Loading...
HomeMy WebLinkAboutTahana Restaurant - 12/31/2019K) Commonwealth 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:. PETER K. Y. CHAN Whose place of business is: TAHANA RESTAURANT 60 OAKLAND STREET PERSON(S) IN CHARGE: PETER CHAN, MANAGER Permit Expires: December 31, 2019 Food Fee: $250.00 License Number: FS-72 BOARD OF HEALTH MichaeC9-Heatey, Chairman Milk & Cream FOR BOARD OF HEALTH USE ONLY Permit # Issued 86 % FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name:-rAHANA PC5TAU9ANj Establishment Address: &D 0AV-I-A^f.P ST MA/'tSFIGL-A 02 r Establishment Mailing Address (if different): v �AMcIi� q Establishment Telephone No: <j 08_ 33 7, 6 S00 rwbF Applicant Name & Title: 114 t Z (EK' CNHN Applicant Address: 07 N /W1T I -0F f;D P�R66 4 LII-ie MA Ozg4:5 S0� _ zS y - Zg I L) CCELL) Applicant Telephone No.: 6/7_73g-©S�77 24 Hour Emergency No.: f7--56q-767Z(CE I—) Applicant Email: V jI LLCHi N f iCT MAIL , COM Owner Name & Title (If different from applicant): PETEQ Cl4AN A4MAC7EK Owner Address: 107 NIA_r-RQVP fZ-'D B)1,-60KLjNE MA Owner telephone number: 61r7-739-05`kG ' Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or !-1 An Association partner. tF A Corporation Name Title Address 0 An Individual FETcKc9ANFKESU E-AI.T #(07WIN _FffK0'RT>t39xgLL El A Partnership �i VA- C1+AN _ TF,&ASUf\Ef:� _--_75AME - D other legal Entity - --- !_W�u IALI CNAIJ C �� K . _ :�A ME Pers�ly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: rETEK C14AN "'6rNAC7EK Address: 107 WINT+1iZO P !Z-P 5-f->00i<L N& M q Telephone No: 24 Hour Emergency No: SOPS q ( 0 CCCIL FAX: SOS- 337- &g-q 3 E-mail: Alt E-Mail: WILL.CtfAN 8'8-0 ROI MArL,CON1 District Or Regional Supervisor (if applicable) Name & Title: � Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: i_ww MA WATER SOURCE: PUrLI C DEP Public Water Supply No: (If applicable) DAYS/HOURS: Food Establishment Information SEWAGE DISPOSAL: flap L IL No of Food Employees 3 — (00A" 2>41I— Name of Person In Charge Certified in Food Protection Management: If more than 3 individuals are certified, complete list is on file. I LWAM Person Trained in Anti -Choking Procedures (If 25 Seats or more): El Location: LV t n Moblie Mobile Start Dale: Mobile End Date: Mobile Comments: Length of Permit: L] Annual Seasonal Seasonal Dates: Temporary Temporary Start Date: Temporary End Date: Temporary Time: Rain Date: Food Operations: i(Check all that apply): Location Establishment Type: Retail -NO FOOD PREP ( Sq. Ft) $1 Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Caterer$35.00 Milk & Cream $10.00 0 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 Manufacture Frozen Desserts/Ice Cream rVFood Service for 101 -200 seats $250.00i $25.00/freezer Food Service for 201+ seats $300.00 ❑ Pushcart $50.00 9 of Pushcarts: Supermarkets $400 ❑ Residential Kitchen $100.00 Tobacco Products $150.00 0 Retail Snack Food $50.00 Definitions: PHF - Potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food(no timMemperature controls required) RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherpmcessing) Q 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 L Customer Self -Service of Non PHF and Non - Perishable Foods Only F-1 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 Customer for Retail Sale 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 0 Use of Process Requiring A Variance and/or HACCP Plan (including bare hand contact alternative, time as a public health E] Juice Manufactured and Packaged for 0 Offers Raw Or Undercooked Food Of Retail Sale Animal Origin Offers RTE PHF in Bulk Quantities 0 Prepares Food/Single Meals for , Catered Events or Institutional Food Service 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 n waived I, the undersigned. attest to the aeCurady of the information proµrded irf�this application and affirm that the food establishment operation will comp y�with 105 CffvvjjR 590.000 and�tgelLDther applicable law. I have been instructed by the pppboard of health on how to obl=opi@.yof 105ZR 590.000,agd the federal Food Code. \/ Signature of Applicant: /!\\Pursuant to MGL Ch.62C, se . 49A, I certify and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: penalties of perjury that I, to my best knowledge and belief, have filed all state lax returns 0q- z qoS 7 TAX CER I'IFICATION 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. 7 r,4 k.�� �, �✓ � ,r'r4 Si nature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) **Social Security No. (Volantary) 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 (UsersAsleitcADcsklopAScotts DocumemsVFood Establishments TempATAX CERTIFICATION FORM doe The Common wealth of Massachusetts Department of Industrial Accidents Office of Investigations Ulf 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 ANANA lZCs714ufZArqj Address: �D 0 OAKLAND S I City/State/Lip:_L\J_f}N,; f - (t t M& 0z0 q-9` Phone #: _v FS — 3 3 % —WSOy Are you an employer? Check the appropriate box: Business Type (required): 1. I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ?`kcstaurant/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] A. ❑ 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]** 4. ❑ We are a non-profit organization, staffed by volunteers, 11 ❑Health Care with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box #] nmst also fill out the section below showing their workers' compensation policy information. **I Nile 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. I ant an entplover that is providing workers' compensation insurance for ntv entpioyees. Below is llte policy information. Insurance Company Name: REKKsRI2E AMMAY 6"AQ) ':1:NSUi ANCE CD. hiswrer's Address: o Ro)( 6 —f t L S R — SUH: City/State/zip: _(nJ I LK Es - Policy # or Self -ins. Lic. # 7A w C gggq `/� Z. Expiration Date: 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 MOL 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 dd' against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations oftlieJblA for insurance coverage verification. I tlo hereby c / {f; under th pnins mul: altles of petjurp that the information provided above is true and correct. ._...' J Si nature �� ti " /V�/�j . �L % Date: Phone #: 50 8- . 3 3 -7 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 Cleric 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia M / �v!Berkshire Hathaway Insurance V U A R DCompanies Worker's Compensation and Employer's Liability Policy NorGl1ARD Insurance Company - A Stock Co. Policy Number TAWC989942 Renewal of TAWC821576 NCCI No. [25844] Policy Information Page [1]Named Insured and Mailing Address Tahana Inc DBA/TA Tahana Chinese Restaurant 60 Oakland St Mansfield, MA 02048 Federal Employer's ID 04-2905244 Risk ID Number 78891 Additional Names of Insured (N2) Tahana Chinese Restaurant Agency RICHARD SOO HOO INSURANCE AGENCY, INC. 1148 Washington Street Boston, MA 02118 Agency Code: MARISO10 Insured is Corporation [2] Policy Period From March 25, 2018 to March 25, 2019, 12:01 AM, standard time at the insured's mailing address, [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States' Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A.i;and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) =TolalEstlmated Policy Premium $ 1,121 rges/Assessments $ 37.00 ted Cost $ 1,158.00 INTERNAL USE xx Page - 1 - Information Page MGA :TAWC989942 WC 000001A Date 02/18/2018 MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 • www.guard.com lob* O b E w 0 c 0 ,r0 O d� V 0 iG w µ o L o Lr a_ � Z O N w Q 0 O v LO \O 00 X \ LO C3i w Oc a t = c � 0 `o -o Z o c 0 'q � N w � Q m W s � �L 00 � V N o C V H S � � 0 3 � O; £ � ■� Ln Q� z � z \ ! K / ƒ .\ ) % z \ / `\}y / ~N ƒ 3 f B (\\) � /