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HomeMy WebLinkAboutCheng Du Restaurant - 12/31/2019C6 Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Serviee 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:. TI (SONNY) TANG, PRESIDENT Whose place of business is: TANG SZ, INC., dba CHENG DU RESTAURANT 249 NORTH MAIN STREET PERSON(S) IN CHARGE: TI (SONNY) TANG/JAY TANG Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS-73 BOARD OF HEALTH NichaeCHeatey, Chairman Milk & Cream IBC 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) Establishment Name: Y-,44(r PZ.rN(' D&.,g C1.1f77i)(y_ Establishment Address: P41q 4, il,141,17 S7- Establishment Mailing Address (if different): A Establishment Telephone No: VIEC Applicant Name& Title: -ri' (5'onby) Applicant Address: Vzlcl /J. I_jq14.TT Applicant Telephone No.: 5d8-4jj 1-6387 24 Hour Emergency No.: Xef8 //.r/ -e� e 7 Applicant Email: 5' 0,17n Y rl-llvl� /-13 e ZcYvlf L� 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 H An Association partner. K A Corporation Name Title Address E] An Individual H A Partnership S' —8— Ell Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: 7-,, V) 77qA),O / 17-4 77-9A) Address: 6 Jz&Y 7-/.,), Z-1 P4n sPi e /4 . A-1,9 e, -5 6 v 9 Telephone No: 3'G%8­41S1-e8,07 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: No. of Food Employees: DEP Public Water Supply No: (If applicable) 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): Location: r❑'�` Permanent Location Establishment Type: Cater _$35.00_- E3 Moblie Moblie Start Date: Q Retail ( S . Ft $125 Milk & Cream $10.00 Moblie End Date: Moblie Comments: Food Service up to 100 INCLUDIN FOOD TRUCKS $175.00 E'-1 Food Service up to 101 -200 $250.00 Q Mobile Food Consession NO PHF PREPARED ON SITE $100.00 [A Manufacture Frozen Desserts/Ice Cream $25.00/freezer Length of Permit: g E] Annual ❑'"i Food Service up to 201 + $300.00 Q Supermarkets $400 Pushcart $50.00 # of Pushcarts: � Residential Kitchen $100.00 p Tobacco Products $150.00 E3 Retail Snack Food $50.00 - -- ['! Seasonal Seasonal Dates: _ In Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: (Check all that apply): Definitions:PHF - Potentially hazardous food (timeRemperature controls required) Non-PHFs - non -potentially hazardous food(no time/lemperature controls required) RTE - roady-to-eat foods (Ex. sandwiches, salads, mums which need no furtherprocessing) i„ Sale of Commercially Pre -Packaged Non-PHFs Ed PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs ", Preparation of PHFs For Hot And Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Prepared by Consumer Customer Self -Service Reheating of Commercially Processed Foods for Service Within 4 Hours ElCustomer Self -Service of Non PHF and Non- Q Vacuum Packaging / Cook Chill Use of Process Requiring di Variance and/or HACCP Plan (including bare hand Perishable Foods Only contact alternative, time as a public health control) Ice Manufactured and Packaged for Retail Sale 0 Preparation of Non-PHFs Other Food Operations Juice Manufactured and Packaged for Retail Sale 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 €_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 CMR 590.000 and the 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. Social Security Number or Federal ID: Signature of Individual or Corporate Name: 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. oL1G3�2 5. l � �G'��u Signature of Individual or Corporate ame By: Corporate Officer (Mandatmij, ifAppl ble) **Social Security No. (Voluntanj) 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\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 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 1,41JCy /p/ 4 ZIJC _0/'.9 C �/�.i/E-i -Af �r'� iAu/�re c17 Address: a� A). XMII/ P T City/State/Zip: P,41)1 /d . 1-14 /9 Phone #: .f'e &'- V e Are you an employer? Check the appropriate box: Business Type (required): L ❑ I am a employer with employees (full and/ 5. ❑ 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. R 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]** I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #I 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 isproviding workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: �/A t� NFL AJy1Fi�Y� U �r� �GtRr�»Ctz �6rnP�ro y Insurer's Address: City/State/Zip: �zx) Ag&m 114'aqd 6 G Policy # or Self -ins. Lie. # c d C) t7 "/,f — 6 / Expiration Date: - /O �/T 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 the pains andpenalties ofperjury that the information provided above is true and correct. /,0- // - /e Phone #: J`6 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 Contact Person: Phone #: www.mass.gov/dia WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE MARKEL"' Original Printing Issued September 11, 2018 Standard NCCI Carrier Code:28576 Type : Stock Markel American Insurance Company 4521 Highwoods Parkway Glen Allen, VA 23060 1. The Insured's Name and Mailing address: Tang SZ Corp. 249 N Main St Mansfield MA 02048-2214 5084516387 Policy Number JAWC0006265-01 Renewal of Policy: Rewrite of Policy: Fein # / Risk ID #: 042655616/ DBA Name: Cheng-Du Restaurant SIC CODE: 5812 Otherwork place not shown above:See Attached Location Schedule Type of Corporation entity: 2. The policy period is from 09/10/2018 to 09/10/2019 112.01 AM Standard Time] at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of this policy applies to the Workers Compensation Law of the slates listed here: MASSACHUSETTS B. Employers liability Insurance: Part Two of this policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident: $100,000 each accident Bodily Injury by Disease: $ 500,000 policy limit Bodily Injury by Disease: $100,000 each employee C. Other Stales Insurance: Part Three of this policy applies to the states, if any, listed: here NO COVERAGE AFFORDED FOR OTHER STATES D. California Endorsements and Schedules Other State Endorsements and Schedules: MDWC 1001, MWC 1201, WC000000C, WC000308, WC000406A, WC000414, WC000422B, WC000425, WC 2003 01, WC 20 03 02 A, WC 20 03 03 D, WC 20 04 01, WC 20 04 05, WC 20 06 01 A, WC 20 06 04, MJ W C 1000, MIL 1214, MPIL 1083, MPIL 1007 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All Information required is subject to verification and change by audit. Minimum Premium: 195.00 Deposit Premium:$291.00 Total Estimated Annual Premium:$1,144.00 Pay plan: Payroll Reporting- 0% Producer: Pittsburgh -Automatic Data Processing Ins Agency Inc Countersigned By: 1000 GSK Drive, Suite 22g0 412-397-9400 Date: 09/11/2018 Coraopolis, PA 15108 Servicing office: Markel Service, Inc., (888) 500-3344 Central Park Plaza, 222 South 15th Street, Suite 150ON Omaha, NE 68102-1680 (See extension of Information page for class code rate and premium detail) THIS INFORMATION PAGE WITH THE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AND ENDORSEMENTS, IF ANY ISSUED TO FORM A PART THEREOF, COMPLETES THE ABOVE NUMBERED POLICY MDWC 1001 05 10 1 of 28 008012-013226-43338334-09112018 AWC0006265-01 a j R i w m� .° c N on Q� *-0 k; ■� I I \ © »J \ \ . _ / ? \ ae} / $f\\ ® \\/\ ƒ§\ \ [{} ® pi ƒ $ Si \%\ � /