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HomeMy WebLinkAboutCheng Du -12/31/2021f466_36- 25 f = FOR BOARD OF HEALTH USE ONLY .Permit # Issuod FOOD ESTABLISHMENT PERMIT APPLICATI6k, (Application must be submitted at least 30 days before the planned opening dais Establishment Name 646/JF/ bLi A4,57;96 R,44 T Establishment Address cA/?�V,A/,q/n6T,PiA 0dif Establishment Mailing Address (if different) Establishment Telephone No Applicant Name & Title: Applicant Address 6 I%u,ST/n 6P, e&/ - �>// ®✓�"1 P Applicant Telephone No.: jd -qd-/ _ &3 6 24 Hour Emergency No.: S'o8 U� / ••E3 g % Applicant Email ✓6`/h�%9/V�i i�3 ICC6u/� . Coin Owner Name & Title (If different from applicant) Owner Address Owner telephone number Owner email: Establishment Owned By: ❑ An Association VA Corporation ❑ An Individual El Partnership ❑ Other legal Entity If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Address 1_ T lJ6r _ _ % _ %usi�n �_�nj FCi]. X-16 -�j�J Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Alt E-Mail: .4 District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: 24 Hour Emergency No: FAX: E-mail: Food Establishment Information WATER SOURCE: T wV SEWAGE DISPOSAL: O I.,,I KI DEP Public Water Supply No: (If applicable) No. of Food Employees: DAYS/HOURS: Name of Person(s) In Charge Certified in Food Protection Management: Name of Person(s) In Charge Certified in Allergen Awareness Training 'TiA Ci . 6,1 / c—y-/ 774N6 . ! 9In /-t_L VNAl Name of pest control company routinely inspecting the premises for evidence of pests PFr-r Conti cn 4 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. [iR Yes Does this establishment require a FOG permit? YFS If yes, please attach the FOG permit application. Length of Permit: Establishment Type: [ilAnnual ❑ Retail Food $125.00 ❑ Mobile Food Consession ❑ Temporary © Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 [i Manufacture Frozen Desserts/Ice Cream Temporary Start Date: ❑ Food Service up to 101 -200 $250.00 $25.00/freezer Temporary End Date: ❑ Food Service up to 201 + $300.00 ❑Pushcart $50.00 # of Pushcarts: Temporary Time: ❑ Supermarkets $400 ❑Residential Kitchen $100.00 Rain Date: Milk &Cream $10.00 ❑Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required) apply): Non-PHFs - non -potentially hazardous food(no time/temperalure controls required) (Check all that pP y): RTE - ready -to -eat foods (Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Sale of Commercially Pre -Packaged Non-PHFs []zPHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held ❑ Sale of Commercially Pre -Packaged PHFs [krPreparation of PHFs For Hot And for More Than a Single Meal Service Cold Holding For Single Meal Service [tvJ Delivery of Packaged PHFs ❑ PHF and RTE Foods Prepared For Highly Susceptible Population Facility ❑ Sale of Raw Animal Foods Intended ❑ Reheating of Commercially to be Prepared by Consumer ❑ Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Q'Customer Self -Service and/or HACCP Plan (including bare hand ❑ Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only ❑ Ice Manufactured and Packaged for control) ❑ Preparation of Non-PHFs Retail Sale [] Offers Raw Or Undercooked Food Of ❑ Juice Manufactured and Packaged for Animal Origin Other Food Operations Retail Sale ❑ Vacuum Packaging /Cook Chill ❑ 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 590.900 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: ��ilb tilYi�[Y7:V Y (�7���Y7 tiT] 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 Corpora e Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Nuinber *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\slcite\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 W�r7j� www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ADDlicaut Information Please Print Letfibly Business/Organization Name: 71�.V fy X Z Znl c' b)i�,V 04-CIV6 y ca Address: 024/9 /V f✓I19113 Y7- City/State/Zip: /C/, /2I T/-/4FG /) tiIa o ,Z o Phone #: Are you an employer? Check the appropriate box: Business Type (required): I. ❑ 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. 8. ❑ Non-profit [No workers' comp. insurance required] 3.Er We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have I I0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We staffed by volunteers, 11 ❑Health Care are a non-profit organization, 12.❑ Other with no employees. [No workers' comp. insurance req.] *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 toy employees. Below is the policy information. Insurance Company Name: /1&,QS el_ 4M6P1c'91,,1 .rA,15 A( 19lJfC C01Z71':a1r/ Insurer's Address: 4I 3-09 / 1V 1 r* 14 to/,t„ A,P ! 4e City/State/Zip: C765V ,911Fii/ IIA -P z?o A 0 Policy # or Self -ins. Lic. # A We OO eq / �- l J' D Expiration Date: 9' 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 a 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 forni of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerdjf , under the pains and penalties of perimy that the information provided above is true and correct Phone#• 70$ z/S-/-d38% 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 AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE IM"ARKEL' I Original Printing Issued September 3, 2020 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 5094516387 Policy Number: AWC0006 665-03 Renewal of Policy: AWC0006265-02 Rewrite of Policy: Fein # / Risk ID #: 042655616/ 0100399 DBA Name: Cheng-Du Restaurant SIC CODE: Other work place not shown above:See Attached Location Schedule Type of Corporation entity: 2• The policy period is from 09110/2020 to 09/10/2021 [12.01 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 states 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 States 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, WCOOOOOOC, WC000308, WC000406A, WC000414, WC000414A, WC000422B, WC000425, WC 20 03 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, MJWC1000, MIL. 1214, MPIL 1083, MPIL 1007 0120 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: 191.00 Deposit Premium: Producer:Pittsburgh - Automatic Data Processing Ins Agency Inc Countersigned By: 1000 GSK Drive, Suite 22QD 412-397-9400 Date: 09/03/2020 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) Total Estimated Annual Premium:$1,393.00 Pay plan: Payroll Reporting- 00/6 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 100105 10 1 of 31 008621 -01 3NgA861161 "9032020 AWC0006265-03 ' �. ' 1 a •� �: r r r l Ii: � � � i Business/ Food Establishment Name: /5A/Ei r/ I Zt/C /)i3A C-/�/AF bit Address: 62 4/% ,d/ , J4 //y S7 Mailing Address: I lz.,,r a Phone/Fax Number: -69 3 3 9 - r94/6' Email: ;1L'2" �/ /f'V 2 /J 3 © I Czoa b , co'-" Contact Person/Title for Grease Traps: 'iG/222 K Z ICC/)XC- # ?4 /()o✓9 Name of Company scheduled to pump internal grease trap(s) monthly: jUlkl" j,P :'rco e C Name of Company scheduled to pump external grease trap quarterly: !P4NE,P'S Cr.m�nvai7iFS 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 $50 container 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 information submitted in these documents is true, accurate and complete. Date /i— -0o - B e Print Name %/ygJC 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): / o Normal Hours of Food Preparation/Service: Monday v Thursday Sunday Tuesday Friday v Wednesday v Saturday VI 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 O Mop Sink O Garbage Disposal Ice Making Machines 3 Fryolators 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): vA TF /-/nx>d> 61&9A11Nf5- l'o m.P.g.VY Is dinnerware pre -rinsed before being washed? V Yes If yes, at what station/sink? 2)1,7</t zd 5W 5'TAr_1aN No 7 . � , § .� .. ¢; §® j JG G y. % ( \ _} \ \ .? � � � < k F /( wz d MO d CD /w' L CD too 0 n 0 3 0 n T � • N n _ T � N 3 @ Q ' Z Q- Q o' o a a 7 o: i °£ € l f `e $ 3 p g is s� � h i L tp7a � F p6p6K *� �pqg� 4� p�I `M lei 9EE i r i n e N Az c. 3 'm ivZ o c c k Dam � i M '•E T � A q c w d 3 3 m oa m = c T l O.CD -73 CD on o h'd S' n � d 0 N 6 l 8%E