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Home My WebLink AboutKyoto Japanese Steak House -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:. LONG XING LIN Whose place of business is: LR KYOTO, INC.0/B/A KYOTO JAPANESE STEAK HOUSE 242 CHAUNCY STREET PERSON(S) IN CHARGE: LONG XING LIN Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -42 BOARD OF HEALTH Milk & Cream MichaeCHeaCey, Chairman FOR BOARD OF HEALTH USE ONLY Permit # Issued FS -40 FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Name LR KYOTO, INC.0/BIA KYOTO JAPANESE STEAK 5 Establishment Address 242 CHAUNCY STREET43 tA Establishment Mailing Address (if different) 242 CHAUNCY STREET' /fi ra z MANSFIELD, MA 02048 Establishment Telephone No (508) 339-8822 <r= Applicant Name & Title: LONG XING LIN, OWNER Applicant Address 2 ALEX LANE, FOXBOROUGH, MA 02035 Applicant Telephone No.: (626) 236-0690 24 Hour Emergency No.: (570) 677-0210 Applicant Email Owner Name & Title (If different from applicant) LONG XING LIN Owner Address Owner telephone number 646-508-6988 Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or An Association partner. V A Corporation Name Title Address An Individual ...._................ . A Partnership Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: LONG XING LIN Address: 242 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: (646) 508-6988 24 Hour Emergency No: (570) 677-0210 FAX: (508)339-8885 E-mail: JASON_LIN1982@ICLOUD.COM KYOTOMANSFIELD@YAHOO.COM Alt E -Mail: KYOTOMANSFIELD@YAHOO.COM (Met"/ r°om District Or Regional Supervisor (if applicable) J Name & Title: LONG XING LIN Address: 242 CHAUNCY STREET, MANSFIELD, MA 02048 Telephone No: (646) 508-6988 24 Hour Emergency No: (570) 677-0210 FAX: (508)339-8885 E-mail: KYOTOMANSFIELD@YAHOO.COM Food Establishment Information WATER SOURCE: TOWN SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) _ No of Food Employees' 4 DAYS/HOURS: I Name of Person In Charge Certified in Food Protection Management: LONG XING LIN If more than 3 individuals are certified, complete list is on file. '.. Person Trained in Anti -Choking Procedures (If 25 Seats or more): Location: .%] Permanent Location Establishment Type: Caterer $35.00 -I Mobile Moblie Start Date: i_: i Retail ( Sq. Ft) ,d, Milk & Cream $10.00 Moblie End Date: 'V] Food Service up to 100 INCLUDING Mobile Food Consession Moblie Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 --- ---_-- Length of Permit:; Manufacture Frozen Desserts/Ice Cream Food Service up to 101 -200 $250.00 $25.00/freezer V Annual Food Service up to 201 + $300.00 Pushcart $50.00 # of Pushcarts: 0 Seasonal Residential Kitchen $100.00 Seasonal Dates: - ! Supermarkets $400 Retail Food $125.00 Temporary Retail Snack Food $50.00 Temporary Start Date: [_] Tobacco Products $150.00 Temporary End Date: '.. Temporary Time: Rain Date: Food Operations: Definitions: PHF- Potentially hazardous food (timeltemperature controls required) Non-PHFs - non -potentially hazardous food(no tlme/temperature controls required) (,(Check all that apply): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs �!, '�j PHFCooked To Order Hot PHF Cooked and Cooled or Hot Held - ----- - for More Than a Single Meal Service Sale of Commercially Pre -Packaged PHFs I ' 1 Preparation of PHFs For Hot And _.. - - -- Cold Holding For Single Meal Service PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs - - Susceptible Population Facility - Sale of Raw Animal Intended Reheating of Commercially Consumer to be Preparedd by C Vacuum Packaging /Cook Chill Processed Foods for Service Within 4 Hours�I ton P an on lf - -�, ]Customer Self -Service Use of Process Requiring A Variance and/or HACCP Plan (including bare hand Perishable Foods Only - _-- Ice Manufactured and Packaged for contact alternative, time as a public health Preparation oNon PHFs Retail Sale control)', Other Food Operations 1Juice Manufactured and Packaged for I Offers Raw Or Undercooked Food Of Retail Sale Animal Origin _ _.... l Offers RTE PHF in Bulk Quantities 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: $125.00 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 obtgm copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49certify and paid state taxes required under aw. Social Security Number or Federal ID: Signature of Individual or Corporate Name: the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns Town of Mansfield - Board of Health Application for Milk and Cream Permit Town of Mansfield 6 Park Row Mansfield, MA 02048 I hereby make application for a MILK AND CREAM PERMIT, which expires on December 31st of each year. NAME OF BUSINESS: LR KYOTO, INC.0/B/A KYOTO JAPANESE STEAK HOUSE ADDRESS: 242 CHAUNCY STREET TELEPHONE AT LOCATION: (508) 339-8822 FAX NUMBER: (508) 339-8885 OWNER OF BUSINESS: LONG XING LIN TELEPHONE OF OWNER: 646-508-6988 FEDERAL ID/SS NUMBER: 46-1232734 FEE: $10.00 PERMIT NUMBER: FS -40 SIGNATURE: DATE: i o �/ TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. U `C QUI}—(HCl L tl� Signature of Individual or Corporate Name By: Corporate Officer (1Mandatory, if Applicable) 1 "Social Security No: (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. R:\FlenitWan&s Documents\PERMIT APPLICATIONS\TAX CERTIFICATION FORM.doc ^From•_bhan and Company LFax: (212) 566-0660 To: Fax: (508) 338.8885 Page -1 .of 1 1111012017 3:14 PM jj�QDEPARTMENT, OF THE TREASURY t. .. .: . + �!•"119TERNAL::REVENUE SERVICE -_.. . CINCINNATI -.OH 4�99-0023 - - Date of this notice; 10-22-2012` Employer Identification Number: ... . _ .. •._..46-1232739 Form._ ..$S^4. - .. A ....Number of this notice- CP '575 .. ... ... - -_.. KYOTO JAPANESE - STEAK -MUSH _._.. 242 CHAUNCY3T.. � ��-�� Forassistance.You May..ball us at: _MANSFIELD, `MA 02048. IF.'YOU.VRITE,IATTACH THE - ., ... .. ` STUB'AT-THE ZEND OF THIS NOTICE. . .-- ...... W$ ASSIGNED •YOU AN EMPLOYER, IDENTIFICATION NUMBER - ^ 'Thank you for applying for. an Employer Identification,Number (EIN). -•We:assigned you, -- BIN 46-1232734..This EIN will.identif u business"acoounta; tax returns., ��.and �-.. Y you, your '.documents,'..e you have:no employees._', Please keep :thi@:notice-:in`your permanent ven if, u ,. records,. .. ...,_ .. _. When filing tax docmments, payments, and related corres pondence, it is very:important that_.you;use..your.SIN. M&complete"name and address exactly as shown above. Any 'variation may c&We,a da ay' n"processing, result in incorrect_,infoxmat of �n„your,aaaount,,or...even - cause yoq to be ed thanone EIN If -the `information,is`not borreet.'as shown :above, -.please,`make`the-correction`using__the -attached: tear .%off” stub:and.return -it to us. 'Based on the information received.:=from :you or your representative, you:must file '.the following form(e) by.the date(a) shown. 04/30/2013 Form .940 ..... - .: � ._...01/31/2014 - . -. . -. .. .._.... Form 3120 ..., ._. ...,..� �". 03/15/2013_. -I€„YOAihave questions about the: form (a)-or..the"due.: date (5) -shown,:. you can call us at the.phone..number or:write-to us at the-addresa"shown:at. the top of this notice.. If you - `•;;need help.in determining" -your annual accounting. period (tax year), see Publication 538, .:Accounting Periodsa+rid 4. We ass; ou a Cax"claas?ficat ork based:on information obtained from you or .your 9n4'd:y _... `:representative';" It is:inot a legit determination' Of your tax classification, and is not "".bindiggf.onahe'aRS. if -'You want::a`legal�determination of your tax classification, you may, --request"a private letter ruling from. the TRS::uPtder the guidelines-in.ReVeinle Procedure y •";2004 1,-;209.4 1 I. R H .1 ,(ot superseding -Revenue Procedure,for..�the..year at.""idsue). Note:.. -. .., :Certain=tax-claesa.ficatlon`=:electipns can be.. re - - quested by filing porlrt 6832,.:;sntlty See Form '88 its inaaructione"for additional information. glassification.;Election l 2 ..IDIRORTA2IT INPORIl1►TIOi7 4OR 8 CORPORATION ELECTION: ... .. If you, inteno:,to. elect to file -- . y your..return as ,�aismall.. business corporation, an .. . - " - election to;file: :a_-Fcrm:2120-S must be made within `certain kimeframes.and the: corporation_muat..meet certain tests, All.of this information,-ia included in the instructions `fpr Fortn.2553,.&Iection by a:Small'Businesa Coporatign. w H w U 0 z 0004 z con W4 z z w ✓iJ U' r �� - i o i) w Z U A w ;g iotl a n b d a y « 1, VVV NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: NorGUARD Insurance NAME OF INSURANCE COMPANY P.O. Box A -H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 ADDRESS OF INSURANCE COMPANY LRWC956024 01/31/2018 01/31/2019 '- POLICY NUMBER 220 Harrison Avenue EFFECTIVE DATES CHAN INSURANCE AGENCY Boston, MA 02111 617-451-6733 NAME OF INSURANCE AGENT ADDRESS PHONE # LR Kyoto: Inc. 242 Chauncy St. Ste 1 Mansfleld, MA 02048 EMPLOYER ADDRESS 12/27/2017 EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER The Commonwealth of Massachusetts Department of Industrial Accidents i 1 Congress Street, suite 100 r Boston, MA 0211 4-2 01 7 www. mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERWTTING AUTHORITY. Applicant Information PIease Print Legibly Business/Organization Phone Are you an employer? Check the box: Business Type (required): 1,IJ ��appropriate Iamaemployer with tllemployees (full and/ \ __ ` 5. ❑Retail 6. Restaurant/BazBatingEstablishment orpart-time).* 2. lam a sale proprietor or partnership and have no 7, Q Office and/or Sales (incl, real estate, auto, etc.) employees working for me in any capacity. ' 8• F1 Non-profit 1 ❑ [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, ❑ Manufacturing no employees, [No workers' comp, insurance required]* 11.0 Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, 12,0 Other with no employees. [No workers' comp, insurance req.] *Any applicant that chwks box In must also fill out the section below showing their workers' compcnsetion policy information. **If the corpumte officers have exempted tbcrosclVa, but the corporation has other employees, a workers' compensation policy is requ and and such an organization should cbmk boxP{l. lam an employer thatis providing workers' compensation Insurance for my employees. Below is the policy information, Insurance Company Nar. Insurer's Address; City/State/Zip; Policy # or Self -ins, Lic. Affach a copy of tba wr 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 DLA for insurance coverage verification, Ido hereby certify, under the ns an. enaldes ofperjuty that the heformation provided a ope is eQa�nd correct �:..........e. __..., Data: 41. 6 I U r official use only. Do not write in this area, to be completed by city or Lown official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact www.mns,gov/dia