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Home My WebLink AboutLR Kyoto - 12/31/202112 IF _ rt:'sl vi OR BOARD OF HEALTH USE ONLY Permit# Issued76 FObb STABLISHMENT PERMIT APPLICATION A l cation must be submitted at least 30 days before the planned opening date (pp Y P P 9 ) Establishment Name VVP w\ C Establishment Address (� C� ��1 f Y14 r �1,� t (\-U� (��0 f Establishment Mailing Address (if different) Establishment Telephone No Applicant Name &Title: to))� X �n j) Y� oukt c Applicant Address ) Al k Ln Toxb( u—uw � 02 03�5 Applicant Telephone No.: %�G�6) St) ,�� 24 Hour Emergency No.: Applicant Email jj* � 1 W'Iu). CoYvI . QI^ 506. v �570 (-1 006 �nCi-' C0>7q 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 El An Association 14 Corporation partner. Name Title Address El An Individual 1�%_ N \�lt El A Partnership I)j{__ El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title: hny k;n� .LG (� Address: �_ W'c- Lfl o��OcO L��I IvA ()DO'S Telephone No: %)AC 1 j(�� is 24 Hour Emergency No: D - FAX: E-mail: h0D CQ�� Alt E-Mail: 3 JaS ot� I;� �qg 2 District Or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: W3 E-mail: 24 Hour Emergency No: Nc uq Food Establishment Information WATER SOURCE: n SEWAGE DISPOSAL: �d�N 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 Logy X'nc L C) Name of pest control company routinely inspecting the premises for evidence of pests ro 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 ZYes Does this establishment require a FOG permit? e If yes, please attach the FOG permit application. Length of Permit: Establishment Type: 21 Annual ❑ Retail Food $125.00 U Mobile Food Consession Temporary LZ Food Service up to 100 INCLUDING NO PHF PREPARED ON SITE $100.00 FOOD TRUCKS $175.00 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: L!�`Miik & Cream $10.00 ❑ Caterer $35.00 Food Operations: Definitions: PHF- Potentially hazardous food (time/temperature controls required) (Check all that apply): Non-PHFs - non -potentially hazardous food(no time/temperature controls required) RTE - ready-to-eal foods (Ex. sandwiches, salads, muffins which need no further processing) Sale of Commercially Pre -Packaged Non-PHFs ❑ PHFCooked To Order VHot PHF Cooked and Cooled or Hot Held Sale of Commercially Pre -Packaged PHFs ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service Delivery of Packaged PHFs Cold Holding For Single Meal Service ❑ PHF and RTE Foods Prepared For Highly Sale of Raw Animal Foods Intended Susceptible Population Facility Reheating of Commercially to be Prepared by Consumer E] Use of Process Requiring A Variance Processed Foods for Service Within 4 Hours Customer Self -Service and/or HACCP Plan (including bare hand i Customer Self -Service of Non PHF and Non- contact alternative, time as a public health Perishable Foods Only U Ice Manufactured and Packaged for control) LJ 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 590.000 and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A,'1-Eertify 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: D 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. L-,L` (. Signature of h4clividuai or Corporate Name By: Corporate fficer ( andatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. x" 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:ADsers\sleitcADcsktop\Scott''s Documents\Food Establishments-TempATAX CERTIFICATION FORM.doe The Commonwealth of'Massachusetts UlfDepartment of Industrial Accidents Office of'Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 1_Kyt* i11C- Address: City/State/Zip: Are you an employer? Check the appropriate box: I. ❑/r I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]' 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp, insurance req.] a 17 —oho Business Type (required): 5. ❑ Retail 6. Restam•ant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑Non-profit 9. ❑ Entertainment 1 o.❑ Manufacturing 1171 IIealth Care 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 #1. I am an employer that is provirRng workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/Slate Policy # or Self -ins. Lic. # ? I we 10 63 Expiration Date: — Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (1a e). 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 tip 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 pain and penalties ofpeijmy that the information provider! above is true and correct. Sienattire: /I,YI ,a11_ - Date: I)O ! -�� Official use only. Do not wrile 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 Phone www.nrass.gov/dia Town of Mansfield Health Department APPLICATION FOR FATS OILS and GREASE DISCHARGE PERMIT RESTAURANT& FOOD PREPARATION ESTABLISHMENTS Business/ Food Establishment Name: KV'CS1U ,�lC Mailing Phone/Fax Number: \'_DL�6 )'135�j 18b 2Z / «D� I -S-Dj— Contact Person/Title for Grease Traps: Name of Company scheduled to pump internal grease trap(s) monthly: Name of Company scheduled to pump external grease trap quarterly: Cv �iad ]A')12_S 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 Lao L-1 0 Print Name X1' �UC, Lc�\ Facility Onerational 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 — Tuesday �VDU—q=op Wednesday =Ov UJ Thursday 0 Friday p o — Saturday -IT, , 17 u _ �_ v Sunday : 0 0_0 0 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 Mop Sink Garbage Disposal Ice Making Machines Fryolators Grills or Ovens Exhaust Hoods C> 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? Yes No If yes, at what station/sink? 7 Grease Trans and Grease Removal Internal Grease Traps How many indoor Grease Removal Units (GRU/trap) are on site? 0 Please list fixtures attached to each grease trap Grease Trap 1 Q Albe Grease Trap 2 �J�( C • (i t o�� GreaseTrap3 Grease Trap 4 Grease Trap 5 External Grease Traps Does this establishment have an outdoor Grease Removal Unit (GRU/Interceptor)? Yes No Size (y gallons Where is the existing outdoor GRU located? 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: LZ 04�u) �ZedM Property Owner's Address: 'II L (�-AkM_U SA1e--- -1 i`n (VI- Property Owner's Telephone Number: ) S -) ). — 6111-1 Ji Yellow Grease Waste Do you store yellow grease waste from fr) Where is the grease storage unit located? How often is this grease storage unit emptied? ti N Please list the vendor who removes the waste: \ 1 3 TOWN OF MANSFIELD LOCAL BYLAWS The following bylaws apply to all food establishments permitted by the Mansfield Health Department: Plastic Waste Reduction; Polystyrene Container Reduction; and Plastic Straw/Stirrer Reduction. A copy of each bylaw is included. It is the responsibility of the applicant to read and understand all bylaws. Please indicate by initialing the following statements that the permitted food establishment will adhere to all applicable bylaws. The applicant and associate corporation are subject to fines associated with violations. Plastic Waste Reduction No retail establishment in the Town of Mansfield shall provide thin-film, single -use plastic check-out bags to customers. XI have received a copy of the Plastic Waste Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Polystyrene Container Reduction (effective January 1, 2021) Food establishments are prohibited from dispensing prepared food and drink in disposable food service containers made from expanded polystyrene. All food establishments are strongly encouraged to use reusable food service containers and cutlery, and when possible biodegradable, compostable alternatives. Compostable materials must meet ASTM (American Society of the International Association for Testing and Materials) Standards for compostability. -Z-I have received a copy of the Polystyrene Container Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Plastic Straw/Stirrer Reduction (effective January 1, 2021) Plastic beverage straws and plastic stirrers shall not be used or dispensed or sold except upon request in conjunction with the serving by business establishments or at any town -sponsored event of liquid, slurry, frozen, semi -frozen, or other forms of beverages to the public for consumption. I have received a copy of the Plastic Straw/Stirrer Reduction bylaw. I understand my responsibility to ensure that this bylaw is adhered to at the permitted food establishment. I understand violations of this bylaw will result in fines. Applicant Signature Date: U LOU . Applicant Name (please print clearly) A 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 chapte_ by insuring with: NorGUARD Insurance Company NAME OF INSURANCE COMPANY P.O. Box A-H, 39 Public Square, Wilkes-Barre, PA 18703-0020 ADDRESS OF INSURANCE COMPANY LRWC147093 01/31/2020 01/31/2021 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 Mansfield, MA 02048 EMPLOYER ADDRESS 12/27/2019 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 �' AC, RLf CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYVY) 10/20120 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(les) 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 CONTACT NAME: P ONE E 617.451.6733 Ac Na: 617.451.6735 Chan Insurance Agency, Inc. AooREss: info chaninsurance.com 220 Harrison Avenue Boston, MA 02111 INSURER(9)AFFORDING COVERAGE NAICe INSURER A: Utica First Insurance Company INSURED INSURER B; Guard Insurance Group INSURER C; LR Kyoto Inc. Kyoto Japanese Restaurant 242 Chauncy St. Ste 1 Mansfield, MA 02048 INSURER I 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. LTR TYPE OF INSURANCE INSD MD POLICY NUMBER IMMIDDNYYYI fMWDDfYYYY)LIMITS x COMMERCIAL GENERAL LIAOILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE ❑OCCUR PREMISES Ea occurrence $ 50,000 MED EXP (Any one arson $ 5,000 PERSONAL B AOV INJURY $ A BOP442590804 01/31120 01131121 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ JEC LOC GENERALAGGREGATE $ 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOeILE LIABILITY COMBEaaxlldeot NED SINGI-E IT $ BODILY INJURY (Per person) -_,— $ ANYAUTO OWNED SCHEDULED AUTO$ONLY AUT09 BODILY INJURY (Per accident) $ —PROPERTY —DAMAGE Per=Went $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY U MDRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DEC I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTNE OFFICER/MEMBH) EXCLUDED? (Mandatory In NH) N/A LRWC033683 01131120 01131 /21 SPER OTH I TATLITE ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYEEI $ 100,000 If DESSGId scribe under RIPTON OF OPERATIONS below E.L. DISEASE -POLICY LIMIT I $ 500,000 A Liquor Liability BOP44259084 01131/20 01/31121 Each Occ 1,000,000 2,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Addlllonal Remarks Schedule, may be attached If more spoce Is required) Town Of Mansfield 8 Park Row Mansfield, MA 02048 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Frank C Chan V 1933-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD