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HomeMy WebLinkAboutSake Steakhouse - 12/31/2020ID �0 3 FOR BOARD OF HEALTH USE ONLY Permit # FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment N a me 4e gect Q,14" Establishment Address vp St/toaL Oyee6 I / Establishment Mailing Address (if different) itAgo Establishment Telephone No z�7_ Applicant Name & Title. (t DF A/j ( Applicant Address toe 4Ywt44o,,tcj Avetm 2 Iv1e'Z�t1�vvl./�1dd Applicant Telephone No.: 24 Hour Emergency No.: G Applicant Email { b l 6 C),3- i� 3 -.2 60 3- Owner Name & Title (If different from applicant) c44 (C : y 1 r { Owner Address � � rvo S44,u, tN!AV/evtue-J1vte_41,vevl , m /I Owner telephone number G U - 410 Owner email: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or 11 An Association partner. WJ A Corporation Name Title Address ❑ An Individual O A Partnership Other legal Entity Person Directly Respo7BiblleJFor Daily Operations (owner, person in charge, supervisor, manager etc.) Name&Title: M LdieLte I,-, iiif`,u,L'Y Address: It �j vt Aj> ( I _FOt tMoLl Telephone No: W - 41 J ' U LZf? 24 Hour Emergency No: FAX: S � -S ? � - ) � D'W E-mail: /1!(t C le1L21,1GG1 0 ��00, (ot'ti Alt E-Mail:-------- District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: > > 24 Hour Emergency No: FAX: �')}e _ - � '2 x > // [ E-mail: � (Ike fitettt� (�Ju Se' _ /M 0 (/ o- m (,'L I �Uvvt Food Establishment Information WATER SOURCE: SEWAGE DISPOSAL: 'I DEP Public Water Supply No: (If applicable) No. of Food Employees: ' DAYS/HOURS: )�to✓l" buy ��.00AM Name of Person(s) In Charge Certified in Food Protection Management: I vl Puck LGGvt iCI CA06f vie l' ;ZkU t7-- Name of Person(s) In Charge Certified in Awareness Training )Allergen QCmy\`" Name of pest control company routinely inspecting the premises for evidence of pests If there is seating for 25 people or more, a person trained in manual choke saving procedures will be onsite at all times food is being prepared. O Yes Does this establishment require a FOG permit? { If yes, please attach the FOG permit application. Length of Permit: Establishment Type: V Annual ❑ Retail Food $125.00 F1 Mobile Food Consession NO PHF PREPARED ON SITE $100.00 E] Temporary 0 Food Service up to 100 INCLUDING FOOD TRUCKS $175.00 El Manufacture Frozen Desserts/ice Cream Temporary Start Date: �✓] Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: 0 Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: E] Supermarkets $400 E] Residential Kitchen $100.00 Rain Date: 91 Milk & Cream $10.00 E] Caterer $35.00 Food Operations: Definitions.PHF - Potentially hazardous food (emedempereture 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) Sale of Commercially Pre -Packaged Non-PHFs Pf 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 Hot And Cold Holding For iSingle Fs rMeal ervice E] PHF and RTE Foods Prepared For Highly ] Delivery of Packaged PHFs Susceptible Population Facility Sale of Raw Animal Foods Intended ,�/ y6 Use of Process Requiring A Variance Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours and/or HACCP Plan (including bare hand Customer Self -Service contact alternative, time as a public health Customer Self -Service of Non PHF and Non- Perishable Foods Only 0 Ice Manufactured and Packaged for control) Retail Sale E]Offers Raw Or Undercooked Food Of El Preparation of Non-PHFs [] Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale 0 Vacuum Packaging / Cook Chill E] Offers RTE PHF in Bulk Quantities Prepares Food/Single Meals for ] Retail Sale of Salvage, Out -Of -Date Catered Events or Institutional Food Service or Reconditioned Food 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 arJ the federal Food Code. Signature of Applicant: C; 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: v v the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns 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:_ Address: vo �(//L vt, City/State/Zip Ocnt v�{ Phone Are ou an employer? Check the appropriate box: Business Type (required): 1. 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 (met. 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]* 4. ❑ We are a non-profit organization, staffed by volunteers, l l ❑ Health Care 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 #l. I out an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: p V eVYtO SS'C / l K �'7AYfNn L� C1) O LL {2 Insurer's Address: /�y/ City/State/Zip: C6t Ya Policy # or Self -ins. Lic. #� (d 1 ( ff 99M --� q (,) `t" Expiration Date: / 0 / 2,? / -�—`2 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 ofperjary that the information provided above is true and correct. Signature: 4'vtcI'11i^"_ _ 4 Date: Phone #• - o K — � 3 ( — ) W, 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 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. �ake Meat/ l-h`ttse- Signature of Individual or Corporate Name _f)�)?z-�?W_ "Social Security No. (Voluntary) or Federal Identification Number 14 �� 6 �2 � By: Corporate Officer (Mandatory, 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. C:\Users\sleite\Desktop\Scoft's Documenls\Food Establishments- Temp\TAX CERTIFICATION FORM.doc Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: 4C+iLt? f k�hie ' 0 R14 �C,k6 Mailing Address: �Yo SGGt it ( iYe� 1 . ayt �T2LLG t /�1�a 0 Phone/Fax Number: �091-- � � 1 i �1�r6l� / - a-09 3 1 ? �) ? 9 Email: LAN Wp64/ 6e & t IL,1,2 , CJ M Contact Person/Title for Grease Name of Company scheduled to pump internal grease trap(s) monthly: &ki- i (21 &1' V I LLf- �,Fnc Name of Company scheduled to pump external grease trap quarterly: Please attach the following documents to this application: • Most recent waste hauler receipt or waste hauler manifest Appropriate permit fee based on new fee schedule (Checks can be made out to the Town of Mansfield) Food Establishments fee 3 grease interceptors/traps or less and/or 1 yellow grease collection container $50 Each grease interceptor/trap over 3 $50 ($200 max) I THE UNDERSIGNED HAVE OBTAINED AND REVIEWED THE MANSFIELD BOARD OF HEALTH FATS, OILS, AND GREASE (FOG) REGULATIONS APPROVED AND ADOPTED ON OCTOBER 4, 2018. In consideration of the granting of the permit, the undersigned agrees to the conditions of the permit and acknowledges that the info AA submitted in these documents is true, accurate and complete. Signed �A �7 A Date _ 1 1 1 4 '' I Print Name C Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? Please list fixtures attached to each grease trap Grease Trap 1 w- Grease Trap 2 Grease Trap 3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? �Z Yes No Size gallons Where is the existing outdoor GRU located? y ,I (� ,-AS, If the owner is responsible for external trap pumping, provide the Name, Address and Telephone Number of the property owner below: Property Owner's Name: _ Property Owner's Address: Property Owner's Telephone Number: Yellow Grease Waste Do you store yellow grease waste from fryolators? ja�� Where is the grease storage unit How often is this grease storage i Please list the vendor who remov Facility Operational Information Please answer all questions in this section. If an item is not applicable, indicate "N/A". Unless otherwise specified, please print or type. Seating Capacity (per Fire Department Regulation): Seating Capacity (Actual Count): Normal Hours of Food Preparation/Service: Monday �o e ? MTuesday t� �� Wednesday ; ut llD: u l�iyv� Thursday: _ Friday i r — _ �y Saturday l zJvvi Sunday a e VI/1 Please indicate the NUMBER of kitchen fixtures used in your establishment and if it is attached to a Grease Removal Units (GRU/trap) Number in establishment Attached to GRU 3 compartment sink Handwashing sink Commercial Dishwasher ( Bar sink 1 Mop Sink 3 Garbage Disposal Ice Making Machines �. Fryolators 1 Grills or Ovens Exhaust Hoods Floor drains Other: How are hood vents cleaned? (i.e., in three (3) bay sink, off site by private company): Is dinnerware pre -rinsed before being washed? rr _Yes No If yes, at what station/sink? c� �\ '� o'� 2 From: Janet LI Fax: 16173388268 To: Fax: (500) 337.2320 Page: 1 of 1 SASTE-1 12109/2019 3:26 PM (019d11111 Ai ✓ CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYV) 12r0912019 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 617-338-8168 Richard Soo HOD Insurance 123 Beach Street rciAVJ.ADT Richard Soo HOD Insurance PHONE 617-338.8168 FAX 617-338.1148 (AIC, No, Eae: (A/C, No): Boston, MA 02111.2511 ss: INSURER(S) AFFORDING COVERAGE NAIC 0 INSURERA:The Hartford 29424 N uR a e Be ouse INSORERB:The Hartford 29424 INSURER C: a e tea ottustet, In Mansfieid28 ,MA 02�48�00 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. NSR LTRM TYPE OF INSURANCE N DL UBp POLICY NUMBER POLICY EFF POLICY E%P IDDIYY Y LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS MADE O OCCUR Business Owners 8SBAAB7827 10/28/2019 10/28/2020 EACH OCCURRENCE $ 2,000.000 DAMAG ETO R uNTvDence $ 1,000.000 X MED EXP An one erson $ 5,000 PERSONAL&ADVINJURY $ 2,000,000 AGGREIG�AT�EI pL�IMIT APPLIESPER: POLICY uJEL4T �LOC GENERAL AGGREGATE $ 4.000,000 GEN'L X PRODUCTS-COMPIOPAGG S 4,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINE D SINGLE LIMIT EaaCCld Bnt S BODILY INJURY (Per erson _ S ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ W p ALTOS ONLY AUTOS ONLY PPeEaiaJ.nl AMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ AGGREGATE S EXCESS LIAR CLAIMS MADE DED I I RETENTION It $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN AAQNNpY PROPREIIET�O�WARTNEILEXEWTIVE (man atoryin NH) EXCLUDED? If yes, describe under DESCRIPTION OF OPERATIONS below NIA C012649713 06/01/2019 06/01/2020 X OT STATUTE ER EL.EACHACCIDENT $ 11000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L.DISEASE POLICY LIMIT $ 1,000,000 A Liquor Liability BSB 28 0101910/28/202 Com Cause ,000,000 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached it more space is required) LOCATION: 280 SCHOOL ST, MANSFIELD, MA 02048 MARSHFI Town of Marshfield 870 Moraine St. Marshfield, MA 02050 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE AUUKU LO tLU Ie/W) U 19UU-ZU15 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD wim! ' \ w®,\ ® \\2} \ \\ � /\/\ \\ } 0 M / © CD / \ / � \ � � � rTl � � � z � � � � z tTl (A CA � � � z � z 0 � � � �