organization, staffed by volunteers, 12.0 Other with no employees. [No workers' comp. insurance req.J *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 #]. I am an employer that is providing wor ers' eom ensa7.0 nsura ce forr Y employees, Below is the�I olicy Information . ( lTr1 oVfi� / ore_ VV\0la� 1ICU r�� �roVp Insurance Company Name: � / / insurer's Address: `, O s LL U 19X qr V V y� City/State/Zip: L S L Y -e 1 0 Policy # or Self -ins. Lic. #- N Pn IC, 2 I� Expiration Date: jr) / 2 q l I l 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, and rr the pains and pen as of perjury that the information provided abov is true and correct. Signature • V�b Date. 1 7 9 19 n 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 Phone Information and Instructions Massachusetts General Laws chapter 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 152, §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 performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the coni acting 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. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the 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 number 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 permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/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 future permits or licenses, A new affidavit must be filled 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 Department's address, telephone and fax number; The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 www.mass.gov/dia forth Revised 02-23-15 From:Janet Li FaxID: Page 3 of 3 Date:11/82018 12:32 PM Page:3 of 3 CASTE n no In, N nnvea once P.coTTCIP.ATC NIIIMRFR- REVISION NUMBER: V 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 Poo TrnP ATc CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ACORO° �.•�' CERTIFICATE OF LIABILITY INSURANCE DATE IMNIDD YVVYI 1110612018 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 loins certificate holder in lieu of such endorsement(s). PRODUCER 617-338.8168 Richard Soo Hoo Insurance 1148 Washington St, Suite 1 Boston, MA 02118-2108 G NEACT Richard Soo Hoo Insurance PxoxE 617.338-8168 FAX 617.338.1148 ac, No, EM : tae, nol: n E ; INSURERS) AFFORDING COVERAGE NAIC b EACH OCCURRENCE S 2,D00,000 INSURER A: The Hartford 29424 INSURED Sake Steakhouse INSURER B: Foremost Insurance Group INSURER C: Sake Steakh DUse, Inc. 280 School St. Ste -J100 10128/2018 10/28/2019 Mansfield, MA 02048 INSURER D: INSURER E: INSURER F: nnvea once P.coTTCIP.ATC NIIIMRFR- REVISION NUMBER: V 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 Poo TrnP ATc 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 I ToIN TYPE OF INSURANCE ADDL 0 SUB VIVO pOI.ICV NUMBER POLICY EFF POLICY EXP DD/YYYY MIDD V LIMITS A X c midERSIALGENERALLIABILITY Mansfield, MA 02046 AUTHORIZED REPRESENTATIVE EACH OCCURRENCE S 2,D00,000 DPREMISAMAGET EREWED 3 1,000,000 CLAIMS -MADE [7X] OCCUR OOSSAAB7827 10128/2018 10/28/2019 MED EAP An•ore ,son 3 51000 PERSONAL B ADV INJURY 3 2,000,000 G`_N'L AGGREGATE LIRRNIT APPLIES PER: X POLICY ❑ jECT LOC GENERAL AGGREGATE $ 4'000'000 PRODUCTS - COMP:OP AGO S 4,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1E.a cid. BODILY INJURY (Per ere.) 3 ANY AUTO BODILY INJURY (Per accident 3 OWNED SCHEDULED AUTOS ONLY AUTOS AUEC ONLY PVTOS ONES PROPE3i" AMAGE Per acs eft S UMBRELLA LIABOCCUR EACLI OCCURRENCE AGGREGATE 3 EXCESS LIAR CLAIMS -MADE OED RETENTIONS A WORKERS COMPENSATION AND EMPLOVERS'L1ABX.ITVYIN OFRGEFPITE ERE%CLUEED ECUTNE ❑ (Mandatory In NEU NIA WC012649713 06/01/201$-06/01/ZM `""F1 PERUTE ETR X I - 1,000,000 EACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE 3 1'(100'000 E.L. DISEASE -POLICYLIMIT 1,000,000 it yes, dosabe under DESCRIPTION OF OPERATIONS below A Liquor Liability 08SBAAB7827 10/28/2018 10/28/2019 Com Cause 1,000,000 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be aaached if more space is rexuimd) LOCATION: 280 SCHOOL ST, MANSFIELD, MA 02048 HOLDER CANCFI I. ATION MANSFI1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Mansfield 6 Park Row Mansfield, MA 02046 AUTHORIZED REPRESENTATIVE ACORD 26 (2016103) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 0 P. \ \\ 4 : ~\ i \) : / LO `j / )) P. \ \\ »| : ~\ i \) : / LO `j / )) M CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: ourvlc6ni Certificate Number: 2005760 Date of Completion: -7n016 Date of Expiration: 4m@021 Dir abovr named person is hereby issurd this crrtifrrate fbt rmnpleting an allergen awareness trainingprograns recognized by the Massachusetts Department ofAdVic Health in accordance with 105 CAIR 590.009(C)(3)(a). Bis rertifirate will be valid for five (5) yearsfi'om (late ofraupletion. Issued By: ^'NATIONAL ASSOCIATION;, Nlasmchusetn Resmmaat Aszodafion 800.765.2122 333 Turnpike Road, Suite 102 svzs,eresmumntorg Southborough,N'IA 01772 508-303-9905 .m�emaresmumnmszoc.org ✓�� SCI, �L �'�12t,��•-�pt✓r�� Y CC i � �C..". /iii ry W14 0 � � u � W=4 � a Ln Q� z � z � � W-4 z W-4 P4 }NO ! \ Q" \ k\)\ ƒ)}\\) rl t ƒ ) ( *§\§ \ a � \ \ \. d \ Q }NO ! \ Q" \ k\)\ ƒ)}\\) rl g \ Q" \ k\)\ ! *§\§ \ ƒ\\\ } \\\} \ . q I N mie naMPRFoundgUon' Provider Card Saldent Xing Dong Wang The mentioned Individual is now Cedified In the mentioned Course by demonstrating proficiency by successful )y passing the Examination in accordance with the Terms and Conditions of National CPR Foundation (NCPRF). Valid for 2 Years. (Infant -Child -Adult) ID#: 81D72 Certificate: Standard-CPR/AED Date: 1/18/2018 Provider Card Student: Lin Wen The mentioned individual Is now Certified in the mentioned Course by demonstrating proficiency by successfully passing the Examination in accordance with the Terms and Conditios of National CPR Foundation (NCPRF). Valid for 2 Years. (Infant - Child - Adult) ID#: 1397CC Certificate: Standard -CPR/AED Date: 1/18/2018 NationalOP Fcaundation" Provider Card Student-. Jimmy Xiao The mentioned individual is now Certified in the mentioned Course by demonstrating proficiency by successfully passing the Examination in accordance with the Terms and Conditions of National CPR Foundation (NCPRF). Valid for 2 Years. (Infant - Child - Adult) ID#: F74392D9 Certificate: Standard - CPR/AEDDate: 1/18/2018